Walk With Ease: The First Step to Better Health
Class Coversheet
Please complete this form for each lesson delivered and return it to the OSU Extension Office. Completed forms
should be forwarded to Jamie Davis, Lake County Extension Service, 103 South “E” Street, Lakeview, OR 97630.
County: _________________________
Class Date: ________________________________
Number of Participants: ____________
Location of Class: ___________________________
Instructor Type: ___ Volunteer ___ FCH Faculty or Staff ___ Other? ______________________
Name of FCH Faculty or Staff Member: _____________________________________________
Was the provided evaluation completed?
___ Yes ___No
If evaluations were completed, would you like specific county results tabulated for you?
___ Yes ___No
As an instructor, please provide any comments regarding this lesson:
Note to FCH Faculty and Staff: If sufficient data is collected, a collective impact statement for this lesson
would be created and those who provided data will be included as a collaborator.