Participant Information Form

[Program Name] Participant Information Form
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. Did your health care provider suggest that you attend this program?
2. How old are you today?
3. Do you live alone?

 Yes

 Yes

 No

years

 No

4. Are you a Caregiver of an older adult?
5. Are you of Hispanic, Latino, or Spanish origin?

 Yes

 No

 Yes

 No

6. What is your race? Check all that apply.
American Indian or Alaska Native
Asian
Black or African American

Native Hawaiian or other Pacific Islander
White
Other (please specify)

7. What is the highest grade or level of school that you have completed?
Some elementary, middle, or high school
High school graduate or GED

Some college or technical school
College (4 years or more)

8. Has a health care provider ever told you that you have any of the following chronic or progressive
conditions (i.e., one that has lasted for three months or more)?
YES NO
YES NO
Alzheimer’s Disease or other
Mental health condition
YES
dementia
Anemia
Obesity
Arthritis/Rheumatic Disease
Osteoporosis (Low Bone Density)
Asthma/Emphysema/Other
Parkinson’s Disease
Chronic Breathing or Lung
Problem
Cancer or Cancer Survivor
Stroke
Chronic Pain
Sudden Weight Loss
Diabetes (High Blood Sugar)
Traumatic Brain Injury
Hearing Loss
Urinary Incontinence
Heart Disease
Vision Impairment
High Cholesterol
Other Chronic or Progressive Conditions
Hypertension (High Blood
Pressure)
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9. In general, would you say that your health is:

 Excellent  Very Good

 Good

 Fair

 Poor

 Often

 Always

10. How often do you feel lonely?

 Never

 Rarely

 Sometimes

11. 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.
12. In the past 3 months, how many times have you fallen? ____times

 None

If you fell in the past three months:
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

13. In the past 3 months, 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

14. How confident are you today that you can do the following activities without falling?
Activity

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
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15. 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)
16. What is your current gender (select one)?

 Man
 Woman
 Non-binary
 Other (please specify) ____________________
 Prefer not to answer
17. Do you consider yourself to be transgender?

 Yes  No  Prefer not to answer
18. Which of the following best represents how you think of yourself? [Select ONE]

 Lesbian or gay
 Straight, that is, not gay or lesbian
 Bisexual
 [If respondent is AIAN:] Two-Spirit
 I use a different term (please specify) _________________
 Don’t know
 Prefer not to answer

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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