Data Forms for Community Classes

OMB Approved Data Forms for MOB Community Classes

  • Group Leader Script (available in English and Spanish) - Designed to be read/paraphrased to program participants prior to their completion of the participant information survey to explain the purpose of the data collection and its voluntary nature.  
  • Falls Attendance Log - MOB -To capture the number of sessions or intervention dose that each Falls Prevention Program participant is completing. This log should be filled in by the person delivering the program (e.g. coach).
  • Participant Information Form (available in English and Spanish) - To collect participant demographics, health and disability status, falls history, risk factors, etc., before a participant begins a falls prevention program.
  • Participant Exit Form - To collect participant evaluation of program as a mechanism to understand its impact.

Data Forms for NH Tai Ji Quan Community Classes

  • Falls Program Information Cover Sheet - Cover sheet to be submitted with all other data forms with information about program site, leader/instructor/coach information, and start and end dates.
  • Attendance Log Tai Ji Quan - To capture the number of sessions or intervention dose that each Falls Prevention Program participant is completing. This log should be filled in by the person delivering the program (e.g. instructor). 
  • Group Leader Script (available in English and Spanish) -Designed to be read/paraphrased to program participants prior to their completion of the Participant Information Survey to explain the purpose of the data collection and its voluntary nature.
  • Participant Information Form - To collect participant demographics, health and disability status, falls history, risk factors, etc., before a participant begins a falls prevention program.
  • Participant Exit Form - To collect participant evaluation of program as a mechanism to understand its impact.

Please submit all forms within two weeks of completing a class to Gwen Duperron, Foundation for Healthy Communities Data Analyst.

 

This project was supported by grant number 90FC2000, financed solely by Prevention and Public Health Funds, from the U.S. Administration for Community Living, Administration on Aging, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.