Falls Tracking Log

Attachment J. Falls Tracking Log

Falls Tracking Log

As part of your participation in the study, every few months you will be asked about your falls during the prior months. This log is being provided to help you keep track of any falls so you can accurately complete the surveys. This log is not required.

For purposes of these 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.

Example:

Date	Event	Injuries	Treatment
MM/DD/YY	Please include any falls you experienced even ones that did not result in an injury	Please note any injuries resulting from the fall that caused you to limit your regular activities for at least a day or to seek a health care professional	Please indicate any treatment sought for these injuries (e.g., no treatment, doctor’s visit, ER, hospital), and whether that treatment was provided by a [STUDY SITE] provider.
1/1/19	Fell	Hurt left knee.	Saw my doctor at [CLINIC NAME] to check my knee.
2/16/19	COMPLETED SURVEY	--------------------------------------------------------------------	------------------------------------------------------------------
4/19/19	Fell	None	None

Falls Tracking Log Start Date_______________

Please provide the details of any falls you experience in this log. Please fill out a row in the log for every fall that occurs. To help keep track of which falls you’ve already reported to the survey, please also record the date when you take each survey. An example is provided on the previous page.

Again, completing this information will help you accurately complete the surveys for the study

Date	Event	Injuries	Treatment
MM/DD/YY	Please include any falls you experienced even ones that did not result in an injury	Please note any injuries resulting from the fall that caused you to limit your regular activities for at least a day or to seek a health care professional	Please indicate any treatment sought for these injuries (e.g., no treatment, doctor’s visit, ER, hospital), and whether that treatment was provided by a [STUDY SITE] provider.