0920-19boi Registration And Attendance Tracking Form

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Overview

Instructions
Site Data
Registration & Attendance

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Sheet 1: Instructions

	Form Approved
	OMB No. 0920-xxx
	Exp. Date xx/xx/xx
REGISTRATION AND ATTENDANCE TRACKING FORM
OVERVIEW
The Registration and Attendance Tracking Form was developed to help organizations track enrollment and participation in the National Diabetes Prevention (DPP) lifestyle change program. This form should be completed by a lifestyle change coach and/or other program staff at your organization. Overall instructions are provided below. One form should be completed for each introductory session that your organization implements. If your organization implements two introductory sessions, for example, please complete two Registration and Attendance Tracking Forms.
INSTRUCTIONS
How to Use:	Before you begin, please make sure you have included your initials, your organization’s name, its DPRP code, the site/class location, and the date of the introductory session for which you are submitting data in the site data tab. The questions on the Registration & Attendance tab are specific to introductory and post-introductory session activities. Please answer the questions thinking about the introductory session implemented as part of the DPP lifestyle change program. Add more rows if needed.
To be Completed by:	The Registration and Attendance Tracking Form should be completed by a lifestyle change coach or a program staff member who has access to registration and attendance information at your organization.
When to Use:	Please update this tracking form regularly as your organization implements an introductory session, registration, and program delivery. The form covers activities through the first session of the lifestyle change program associated with the introductory session.
When to Submit:	Please submit this form to RTI International within 21 days of the date of the introductory session and do not collect additional information after that time.
	Upload the document to [insert link here]
Whom to Contact with Questions:	Please contact RTI International [Point of Contact Email]
CDC estimates the average public reporting burden for this collection of information as 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxx).

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Sheet 2: Site Data

REGISTRATION AND ATTENDANCE TRACKING FORM
Your Initials	Enter initials here
Organization Name	Enter organization name here
Organization DPRP Code	Enter DPRP code here
Site/Class Location	Enter location here
Date of the Introductory Session for Which You Are Submitting Data:	Enter date here
Please respond to the questions in the next tab.

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Sheet 3: Registration & Attendance

REGISTRATION AND ATTENDANCE TRACKING FORM
REGISTRATION: For each participant who attended the introductory session referenced in the site data tab and who are eligible to participate in a National DPP lifestyle change program, please indicate in the table below whether and when they registered for the lifestyle change program by selecting from the drop-down menu. Registration is the term used to describe an eligible person’s formal documentation of intent to attend the first session of a National DPP lifestyle change program. Formal documentation may include filling out paperwork, providing health insurance information, and/or providing contact information. Registration for the lifestyle change program is not a standardized process and will have a different format among different programs. ATTENDED SESSION 1: For each participant who attended the introductory session, indicate if they attended session 1 of your lifestyle change program by selecting "Yes" or "No" from the dropdown menu. To access the menu, click the cell that you want to edit. Then, click the arrow to select from the dropdown menu.
Participant Identifier (Unique identifier that is used for CDC data submission)	Registration	Attended Session 1