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[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? 

□ 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. 

3. Since this program began, how many times have you fallen? □ None ____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 □ 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. 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 
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Participant Post Program Survey (continued) 

6. Please use an X to tell us how sure you are that you can do the following activities. 

Activities: Not at all sure Somewhat sure Neutral Sure Very Sure 

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

b. I can find a way to reduce falls 

c. I can increase my flexibility 

d. I can increase my physical strength 

e. 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 

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. 

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 of 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. 

□ 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. 

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 is estimated to average 6 minutes per response, including time for gathering and 

maintaining the data needed and completing and reviewing the collection of information. The obligation to respond to this collection is required to retain or maintain 

benefits under the statutory authority of the Older Americans Act and Patient Protection and Affordable Care Act. OMB Control No. 0985-0039. Exp. Date 04/30/2024