Living Well with Chronic Conditions Program Summary

Please complete this short form at the end of each 6-week community program you lead. The Oregon Department of Human Services uses this information to track expansion of the program, and to develop support and refresher programs for Leaders and Master Trainers.

1. Location of Program:

Location of Program:

2. Leader/Trainer Names:

Leader/Trainer Names: 1.
2.

3. Program Start Date:

	MM		DD		YYYY
Date	Program Start Date: Date Month	/	Day	/	Year

4. Program End Date

	MM		DD		YYYY
Date	Program End Date Date Month	/	Day	/	Year