Healthy Movement Quarterly Reporting

This form will be used for quarterly reporting on the Healthy Movement Project. Programs should submit one response per site where a bike is placed. Responses to these questions are due quarterly, within 30 days after the end of each quarter, beginning July 1 2019. Quarter 1 report due by 10/31, Q2 report due 1/31, Q3 report due 4/30, Q4 report due 7/31.

ReportingPeriod*

Select

Company Name

Select or enter value

SiteName*

Type in the name of the site where the bike is located (i.e. Trillium Day Program or Shipyard Blvd Home). The name should match the name provided for the site on the RFA.

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Program Contact Person

Provide the name and job title of the person responsible for orienting members to using the bike, accessing online classes, and reporting any problems with the bikes.

Bike In Use (during COVID)*

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Members Enrolled in the Program

Enter the total number of Trillium members that are enrolled in the program this quarter. For Wellness Cities, report on "active participants" anywhere that "Trillium members" are mentioned.

Healthy Movement Members Engaged

Enter the total number of Trillium members that used the bike(s) during this reporting period.

Healthy Movement Planning

Number of Trillilum members this quarter who have use of the bike in their Person Centered Plan/Wellness Plan.

Healthy Movement Encouraged

Provide at least one (more if possible) example of how the bikes are promoted to members and/or incorporated into the program schedule.

Healthy Movement Impacts

Provide at least one specific example of how use of the bike has impacted a member (do not include PII). Examples: one male member, 38 yo, lost 5 lbs in one month; two members challenged each other to cycle 10 miles in 1 week; a female member was able to use bike on her own after needing assistance for balance.

Bike damage/repair

Provide any information on damage to the bike & repairs provided. Example: pedal came off 10/4, reported to Trillium 10/5, repair scheduled for 10/22. If none, enter N/A.

Other Information

Use this space to share any other information that Trillium should know about how this program is going at your site.

Healthy Movement Project Contact

The Trillium staff person leading the Healthy Movement Project is Cecelia Peers, cecelia.peers@trilliumnc.org. Any problems with submission of a report must be addressed via e-mail no later than 3pm on the due date in order for the report to be considered timely. Programs will be given 3 business days from the date the report issue is resolved to submit a complete report.

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