Dear Living Well Workshop Facilitators

Dear Living Well Workshop Facilitators

Living Well with Chronic Conditions

Letter to Workshop Leaders Regarding Evaluation of the Living Well Program

Dear LivingWellLeader:

Good luck with your upcoming workshop!

These Questionnaires will help us to determine who is being reached by this program and how to improve our services. It also helps our funding agencies show that they are spending their money wisely.

Filling out the questionnaires or release form is completely voluntary and is not required to participate in the program. Participants’ names and contact information will be kept confidential. Please send completed questionnaires to:WIHA Data, Wisconsin Institute for Healthy Aging, 1414 MacArthur Road, Suite B, Madison,WI 53714.

When distributing the questionnaires at the first session, please read this Script’s 11 points:


  1. This workshop is made possible, in part, by a grant from the U.S. Administration on Community Living (ACL) and the Wisconsin Department of Health Services.
  2. We would like to give you aDemographic Questionnaire. It is optional for you to complete it.
  3. Before we can share your information with ACL and its database contractor, the National Council on Aging, we want to explain how your information will be used and protected.
  4. Your information is very valuable to us. We use it to learn who is being reached by this program and to improve our services. It also helps our funding agencies show that they are spending their money wisely.
  5. On the first page of the Questionnaire, pages, we ask for your name. We will assign you a number, which we will then to match your information to an Attendance Log to track how many times you attend a class. We do not share your name with anyone else.
  6. The Questionnaire also asks you to provide information such as your birth date, zip code, and gender. You may skip any questions that you do not want to answer. While doing the Questionnaire, you may ask us to explain any questions that you find confusing.
  7. We follow very strict rules to protect all of your information and to keep it private. We will maintain these paper forms securely following standard practices for protecting private data. After a trained person enters your information into a secure computer database, we will destroy the paper forms
  8. Completing the Questionnaire is entirely voluntary. If you decide not to complete the Questionnaire you can still participate in this program.
  9. Please take time now to read the Survey and let us know if you have any questions.
  10. Along with the Questionnaire there is an information sheet that explains what the Questionnaire is for and what it involves. Please read it before you fill out the questionnaire.
  11. Please return the Questionnaire before leaving today. I will review them for completeness and then I will mail them to the program evaluator. I will not be keeping track of your answers.


Thank you for your help!


Jane Mahoney, MD

UW Department of Medicine-Geriatrics

Executive Director, Wisconsin Institute for Healthy Aging

12/25/18Bring Healthy Aging to Scale (B-HAS)