Form 1 Falls Program Information Cover Sheet

Prevention and Public Health Funds Evidence-Based Falls Prevention Program Information Collection

Falls-Program-Info-Cover-Sheet - 12.21.17

Prevention and Public Health Funds Evidence-Based Falls Prevention Program (Local Respondents)

OMB: 0985-0039

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0985-0039 can be found here:

Document [docx]

Download: docx | pdf
Shape1

OMB Control No. 0985-0039

Exp. Date 01/31/2018

Shape2 Shape3 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^Muⁿⁱ^cⁱ^p^a^l^G^o^v^erⁿ^meⁿ^t	^O^R^e^c^rea^t^ioⁿ^a^l^O^r^g^aⁿⁱ^z^a^tⁱ^oⁿ
^O^A^r^e^a^A^g^eⁿ^c^y^oⁿ^Agⁱⁿ^g	^O^R^e^sⁱ^d^eⁿ^tⁱ^al^Fa^cⁱ^li^t^y
^O^C^o^uⁿ^t^y^H^e^a^l^t^h^D^e^p^a^r^t^m^e^nt	^O^Seⁿ^io^r^C^e^nt^e^r
^O^E^d^u^c^a^t^ioⁿ^a^l^Iⁿ^s^tⁱ^tutⁱ^oⁿ	^O^O^th^e^r^C^o^mm^uⁿⁱ^t^y^C^e^nt^e^r
^O^F^aⁱ^th-^b^a^s^e^d^O^r^g^aⁿⁱ^z^a^t^ioⁿ	^O^T^ri^b^a^l^C^e^nt^e^r
^O^H^e^al^t^h^C^a^re^O^r^g^aⁿⁱ^z^a^t^ioⁿ	^O^Wo^r^k^p^l^a^c^e
^O^Li^b^r^ary	^O^O^th^e^r⁽^p^le^a^s^e^s^pe^cⁱ^f^y^):
^O^M^u^l^tⁱ^-pu^r^p^o^se^s^o^cⁱ^a^l^s^e^rvi^c^e^s^o^r^g^aⁿⁱ^z^a^t^ioⁿ	^O^O^th^e^r⁽^p^le^a^s^e^s^pe^cⁱ^f^y^):

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 Email: _ Name:_ Phone :_ Email:_ _

⁵^.^Program
S^t^a^rt^D^a^t^e⁽^m^m^/d^d^/^y^yy^y⁾^:End Date (mm/dd/yyyy):

Shape4

^□ □

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

7. Name of Program offered (Mark only one.) [Note to Grantee: adapt this to fit local programming]

O A Matter of Balance	O YMCA Moving for Better Balance program
O Stepping On	O Tai Ji Quan: Moving for Better Balance
^O^S^t^ay^A^ctⁱ^v^e^aⁿ^d^Iⁿ^d^e^p^eⁿ^d^eⁿ^t^f^o^r^Li^f^e	^O^O^th^e^r^—^li^s^tⁿ^am^e^:

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 0985-0039. 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, 330 C Street SW, Washington DC 20201, Attention: PRA Reports Clearance Officer

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	Workshop Information Cover Sheet
Author	U.S. Administration on Aging
File Modified	0000-00-00
File Created	2021-01-21