Cdsmp Workshop Participant Attendance Log

Living Well with Chronic Conditions or Living Well with Diabetes

OMB Control No. 0985-0036

Exp. Date 10/31/2019

Attendance Log

Instructions to Program Facilitators: Please clearly print the Program Information and the

Participant IDs below. Write participants’ IDs (first 2 letters of first and last name followed

by last 2 numbers of birth year) as they appear on their Participant Information Surveys.

Mark each session that the participant attends like this:

Implementation Site Name:

Start Date

End Date

(mm/dd/yyyy):

/

/

(mm/dd/yyyy):

/

/

Participant Attendance Log

Session Number*

Participant ID

1

2

3

4

5

6

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

*Adapt this section to include the number of possible sessions. Use additional pages if needed.

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 0985-0036. 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, D.C. 20201, Attention: PRA Reports Clearance Officer.