HTML Print / Save as PDF

Organization Name: ELECTRICODE AGUADA ORGANIZATION INC. (DBA LAST CHANCE)[cite: 89]	CDC DPRP Organization Code: 1216358[ cite: 89 ]
Delivery Mode: In-Person with Distance Learning[ cite: 89 ]	Effective Date: August 01, 2026[cite: 89]
Primary Lifestyle Coach: Heriberto Echevarria ( ADA/NDPP Certified ) [ cite: 89 ]	Biannual Reporting Windows: Feb 1–28 / Aug 1–31[cite: 89]

Cohort ID: EAO-2026-____	Cohort Start Date: ___/___/2026	Participant ID (Unique): ______________	Enrollment Status: [ ] New [ ] Active [ ] Dropped
Participant Name: _____________________________________		DOB: ______/______/______	Phone: (_____) _______-______
Email: ______________________________________________		Payer Type: [ ] Medicare (MDPP) [ ] Medicaid [ ] Commercial [ ] Self-Pay
Primary Eligibility: [ ] Blood Test (HbA1c 5.7–6.4% or FPG 100–125 mg/dL) [ ] Gestational Diabetes History (GDM) [ ] CDC/ADA Prediabetes Risk Score ≥ 5		Demographics & Baseline Metrics: Gender: [ ] M [ ] F [ ] Other | Ethnicity: [ ] Hisp/Latino [ ] Non-Hisp Race: [ ] White [ ] Black [ ] Asian [ ] AI/AN [ ] NH/PI Height: _______in | Baseline Weight: ____ lbs | Baseline BMI: ____

Sess #	Date (MM/DD/YY)	Weight (lbs)	PA Mins (Wkly)	Delivery Mode	Session / Module Focus
1				[ ] IP [ ] DL	Core 1: Welcome & Program Overview
2				[ ] IP [ ] DL	Core 2: Be a Fat & Calorie Detective
3				[ ] IP [ ] DL	Core 3: Three Ways to Eat Less Fat / Cal
4				[ ] IP [ ] DL	Core 4: Healthy Eating & Portions
5				[ ] IP [ ] DL	Core 5: Move Those Muscles (Activity)
6				[ ] IP [ ] DL	Core 6: Being Active - A Way of Life
7				[ ] IP [ ] DL	Core 7: Tip the Weight Balance Scale
8				[ ] IP [ ] DL	Core 8: Take Charge of What's Around You
9				[ ] IP [ ] DL	Core 9: Problem Solving & Triggers
10				[ ] IP [ ] DL	Core 10: Four Keys to Healthy Eating Out
11				[ ] IP [ ] DL	Core 11: Talk Back to Negative Thoughts
12				[ ] IP [ ] DL	Core 12: The Slippery Slope of Lifestyle Change
13				[ ] IP [ ] DL	Core 13: Jump Start Your Activity Plan
14				[ ] IP [ ] DL	Core 14: Make Social Cues Work for You
15				[ ] IP [ ] DL	Core 15: You Can Manage Stress
16				[ ] IP [ ] DL	Core 16: Ways to Stay Motivated
M1 (17)				[ ] IP [ ] DL	Maintenance Month 7: Staying Active
M2 (18)				[ ] IP [ ] DL	Maintenance Month 8: Balance & Variety
M3 (19)				[ ] IP [ ] DL	Maintenance Month 9: Handling Stress
M4 (20)				[ ] IP [ ] DL	Maintenance Month 10: Staying Motivated
M5 (21)				[ ] IP [ ] DL	Maintenance Month 11: Preventing Relapse
M6 (22)				[ ] IP [ ] DL	Maintenance Month 12: Looking Ahead

Total Sessions (Mo 1–6): _______ (Min: 9)	Total Sessions (Mo 7–12): _______	Total Weight Loss: _______ lbs (_______ %)
Starting Weight: _______ lbs	Final Weight: _______ lbs	Avg Physical Activity: _______ mins/wk (Goal: ≥150)

Instructions to Print or Save as PDF 1. Copy the code block above (from  to