[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 or isolated from those around you?

O Never O Rarely O Sometimes O Often O 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.

3. Since this program began, how many times have you fallen? O none O 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? O Yes O No 

c. what happened after you fell? (Please check all that apply)

Went to the Emergency Room Was admitted to the hospital 

Visited my Primary Care Physician Did not seek medical care 

4. How fearful are you of falling? 

Not at all A little Somewhat A lot 

5. Please mark the circle that tells us how sure you are that you can do the following

activities. 

How sure are you that: 

Please turn this paper over and fill out the other side.

Not at all 

sure

Somewhat 

sure

Neutral Sure Very Sure

a. I can find a way to get up if I fall O O O O O

b. I can find a way to reduce falls O O O O O

c. I can increase my flexibility O O O O O

d. I can increase my physical strength O O O O O

e. I can become more steady on my feet O O O O O
Participant Post Program Survey (continued)

6. 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?

Not at all Slightly Moderately Quite a bit Extremely

7. Please tell us your thoughts about this program. Check one circle for each question. 

As a result of this program: Strongly

Disagre

Disagree Neither agree

nor disagree

Agree Strongly Agree

a. I feel more comfortable talking to

my health care provider about 

my medications and other

possible risks for falling

O O O O O

b. I feel more comfortable talking to

my family and friends about 

falling

O O O O O

c. I feel more comfortable

increasing my activity

O O O O O

d. I feel more satisfied with my life O O O O O

e. I would recommend this program

to a friend or relative 

O O O O O

f. I have reduced my fear of falling O O O O O

g. I plan to continue to exercise O O O O O

h. I have made safety modifications 

in my home, such as installing 

grab bars or securing loose rugs.

O O O O O

8. Since this program began, what have you done to reduce your chance of a fall? 

Check all that apply.

O Talked to a family member or friend about how I can reduce my risk of falling 

O Talked to a health care provider about how I can reduce my risk of falling

O Had my vision checked

O Had my medications reviewed by a health care provider or pharmacist

O Participated in or plan to participate in another fall prevention program in my community

9. What best describes your activity level? 

O Vigorously active for at least 30 min, 3 times per week

O Moderately active at least 3 times per week

 O Seldom active, preferring sedentary activities