4 Host ImplementationInfoForm

OMB Control No.
Exp. Date

Host/Implementation Organization Information Form
1. Organization Name: ____________ ______________________________________
Street Address: _______________________________________________________
City:
2. This is a new: O Host Organization*

_____ State:

Zip code: __________

O Implementation Site**

3. If this is a new Implementation Site, please provide the name of the affiliated Host Organization:
_____________________________________________________________________________
4. Type of site (select the type that best describes your site):
O State Unit on Aging
O Municipal Government
O Area Agency on Aging
O State Health Department
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):

5. If this is a host organization, please indicate a contact person’s name and information:
First and last name: _______________________________________________________
Daytime phone number: _________________________
Email address: _________________________________

*A host organization is the organization or agency that coordinates the various aspects of evidence-based program
delivery. The host organization is often responsible for training master trainers and leaders/facilitators and for
planning and monitoring the implementation of programs. Often (but not always) the host organization holds the
program license. Sometimes a host organization is also an implementation site.
**An implementation site is the physical location where the evidence-based program takes place in the community.
An implementation site may be identical to a host organization, or it may be a different location where the host
organization arranges to hold a program.