Host Information Form

Host/Implementation Organization Information Form
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 .5 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. Organization Name: ________________________________________________________________
Address:__________________________________________________________________________
City:_________________________ State:_______________ Zip code:______________________
2. This is a new:

Host Organization*
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):
Municipal Government
Area Agency on Aging
State Health Department
County Health Department
Educational Institution
Faith-based Organization
Health Care Organization
Library

Multi-purpose Social Services Organization
Recreational Organization
Residential Facility
Senior Center
Other Community Center
Tribal Center
Workplace
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: ____________________________________________________________

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*A host organization is the organization or agency that coordinates the various aspects of evidencebased 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.

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