Sample Documents for AGD PACE Applications

The PACE application includes a total of 88 questions: 62 on Form A, 16 on Form B, and 10 on Form C (national providers only). Of these questions, 18 questions ask providers to include sample documentation. (Note: Providers only need to submit the samples that are applicable to their program.)

The Committee on PACE has developed several sample documents that providers can reference and use as examples of the type of samples they should be using in their programs and submitting with their applications.

• If providers are not currently using one of the documents required, they are encouraged to develop the document and begin using it in their program.

• Providers may modify the examples provided by the Committee on PACE to best fit their needs.

Sample documents available:

• Job Descriptions
• Goals Statements
• Needs Assessment Survey
• Course Evaluation Form
• Course Objectives
• Course Verification Form
• Course Roster
• Publicity Brochure
• Guidelines for Commercial Support
• Disclosure Letter
• Conflict of Interest Disclosure
• Consent Form
• Affidavit of Image Authenticity
• Publicity Template Full Page
• Publicity Template Half Page
• Publicity Template