Diabetes Plus Leader Resources
If you would like to submit participant data but will not be entering it directly into ILPTH, email forms to joan.fox@ageoptions.org
Course Materials for Leaders
ILPTH Program Quick Reference: Guidance on facilitating Take Charge, including participant limits, session cutoffs, workshop lengths, and session times.
Data Collection Checklist: Instructions for collecting data from registration through to the final session [In-person workshops] | [Virtual workshops]
Intervention Tracking Form/ Attendance Record: To be completed by the Registered Dietician (RD) during individual sessions, and by leaders during each group workshop session.
Participant Sign-In Sheet: An optional sign-in sheet for participants (not required).
Session 1 Data Collection Script: A script to read aloud to participants during Session 1 [English] | [Spanish]
Session 1 Virtual Data Collection Script: A virtual version of the Session 1 data collection script [English] | [Spanish]
Photo Media Release: Optional; use this form if collecting testimonials or taking pictures. Feel free to customize it for your organization [English] | [Spanish]
Forms for Participants
For the DSMP Plus program, participants will complete paperwork using the following method:
- Paper Forms: Complete a traditional paper form or a fillable PDF.
Session 1: Registration & Individual Assessment
Participant Welcome Letter: Intro to the program and form instructions for online workshops.
Participant Registration Packet: [English] | [Spanish]
Insurance Authorization and Release of Information
Provider Letter for DSMES Order: Cover letter participants are to send along with DSMES Order Form to their physician. Can be customized with your site info. [Editable] | [PDF]
DSMES Order Form: Participant needs to submit this form to their physician for completion and return the document signed.
Participant Pre-Survey: [English]
SMART Goal Participant Sheet: Completed by RD. It is to be given to participants to retain as reference for their goal during the workshop.
Session 2: First Group Session Handouts
(One form per participant)
Workshop Overview and Homework by Session
Menu Planning DSMP Charts 9 & 10
Session 7: Final Group Session
Participant Post-Survey: [English]
Session 8: Individual Follow-Up Session
Participant Support Plan: RD completes collaboratively with each participant.
Provider Follow-Up Letter: Cover letter to send with Support Plan to physician. Can be customized with your site info. [Editable] | [PDF]
3 Month Follow-Up
Participant Follow-Up Letter: Cover letter to send with Follow-Up [Editable] | [PDF]
Participant Follow-Up Survey: [English]
Links and Other Materials
- Workshop 101
- SMRC Leader Certification Guidelines
- Pre-workshop Checklist and Recruitment Plan
- Email Templates: For leaders running online workshops
- Zoom Instructions: For online workshops [English] | [Spanish]
- Certificate of Completion Template
- Crisis Intervention Plan: General crisis guidance
- Fidelity Visit Checklist
- Host Site Survey: Email template for conclusion of workshop
- Book/CD Receipt Template
- Take Charge of Your Pain Digital MEP: https://www.bullpub.com/mep.html
- Brief Body Scan: Contact us for CD purchase or find a free version online or on YouTube.
Marketing Materials
- IL Pathways to Health Logo
- ILPTH Evidence Based Program Flyer
- Take Charge Series Program Flyer
- ILPTH Outreach Toolkit Template: This Toolkit includes templates for flyers, posters, social media posts, etc. You will need a Canva account to access the template and create a COPY to make edits (DO NOT EDIT THE TEMPLATE). If you need help, refer to our ILPTH Outreach Toolkit User Guide.