Participant Post Session Survey

[Program Name] Participant Post Program Survey
Admin Use Only: Participant I.D.: The facilitator or program staff should complete this part of the form and mark the
sequential number of the participant to the name on the attendance form.
State abbreviation : __ __ (e.g., NY, VA, etc.)
First four letters of the site name : __ __ __ __
Start date of program : __ __ / __ __ / __ __ (e.g., 12/01/19)
Participant number : __ __ (e.g., 01, 02, 03, etc.)

1. In general, would you say that your health is:

 Excellent  Very Good

 Good

 Fair

 Poor

2. How often do you feel lonely?

 Never

 Rarely

 Sometimes

 Often

 Always

3. How often do you feel isolated from those around you?

 Never

 Rarely

 Sometimes

 Often

 Always

The next few questions ask about falls. By a fall, we mean when a person unintentionally comes to rest
on the ground or another lower level.
4. Since this program began, how many times have you fallen?

____times

 None

If you fell since the program began:
a. how many of these falls caused an injury? (Caused you to limit your regular activities for at least a
day or to go see a doctor.)
number of falls causing an injury
b. what happened after you fell? (Please check all that apply)

 Told a family member or friend
 Went to an Urgent Care Center
 Was admitted to the hospital

 Visited my Health Care Provider
 Went to the Emergency Room
 Did not seek medical care

5. Since this program began, has your concern about falling interfered with your normal social activities with
family, friends, and neighbors (e.g., avoiding situations with stairs or uneven ground)?

 Not at all

 A little

 Somewhat  A lot

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6. How confident are you today that you can do the following activities without falling?
Activities

Very
Confident Somewhat Fairly
Not at all
Confident
Confident Confident Confident
1
2
3
4
5

Take a bath or shower
Reach into cabinets or closets
Walk around the house
Prepare meals
Get in and out of bed
Answer the door or telephone
Get in and out of a chair
Getting dressed and undressed
Personal grooming (i.e., washing your face)
Getting on and off the toilet
Total Score
7. What best describes your physical activity level?
 Vigorous-intensity activity at least 3 times per week (jogging, shoveling snow, fitness class)

 Moderate-intensity activity at least 3 times per week (brisk walking, raking the yard)
 Light-intensity activity (slow walk, cooking, light household chores)
 Seldom active (preferring sedentary activity, such as watching TV)
8. Please use an X to tell us your thoughts about this program.
Strongly
Disagree

As a result of this program:

Disagree Neither agree Agree Strongly
nor disagree
Agree

a. I am more comfortable talking to my health care
provider about my medications and other possible
risks for falling.
b. I am more comfortable talking to my family and
friends about falling.
c. I plan to continue to exercise.
d. I plan to participate in another fall prevention
program.
e. I was satisfied with the program.
f. I would recommend this program to a friend or
relative.
Paperwork Reduction Act Public Burden Statement: According to the Paperwork Reduction Act of 1995 5 CFR § 1320.8(b)(3), no persons are required to respond to a collection of information
unless such collection displays a valid OMB control number (OMB 0985-0039). Public reporting burden for this collection of information is estimated to average 0.10 hours per response, including
time for gathering, maintaining the data needed, completing, and reviewing the collection of information. The obligation to respond to this collection is required to retain benefits under the
statutory authority of the Older Americans Act and Patient Protection and Affordable Care Act. The Administration for Community Living (ACL) will use the set of data collection tools to monitor
grantees receiving Evidence-Based Falls Prevention Program cooperative agreements. Data will be kept private to the extent allowed by law. There are no assurances of confidentiality. Send
comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Administration for Community Living, U.S.
Department of Health and Human Services, 330 C Street, SW, Washington, DC 20201-0008, Attention: Office of Nutrition and Health Promotion Programs (ONHPP), and reference the OMB Control
Number 0985-0039. Note: Please do not return the completed Evidence-Based Falls Prevention Program cooperative agreements to this address.

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