Form 1 Program Information Cover Sheet

Your Program Name
Program Information Cover Sheet
Instructions to Program Facilitator(s): Please provide the requested details
about this program. Please print clearly. Use this as a cover sheet for the
completed data collection forms to return to the Survey Coordinator.
1. Site Name:
Address:
City:

State:

Zip:

2. Program Facilitator Names (please provide full first and last names and provide the
daytime phone number and/or email of the best person to contact about any questions
on the forms)
First Name

Last Name

First Name

Last Name

3. Program Start Date (mm/dd/yyyy):
End Date (mm/dd/yyyy):

Ph: (___) ______ - ________________
Email:
Ph: (___) ______ - ________________
Email: __________________________
/
/

/
/

__

4. Did you offer a “Session 0” with this workshop? (Session 0 is an optional pre-workshop
session. Not all workshops offer a Session 0.)
Yes
No
Don’t know
5. What type of program is this? (Mark only one.) [Note to Grantee: adapt this to fit
local programming]
Chronic Disease Self-Management Program (CDSMP)
Tomando Control de su Salud (Spanish CDSMP)
Diabetes Self-Management Program (DSMP)
Programa de Manejo Personal de la Diabetes (Spanish DSMP)
Positive Self-Management Program for HIV
Chronic Pain Self-Management Program
Cancer: Thriving and Surviving
EnhanceWellness
HomeMeds
PEARLS

Workshop Information Cover Sheet—continued
6. Please check which language you used when leading this workshop:
English
Spanish
Arabic
Bengali
Chinese
Dutch
French
German
Greek
Hindi
Italian Japanese
Korean
Khmer Norwegian
Punjabi
Russian Somali
Swedish
Tagalog
Tamil Turkish
Vietnamese
Other:

7. If you charged the participants a fee to attend this workshop, please indicate the amount:
$

PAPERWORK REDUCTION ACT STATEMENT
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection
is XXXXXX. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Administration for Community Living, 300 C Street
SW, Washington, D.C. 20201, Attention: PRA Reports Clearance Officer