Sample Documents

You can use the following sample documents while administering your program or  applying for PACE approval. Providers can modify these documents to best fit their needs.

If you’re not currently using one of the documents required, you’re encouraged to develop the document and begin using it in your program before applying or reapplying for approval.

Sample Documents:
Note: Providers only need to submit the samples that are applicable to their program.

• Job Descriptions
• Goals Statements
• Needs Assessment Survey
• Course Evaluation Form
• Course Objectives
• Course Verification Form
• Course Roster
• Publicity Brochure
• Publicity Template Full Page
• Publicity Template Half Page
• Guidelines for Commercial Support
• Outside Support Disclosure Letter
• Instructor Conflict of Interest Disclosure
• Patient Informed Consent Form
• Affidavit of Image Authenticity
• Provider Contact Information
• Joint Program Provider Responsibliity Checklist
• Joint Sponsorship Letter of Agreement
• PACE Logo Guidelines