Form 1 Falls Program Information Sheet

Falls Prevention Program Information Cover Sheet
Instructions to the Leaders/Coaches/Instructors: Please use this as a cover sheet for the completed
data collection forms to return to the Survey Coordinator at the end of the program.
1. Site Name:
City:

State:

2. If this is a new program delivery/ implementation site, please also complete 2a and 2b:
a. Street Address: ____________________________________________Zip code:___________
b. Type of site (select the type that best describes your site):
O Municipal Government
O Area Agency on Aging
O County Health Department
O Educational Institution
O Faith-based Organization
O Health Care Organization
O Library
O Multi-purpose social services organization

O Recreational Organization
O Residential Facility
O Senior Center
O Other Community Center
O Tribal Center
O Workplace
O Other (please specify):

3. Name of parent/host/sponsoring organization licensed to offer program: _
4. Leader/Coach/Instructor Names (Please provide your first and last names and provide the daytime
phone number or email of the best person to contact about any questions on the forms.)
Name:

_ Phone

Name:_

Phone :_

5. Program Start Date (mm/dd/yyyy):

Email:

_

Email:_

_

End Date (mm/dd/yyyy):

6. Did you offer a “Session 0” with this workshop? (Session 0 is an optional pre-workshop session provided
by some agencies.)
Yes
No

□

□

7. What type of program is this? (Mark only one.) [Note to Grantee: adapt this to fit local programming]
O A Matter of Balance
O Stepping On
O Stay Active and Independent for Life

O YMCA Moving for Better Balance program
O Tai Chi: Moving for Better Balance
O Other—list name:

8. Number of participants enrolled (who attended at least one class):
Number of completers (who attended at least 60% of the possible classes, excluding Session 0):