Program Information Cover Sheet

OMB Control No. 0985-0036
Exp. Date XX/XX/20XX

Program Name
Program Information Cover Sheet
Instructions to Program Facilitator(s): Please provide the requested details
about this program. 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: ___________

2. Program Facilitator Names (please provide full first and last names and provide the
daytime phone number and/or email of the best person to contact about any questions on
the forms)

First Name

Ph: ( )
Email:

Last Name

-

Would you like to receive program information from the National CDSME Resource Center?
Yes

No

First Name

Ph: ( )
Email:

Last Name

-

Would you like to receive program information from the National CDSME Resource Center?
Yes

No

3. How old are you today?________years
4. Are you of Hispanic, Latino, or Spanish origin?

Yes

5. What is your race? Check all that apply.
 American Indian or Alaska Native
 Asian
 Black or African American
 Native Hawaiian or other Pacific Islander
 White
 Some other race (please specify) _________________

No

OMB Control No. 0985-0036
Exp. Date XX/XX/20XX

6. Which option best describes your status as a program facilitator?
 Paid Staff member
 Volunteer
 Other
7. Program Start Date (mm/dd/yyyy):

/

/

_

End Date (mm/dd/yyyy):

/

/

__

8. How was the program delivered?
 In-person
 Online
 Phone
 Mail
 Hybrid (please specify)______________________
9. Did you offer a “Session 0” with this program? (Session 0 is an optional pre-program
session. Not all programs offer a Session 0.)
 Yes
 No
 Don’t know
10. What type of program is this? Mark only one. [Note to grantee: adapt this section to fit
local programming]
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Active Living Every Day
Arthritis Foundation Aquatic Program
Arthritis Foundation Exercise Program
BRI Care Consultation
Cancer: Thriving and Surviving
Chronic Disease Self-Management Program (CDSMP)
Chronic Pain Self-Management Program (CPSMP)
Diabetes Self-Management Program (DSMP)
Eat Smart, Move More, Weigh Less
Enhance Fitness
Enhance Wellness
Fit and Strong!
Geri-Fit
Health Coaches for Hypertension Control
Healthy IDEAS
Health Matters Program
Healthy Moves for Aging Well
HomeMeds
Live in Control (¡Sí, Yo Puedo Controlar Mí Diabetes!)
Living Well in the Community
Mind Over Matter
On the Move
PEARLS

OMB Control No. 0985-0036
Exp. Date XX/XX/20XX

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Positive Self-Management Program for HIV
PREPARE for Your Care
Programa de Manejo Personal de la Diabetes (Spanish DSMP)
Respecting Choices
Screening, Brief Intervention, and Referral to Treatment (SBIRT)
Tomando Control de su Salud (Spanish CDSMP)
Walk With Ease
Wellness Recovery Action Plan (WRAP)
Workplace Chronic Disease Self-Management Program (wCDSMP)

11. Please check which language you used when offering this program:
 English
 Spanish
 Other: ________________________________________
12. What funding source(s) were used in direct support of this program? Check all that
apply.
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ACL CDSME Grant
Older Americans Act (Title III-D, Title III-E, etc.)
Centers for Disease Control and Prevention
Other Federal Funding
Medicaid/Medicaid Waiver
Medicare/Medicare Advantage
Other Health Care Payer
Foundation Funding
Corporate Sponsor
Don’t Know
Other: ________________________________________

Public Burden Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless such collection displays a valid OMB control number (OMB 0985-0036). Public reporting
burden for this collection of information is estimated to average .34 hours per response, including time for gathering
and maintaining the data needed and completing and reviewing the collection of information. The obligation to
respond to this collection is voluntary.