Post Session Survey

[Program Name] Participant Post Program Survey
Public Burden Statement:
According to the Paperwork Reduction Act of 1995, 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
averages and estimate of .10 hours per response, including time for gathering, maintaining the data, completing, and reviewing
the collection of information. The obligation to respond to this collection is voluntary.

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

2. How often do you feel lonely or isolated from those around you?
Never
Rarely
Sometimes
Often

Poor

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.
None

3. Since this program began, how many times have you fallen?

______times

If you fell since the program began:
a. how many of these falls caused an injury? (By an injury we mean the fall 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. Did you tell anyone, such as a family member, friend, or healthcare provider about this fall,
whether or not it resulted in an injury?
Yes
______No
c. what happened after you fell? (Please check all that apply)
Went to the Emergency Room
Visited my Primary Care Physician
4. How fearful are you of falling?
Not at all
A little

Somewhat

Was admitted to the hospital
Did not seek medical care

A lot

5. During the last 4 weeks, to what extent has your concern about falling interfered with your normal social
activities with family, friends, neighbors or groups?
1|Page

Not at all

Slightly

Moderately

Quite a bit

Extremely

6. Please use an X to tell us how sure you are that you can do the following activities.
Not at all
sure
a.
b.
c.
d.
e.

Somewhat Neutral
sure

Sure

Very Sure

I can find a way to get up if I fall
I can find a way to reduce falls
I can increase my flexibility
I can increase my physical strength
I can become more steady on my feet

7. What best describes your activity level?
Vigorously active for at least 30 min, 3 times per week
Moderately active at least 3 times per week
Seldom active, preferring sedentary activities
8. Please use an X to tell us your thoughts about this program.
As a result of this program:

Strongly
Disagree

Disagree Neither agree Agree Strongly
nor disagree
Agree

a. I feel more comfortable talking to my
health care provider about my medications
and other possible risks for falling.
b. I feel more comfortable talking to my
family and friends about falling.
c. I feel more comfortable increasing
my activity.
d. I feel more satisfied with my life.
e. I would recommend this program to a
friend or relative.
f. I have reduced my fear of falling.
g. I plan to continue to exercise.
h. I have made safety modifications in my
home, such as installing grab bars or
securing loose rugs.
9. Since this program began, what have you done to reduce your chance of a fall? Check all that apply
Talked to a family member or friend about how I can reduce my risk of falling
Talked to a health care provider about how I can reduce my risk of falling
2|Page

Had my vision checked
Had my medications reviewed by a health care provider or pharmacist
Participated in or plan to participate in another fall prevention program in my community

3|Page