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:
Ci
ty:
S
t
a
te:
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 Municipal Government
O Area Agency on Aging
O County Health Department
O Educational Institution
O Faith-based Organization
O Health Care Organization
O Library
O Multi-purpose social services organization
O Other (please specify):
O Recreational Organization
O Residential Facility
O Senior Center
O Other Community Center
O Tribal Center
O Workplace
3.
N
a
me
of pa
re
nt/host/sponso
r
in
g
o
rg
aniza
t
ion li
cen
s
ed
t
o off
er
p
r
o
gr
a
m:
_
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
Phone :_
Email:_
_ Name:_
Email: _
5
.
Pr
o
gram
S
t
a
rt
Da
te
(mm/dd/
yyyy
)
:
End Da
te
(mm/dd/
yyyy
)
:
6. Did you offer a “Session 0” with this workshop? (Session 0 is an optional pre-workshop session provided
by some agencies.) Yes No
7. What type of program is this? (Mark only one.) [Note to Grantee: adapt this to fit local programming]
O A Matter of Balance
O Stepping On
O Stay Active and Independent for Life
O YMCA Moving for Better Balance program
O Tai Ji Quan: Moving for Better Balance
O Other—list name:
OMB Control No. 0985-0039
Exp. Date 01/31/2018
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
