Healthy Aging NC

Virtual Delivery Forms

Fillable Surveys and Support Forms for Online Course Delivery. Please visit our Leader Resources and Covid-19 pages to find support material for delivering these programs online safely, and with fidelity.

Online Tai Chi for Arthritis and Fall Prevention

Tai Chi Registration Form with Liability Statement

Falls Participant Agreement & Par Q

TCA/FP Program Info Cover Sheet Fillable

TCA/FP Attendance Log – Fillable with Totals

TCA/FP First Session Online Survey Form

TCA/FP Last Session Online Survey Form

Online CDSME Toolkit Forms

CDSME Cover Sheet Fillable Fields

CDSME Attendance Log Fillable Fields

CDSME Participant Pre-Survey Fillable Fields

CDSME Participant Post-Survey Fillable Fields

Reports generated from data collection are valuable for everyone — participants, community sites, funders and policymakers. These reports are helping the evidence-based movement not only locally in your own communities, but nationally.

Updated paperwork for Living Healthy with CDSME workshops

The Administration for Community Living and the Office of Management and Budget have updated the Chronic Disease Self-Management Education (CDSME) program forms. Please take ~4 minutes to review the updates and tips on how to fill them out. These forms are now required of all CDSME programs.

CDSME Forms Instruction Webinar

The following forms are required for all CDSME workshops (Program Information Cover Sheet, Attendance Log, and Participant Information Survey):

Program Information Cover Sheet (updated January 2020)
CDSME Attendance Log (updated January 2020)
Participant Information Survey and Last Program Session Form (updated January 2020)

Tipsheet for Collecting Data

(New Translations Coming in Early 2020)
Spanish CDSME Participant Info Survey
Spanish Program Info Cover Sheet
Spanish CDSME Attendance Log

Walk with Ease Paperwork

OsteoArthritis Action Alliance (OAAA) Walk With Ease Data Collection Packet

WWE Participant Information Form (updated 1/15/2019)

WWE Attendance Log (updated January 2020)

WWE Participant Post Program Form (updated 1/15/2019)

Fidelity Evaluation Checklist

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Reminder: If you are in one of the WNC regions (A,B,C,D,E) participating in the Mission Health Partners falls prevention referral pathway, please contact us for the appropriate survey forms.