Falls Prevention Program Information Cover Sheet
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1Falls Prevention Program Information Cover Sheet
Instructions to the Leaders/ Coaches: Please use this as a cover sheet for the completed data
collection forms to return to the Survey Coordinator.
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 Municipal Government
O Recreational Organization
O Area Agency on Aging
O Residential Facility
O County Health Department
O Senior Center
O Educational Institution
O Other Community Center
O Faith-based Organization
O Tribal Center
O Health Care Organization
O Workplace
O Library
O Other (please specify):
O Multi-purpose social services organization
3. Name of parent/host/sponsoring organization licensed to offer program: _
______
4. Leaders’/ Coaches Names (Please provide your first and last names and provide your daytime phone
number or email so that we may contact you with any questions about the forms.)
Name: _____________________________ Phone __________________Email:____________________
Name:_____________________________ Phone :__________________Email:____________________
5. Program Start Date (mm/dd/yyyy): ________________ End Date (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 YMCA Moving for Better Balance program
O Stepping On
O Tai Chi: Moving for Better Balance
O Other—list name:
O Stay Active and Independent for Life
8. Number of participants enrolled (who attended at least one class): __
Number of completers (who attended at least 60% of the possible classes, excluding Session 0):
______
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