Cover Sheet

Program Name
Falls Prevention Program Information Cover Sheet
Instructions to the Leaders/Coaches/Instructors: 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.
Public Burden Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless
such collection displays a valid OMB control number (OMB 0985-0039). Public reporting burden for this collection of
information averages and estimate of .50 hours per response, including time for gathering, maintaining the data, completing,
and reviewing the collection of information. The obligation to respond to this collection is voluntary.

1. Site Name: ________________________________________________________________
Address:__________________________________________________________________
City:_________________________ State:_______________ Zip code:_______________
2. Program Leader/Coach/Instructor 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

Ph: ( )
Email:

-

3. Would you like to receive program information from the National Falls Prevention Resource Center?
Yes
No
4.

Program Start Date

(mm/dd/yyyy)

__ __/__ __/ __ __ __ ___

Program End Date

(mm/dd/yyyy)

__ __/__ __/ __ __ __ ___

5. Did you offer a “Session 0” with this program? (Session 0 is an optional pre-program session. Not all
programs offer a Session 0.)
Yes
No
Don’t know
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6. What type of program is this? Mark only one. [Note to grantee: adapt this section to fit
local programming]
A Matter of Balance
Bingocize
CAPABLE
EnhanceFitness
FallsTalk
FallsScape
Fit & Strong!
Healthy Steps for Older Adults (HSOA)
Healthy Steps in Motion
Moving for Better Balance (YMCA)
The Otago Exercise Program
Stay Active and Independent for Life (SAIL)
Stepping On
Tai Chi for Arthritis
Tai Chi Prime
Tai Ji Quan: Moving for Better Balance
7. Please check which language you used when offering this program:
English
Spanish
Other: ____________________

8. What funding source(s) were used in direct support of this program? Check all that apply.
ACL Falls Prevention Grant
Older Americans Act (Title III-D, Title III-E, etc.)
Centers for Disease Control and Prevention
Other Federal Funding
Medicaid/Medicaid Waiver
Medicare/Medicare Advantage
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Other Health Care Payer
Foundation Funding
Corporate Sponsor
Don’t Know
Other:_____________________________________

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