Attendance Log

Your Program Name
Attendance Log
Instructions to Program Leaders/Coaches/Instructors: Please clearly print the Program Information and the Participant IDs below.
Write participants’ IDs as they appear on their Participant Information Form.
Mark each session that the participant attends with an X
Implementation Site Name: __________________________________
Program Start Date (mm/dd/yyyy)

__ __/__ __/__ __ __ __

Program End Date

__ __/__ __/__ __ __ __

Participant ID

(mm/dd/yyyy)

S1

S2

S3

S4

S5

S6

S7

S8

S9

S10

Total classes
attended

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

*Adapt this section to include the number of possible sessions for your program. Modify this form and use additional pages if needed.
Paperwork Reduction Act Public Burden Statement: According to the Paperwork Reduction Act of 1995 5 CFR § 1320.8(b)(3), no persons are required to respond to a collection of information unless such collection displays a valid OMB control number (OMB 09850039). Public reporting burden for this collection of information is estimated to average 0.10 hours per response, including time for gathering, maintaining the data needed, completing, and reviewing the collection of information. The obligation to respond to this collection
is required to retain benefits under the statutory authority of the Older Americans Act and Patient Protection and Affordable Care Act. The Administration for Community Living (ACL) will use the set of data collection tools to monitor grantees receiving Evidence-Based Falls
Prevention Program cooperative agreements. Data will be kept private to the extent allowed by law. There are no assurances of confidentiality. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the Administration for Community Living, U.S. Department of Health and Human Services, 330 C Street, SW, Washington, DC 20201-0008, Attention: Office of Nutrition and Health Promotion Programs (ONHPP), and reference the OMB Control
Number 0985-0039. Note: Please do not return the completed Evidence-Based Falls Prevention Program cooperative agreements to this address.