An initiative of The N.C. Center for Health & Wellness at UNC Asheville

Program Forms

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)
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

Image result for walk with ease logo

 

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.

A Matter of Balance Data Collection Forms

AMOB First Session Survey    (updated 11/13/18) A Matter of Balance Logo

AMOB Last Session Survey    (updated 11/13/18)

AMOB Class Info Sheet

AMOB Attendance Sheet

Participant Agreement and Par Q

 

Tai Chi for Arthritis and Falls Prevention Data Collection Forms

Tai Chi First Session Survey   (updated 11/13/18)

Tai Chi Last Session Survey

Tai Chi Class Info Cover Sheet

Tai Chi Attendance Sheet 20 hrs

Participant Agreement and Par Q