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Breathe Well, Live Well Program Report Form

Thank you for leading a Breathe Well, Live Well program session. Please complete this form within 30 days of completing a program. This information is for informational program purposes only and will be part of overall program reporting. Contact information will not be shared without your prior consent.

1. Facilitator Information *This question is required.

First Name
Last Name
Email Address
Organization
State
Zip Code

2. Primary Setting for Education *This question is required.

Client's home
Clinic
Community center
Hospital
Phone-based
Workplace
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.

3. Education start date *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

4. Education end date *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

5. Total number of Breathe Well, Live Well participants *This question is required.

6. Racial and Ethnic Demographics of Participants (please enter total number for each category) *This question is required.

Asian, Native Hawaiian or Pacific Islander
Black or African American
Hispanic or Latino
Native American/Alaskan Native
White

7. Age of Participants (please enter number of participants for each category) *This question is required.

Young Adult (age 18-25)
Adult (age 26-64)
Elderly (age 65+)

8. Primary location of asthma care for participants (please enter total number for each category) *This question is required.

Regular Primary Care Doctor
Asthma Specialist (allergist or pulmonologist)
Community Clinic
Hospital Emergency Department
University/College Health Center
Other (please specify)

9. Please describe a meaningful experience or success as a facilitator or about your participants from the implementation of the Breathe Well, Live Well program: *This question is required.

10. What would make the Breathe Well, Live Well curriculum/materials more useful to you? *This question is required.

11. What additional support from the Lung Association would be helpful to you to provide future Breathe Well, Live Well program sessions? (choose all that apply) *This question is required.

Online support
Local Lung Association staff support
Training refresher course
Other - Write In Please enter an 'other' value for this selection.