56 Falls Efficscy Scale-International

Attachment 56
Falls Efficacy Scale – International (Short FES-I)

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX

Falls Efficacy Scale-International (Short FES-I) - Adults
Estimated time burden: 2 minutes

[Intro- Short FES-I]

On the next screens, we will ask you some questions about how concerned you are
about the possibility of falling. When you answer, think about how you usually do the
activity. If you currently don’t do the activity (e.g., if someone does your shopping for
you), please think about how concerned you would be about falling IF you did do the
activity.
Choose the answer that best shows your concerns. After you make your choice, the
computer will automatically go on to the next question. If you want to change your
answer, click on the GO BACK button to return to the previous question and then
choose a different answer. 1
Click on the CONTINUE button when you are ready to begin.

[01- Short FES-I]

How concerned are you about falling when getting dressed or undressed?
Not at all Concerned
Somewhat Concerned
Fairly Concerned
Very Concerned

Public reporting burden for this collection of information is estimated to average 2 1/2 hours per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD
20892-7974, ATTN: PRA (0925-xxxx*) EXP: (xx/xxxx). Do not return the completed form to this address.

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[02- Short FES-I]

How concerned are you about falling when taking a bath or shower?
Not at all Concerned
Somewhat Concerned
Fairly Concerned
Very Concerned

[03- Short FES-I]

How concerned are you about falling when getting in or out of a chair?
Not at all Concerned
Somewhat Concerned
Fairly Concerned
Very Concerned

[04- Short FES-I]

How concerned are you about falling when going up or down stairs?
Not at all Concerned
Somewhat Concerned
Fairly Concerned
Very Concerned

[05- Short FES-I]

How concerned are you about falling when reaching for something above your head
or on the ground?
Not at all Concerned
Somewhat Concerned
Fairly Concerned
Very Concerned

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[06- Short FES-I]

How concerned are you about falling when walking up or down a slope?
Not at all Concerned
Somewhat Concerned
Fairly Concerned
Very Concerned

[07- Short FES-I]

How concerned are you about falling when going out to a social event (e.g., religious
service, family gathering or club meeting)?
Not at all Concerned
Somewhat Concerned
Fairly Concerned
Very Concerned