Take Control of Your Health
Peer Leader Contact Information and Training Verification
Site Name

County

Training Dates

Host Organization

Address

City

Zip Code

Master Trainer

Master Trainer

Master Trainer

Program Type: Chronic Disease Self-Management Program Tomando Control De Su Salud

Diabetes Self-Management Program Manejo Personal de la Diabetes Cancer Thriving and Surviving

Language

NAME OF PEER LEADER	STREET ADDRESS,

CITY, ZIP	AGENCY	COUNTY	TELEPHONE NUMBER

AND

E-MAIL ADDRESS	ATTENDANCE

DAY
1	2	3	4

Complete at Peer Leader Training and submit to NJDHS (see below) within 2 weeks of Training Day 4

ACS-23	Return completed form to Andrew Biederman via email at andrwe.biederman@dhs.state.nj.us or via fax to 609-588-7630.

FEB 19

ACS-23, Peer Leader Contact Information and Training Verification

ACS-23, DAS, take control of your health, TCYH, peer leader, contact information, training verification

Windows User

2016-09-16

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