Form ACS-16 "Program Information Cover Sheet" - New Jersey

What Is Form ACS-16?

This is a legal form that was released by the New Jersey Department of Human Services - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2019;
  • The latest edition provided by the New Jersey Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form ACS-16 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Human Services.

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Download Form ACS-16 "Program Information Cover Sheet" - New Jersey

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Program Information Cover Sheet
Program Facilitator Instructions: Please print clearly and return this cover sheet with the
required data collection forms to the New Jersey Division of Aging Services.
1. Site Name:
Address:
City:
State:
Zip:
County:
Name of organization licensed to offer program:
2. Program Facilitators’ 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
Last Name
Phone
Staff or
Volunteer
Email
First Name
Last Name
Phone
Staff or
Volunteer
Email
3. Program Start Date (mm/dd/yyyy):
/
/
End Date (mm/dd/yyyy):
/
/
4. Did you offer a “Session 0”(an optional pre-workshop session) with this workshop
Yes
No
Don’t Know
5. 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)
Programa de Manejo Personal de la Diabetes (Spanish DSMP)
Cancer Thriving and Surviving Workshop (CTS)
Chronic Pain Self-Management Program (CPSMP)
Positive Self-Management Program for HIV
Workplace Chronic Disease Self-Management Program (wCPSMP)
Building Better Caregivers (BBC)
ACS-16
DEC 19
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Program Information Cover Sheet
Program Facilitator Instructions: Please print clearly and return this cover sheet with the
required data collection forms to the New Jersey Division of Aging Services.
1. Site Name:
Address:
City:
State:
Zip:
County:
Name of organization licensed to offer program:
2. Program Facilitators’ 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
Last Name
Phone
Staff or
Volunteer
Email
First Name
Last Name
Phone
Staff or
Volunteer
Email
3. Program Start Date (mm/dd/yyyy):
/
/
End Date (mm/dd/yyyy):
/
/
4. Did you offer a “Session 0”(an optional pre-workshop session) with this workshop
Yes
No
Don’t Know
5. 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)
Programa de Manejo Personal de la Diabetes (Spanish DSMP)
Cancer Thriving and Surviving Workshop (CTS)
Chronic Pain Self-Management Program (CPSMP)
Positive Self-Management Program for HIV
Workplace Chronic Disease Self-Management Program (wCPSMP)
Building Better Caregivers (BBC)
ACS-16
DEC 19
-1-
Workshop Information Cover Sheet – continued
6. Please check which language you used when leading this workshop:
English
Spanish
Other:
7. If you charge the participants a fee to attend this workshop, please indicate the amount:
$
For Survey Coordinator Use Only:
Host Organization Name: __________________________________________________________
Funding Source(s) for this Workshop:
NJDoAS
NJDOH
Title IIID
ACL Grant
CDC
Other Fed.
Foundation
Fee/Self-Pay
Other:
Forms Checklist Examples
Please return the following forms to the Survey Coordinator (contact information below) within one (1)
week after the final session:
This Workshop Information Cover Sheet
Attendance Log
All completed Participant Information Surveys
Send completed forms to:
Andrew Biederman
New Jersey Department of Human Services
Division of Aging Services
P.O. Box 807
Trenton, NJ 08625-0807
Questions can be directed to:
Andrew Biederman
Andrew.biederman@dhs.state.nj.us or 609-438-4797
ACS-16
DEC 19
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