Form 1 Workshop InfoCover Sheet

Your Program Name

OMB Control No. 0985-XXXX
Exp. Date XX/XX/201

Workshop Information Cover Sheet
Instructions to the Group Leaders: Please provide the requested details about
this Workshop. Please print clearly. Use this as a cover sheet for the completed
data collection forms to return to the Survey Coordinator.
1. Site Name:
Address:
City:

State:

Zip:

County:
2. Name of organization licensed to offer program:
3. Workshop Leaders’ Names (please provide full first and last names). If we may contact you
with questions about these forms, please provide your daytime phone number as well.

First Name

Last Name

First Name

Last Name

Staff

Volunteer Ph: (

)

-

Staff

VolunteerPh: (

)

-

4. Workshop Start Date (mm/dd/yyyy): __ __/__ __/__ __ __ __
End Date (mm/dd/yyyy): __ __/__ __/__ __ __ __
5. Did you offer a “Session 0” with this workshop? (Session 0 is an optional pre-workshop
session. Not all workshops offer a Session 0.)
Yes
No
Don’t know
6. What type of workshop is this? (Mark only one.)
Chronic Disease Self-Management Program (CDSMP)
Tomando Control de su Salud (Spanish CDSMP)
Diabetes Self-Management Program (DSMP)
Tomando Control de su Diabetes (Spanish DSMP)
Arthritis Self-Management Program (ASMP)
Programa de Manejo Personal de la Artritis (Spanish ASMP)
Positive Self-Management for HIV
Chronic Pain Self-Management Program
Other, list name:

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-xxx. 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, 1
Massachusetts Avenue, N.W., Room 5203, Washington, D.C. 20001, Attention: PRA Reports Clearance Officer

Workshop Information Cover Sheet—continued
7. Please check which language you used when leading this workshop:
English
Spanish
Arabic
Bengali
Chinese
Dutch
French
German
Greek
Hindi
Italian
Japanese
Korean
Khmer
Norwegian
Punjabi
Russian
Somali
Swedish
Tagalog
Tamil
Turkish
Vietnamese
Other: _______
8. Number of participants enrolled (attending at least 1 session*): ______

9. Number of participants who completed at least 4 sessions*: ______
* Excluding “Session 0”
10. Number of Participant Information Surveys included in the returned packet: ______

If the number of forms is fewer than the number of participants noted in #8 above, please
provide a brief explanation (e.g., illness, refusal, loss or destruction of forms, etc.):

11. If you charged the participants a fee to attend this workshop, please indicate the amount:
______

Forms Checklist Examples
Sample instructions if Group Leaders will return all forms at one time:
Please return the following forms to the Survey Coordinator (contact information below) within
one week after the final session:
This Workshop Information Cover Sheet
Attendance Log
All completed Participant Information Surveys
Sample instructions if Group Leaders will return forms as they are completed:
•

After the first session, complete items 1-7 of this form. Make a copy.

•

Return this copy along with the completed Participant Information Surveys to the
Survey Coordinator (contact information below) within one week of workshop
completion.
Keep the original of this form. At the conclusion of the workshop, complete items
8-10 of the original of this form and send with the Attendance Log to the Survey
Coordinator (contact information below) within one week after the final session.

•

[Survey Coordinator Contact Info]
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-xxx. 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, 1
Massachusetts Avenue, N.W., Room 5203, Washington, D.C. 20001, Attention: PRA Reports Clearance Officer