Att B-3. Falls Calendar & Log

Att B-3. Falls Calendar & Log.docx

Test Predictability of Falls Screening Tools

Att B-3. Falls Calendar & Log

OMB: 0920-1220

Document [docx]
Download: docx | pdf

Att B-3. Falls Calendar & Log


Form Approved

OMB No: 0920-xxxx

Exp. Date: xx-xx-xxxx


Public Reporting burden of this collection of information is estimated at 5 minutes 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 CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333; Attn:  PRA (0920-xxxx).


Falls Calendar – August 2017

As part of your participation in the Health and Stability Survey, at the beginning of every month you will be asked about your falls during the prior month. For purposes of these monthly surveys, a fall is being defined as an event that resulted in a person unintentionally coming to rest on the ground, floor, or other lower level. This calendar is therefore being provided to help you keep track of any falls so you can accurately complete these monthly surveys. Please check the “Fall” box for any days that you fell.


Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

1

2

3

4

5



Fall

Fall

Fall

Fall

Fall

6

7

8

9

10

11

12

Fall

Fall

Fall

Fall

Fall

Fall

Fall

13

14

15

16

17

18

19

Fall

Fall

Fall

Fall

Fall

Fall

Fall

20

21

22

23

24

25

26

Fall

Fall

Fall

Fall

Fall

Fall

Fall

27

28

29

30

31



Fall

Fall

Fall

Fall

Fall



Falls Tracking Log

Please provide the details of any falls you noted on the calendar in this log. Again, completing this information will help you accurately complete the monthly surveys for the Health & Stability Survey.


Date

Time

Location

Cause

Comments

Injuries

MM/DD/YY

  • Morning

  • Afternoon

  • Evening

  • Overnight

  • Inside of home

  • Outside of home (immediately outside door, in yard, etc.)

  • In community (away from home)

  • Trip

  • Slip

  • Loss of balance

  • Knees gave way

  • Fainted

  • Feeling dizzy or giddy

  • Alcohol or medications

  • Fell out of bed

  • Pets

  • Stairs

  • Unknown

  • Other (please specify)

Please provide any further description of the fall (e.g., what you were doing when it occurred, whether anyone was with you).

Please describe any injuries resulting from the fall and whether they required medical attention. Please indicate any treatment sought for these injuries (e.g., no treatment, doctor’s visit, ER, hospital).

1/1/17

AM

Outside home

Loss of balance

While taking walk around the neighborhood with dog.

Scraped hands, sprained knee. Doctor’s visit to check knee.




































































File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorMeg Wise
File Modified0000-00-00
File Created2021-01-21

© 2024 OMB.report | Privacy Policy