Cover Sheet

Program Name
Falls Prevention Program Information Cover Sheet
Instructions to the Leaders/Coaches/Instructors: Use this as a cover sheet for the completed
data collection forms to return to the Survey Coordinator. Please print clearly.
1. *Host Organization Name: ____________________________________________________
Address: ___________________________________________________________________
City: _________________________ State: _______________ Zip code: _______________
2. **Implementation Site Name: __________________________________________________
Address: ___________________________________________________________________
City: _________________________ State: _______________ Zip code: ______________
3. Program Leader/Coach/Instructor Names
_________________________________________(_____)_____________________________
First Name
Last Name
Phone
Email
_________________________________________(_____)_____________________________
First Name
Last Name
Phone
Email
What describes your status as a Leader/Coach?
 Volunteer
 Paid Staff
 Student

 Other

4. Type of site (select the type that best describes your site):
 Municipal Government
 Area Agency on Aging
 State Health Department
 County Health Department
 Education Institution
 Faith-based Center
 Health Care facility
 Library
 Recreational Center
 Residential facility
 Senior Center
 Tribal Building
 Other (please specify): ____________________________________
5. Program Start Date (mm/dd/yyyy) __ __/__ __/ __ __ __ __
Program End Date (mm/dd/yyyy) __ __/__ __/ __ __ __ __
6. Did you offer a “session 0” with this program? (Session 0 is an optional pre-program session.)
 Yes  No
 Don’t know
7. How was the program delivered?
 In-person
 Online

 Phone
Page 1 of 2

 Hybrid

8. Please check which language you used when offering this program:
 English
 Spanish
 Other: _____________________
9. What type of program is this? Mark only one. [Note to grantee: adapt this section to include only
your local programming]
 A Matter of Balance
 Bingocize
 CAPABLE
 EnhanceFitness
 FallsTalk
 FallScape
 Fit & Strong!
 Home Hazard Removal Program (HARP)
 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 and Fall Prevention
 Tai Chi Prime
 Tai Ji Quan: Moving for Better Balance
10. What funding source(s) were used in direct support of this program? [Note to grantee: adapt this
section to include only funding sources for your program(s)]
 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
 Other Health Care Payer
 Foundation Funding
 Corporate Sponsor
 Don’t Know
 Other: ________________________________
*A host organization coordinates the various aspects of evidence-based program delivery, is often
responsible for training master trainers and leaders/facilitators and for planning and monitoring the
implementation of programs and often (but not always) holds the program license.
**An implementation site is the physical location where the evidence-based program takes place in the
community, which may be the same as the host organization, or it may be a different location where the
host organization arranges to hold a program.
Paperwork Reduction Act Public Burden Statement: According to the Paperwork Reduction Act of 1995 5 CFR § 1320.8(b)(3), 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 is estimated to average 0.10
hours per response, including time for gathering, maintaining the data needed, completing, and reviewing the collection of information. The obligation to respond to this collection is
required to retain benefits under the statutory authority of the Older Americans Act and Patient Protection and Affordable Care Act. The Administration for Community Living
(ACL) will use the set of data collection tools to monitor grantees receiving Evidence-Based Falls Prevention Program cooperative agreements. Data will be kept private to the extent
allowed by law. There are no assurances of confidentiality. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to the Administration for Community Living, U.S. Department of Health and Human Services, 330 C Street, SW, Washington, DC 20201-0008, Attention:
Office of Nutrition and Health Promotion Programs (ONHPP), and reference the OMB Control Number 0985-0039. Note: Please do not return the completed Evidence-Based Falls
Prevention Program cooperative agreements to this address.

Page 2 of 2