Recolección de datos /Data Collection

Recolección de datos
Encuesta de la primera sesión:Esta encuesta es confidencial. La utilizamos para medir a quien estamos sirviendo en la comunidad. La encuesta hace preguntas sobre la salud e información demográfica. 

Encuesta para participantes en la sexta sesión: Anime a cada participante a que la llene en la última sesión. Recójala y revísela para sus propios propósitos.


Data Collection

Session One Survey (PDF) 03.01.2018 : This survey is confidential. We use it to measure who we’re serving. The survey asks about health and demographic information.

Session Six Participant Survey: Invite each participants to complete at Session Six, then collect and review for your own purposes. And in English




Below are the files and instructions for Tomando Control de Su Salud data collection. In short, WIHA will send a packet with everything you need to do the data collection (instructions and 12 pre-printed surveys) when your Workshop Notification Form is completed. 
Data Collection Packets will be sent 1-2 weeks before the start of the workshop to the person listed on the said form.


Data Collection Instructions  (PDF )

The Health & Demographic Survey is given out at Session One. These surveys 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. They are completely voluntary and is not required to participatein the program. Participants’ names and contact information will be kept confidential.


Tips & Talking Points and Why data collection is important (PDF )


  • During reminder calls, ask participants to come at least 15 minutes prior to the start time to fill out a short survey.
  • If new participants arrive at the second session, please ask them to fill out the Baseline Questionnaire before you start Session 2.

Talking points to say to participants:

  • This survey asks questions about you and your health.  We would appreciate it if you would complete the survey, but it is up to you.  Feel free to skip any questions you don’t want to answer.
  • We ask you these questions for a few reasons: Understand who comes to the workshops. Help health providers work more effectively with their patients. Understand if we make a difference in your health or how you take care of yourself. And to ask health plans, employers and foundations to help support the program – keeping them low-cost to the community. Completing the Questionnaire is entirely voluntary. If you decide not to complete the Questionnaire you can still participate in this program. 
  • We follow very strict rules to protect all 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.
  • While doing the Questionnaire, you may ask us to explain any questions that you find confusing.
Attendance Log  (PDF )
Leaders: Mark on the sign-in sheet who completed the Health & Demographic Survey as well as weekly attendance.
Return completed forms to your Program Coordinator or local organization.
They will send a copy to WIHA:
Wisconsin Institute for Healthy Aging
1414 MacArthur Road, Suite B Madison, WI 53714


Health & Demographic Survey (PDF October 2018)

Make copies and distribute to each participant at the first session.  Leaders will collect completed Demographic Questionnaires, review for completeness, ask individuals to complete any missing sections, and store in a safe place.  Send to WIHA, with a photocopy of the Attendance Log, after the sixth session.  



The following forms are optional (but encouraged) to administer: 

Provider Feedback Letter template: Optional. Hand out at the end of Session 5. Helps provide feedback about the workshop. Acts as a template for participants to share what they've learned from this workshop with their health care team.


Session Six Evaluation: Optional. Template. Invite each participants to complete at Session Six, then collect and review for your own local purposes.

If you have any questions about the data collection process, please contact us at WIHA right away: or 608-243-5694.

Program Fidelity

Fidelity Tool: Fidelity Coach will use this if/when there is a Fidelity Coaching session being administered - generally conducted at Session 3. They will let you know in advance.