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Protocol - Falls

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Description:

The respondent views a monthly calendar and notes the dates on which he or she fell to the ground during that month. Then, after the respondent receives the calendar by mail, an interviewer calls the respondent and asks a series of questions about each fall that appears on the calendar.

Protocol:

COMPLETE THIS FORM FOR EACH FALL REPORTED ON THE FALL CALENDAR.

DATE OF FALL: __ __ /__ __/__ __ __ __ (MM/DD/YYYY)

IF MULTIPLE FALLS ON THIS DATE: (this survey is with regard to the # fall) ____ of (total # falls) ___ on this date

DATE OF INTERVIEW:__ __ /__ __/__ __ __ __ (MM/DD/YYYY)

Hi, this is [INTERVIEWER NAME] from the Mobilize Boston Study. How are you? I am calling to thank you for sending us the Falls Calendar that you completed for the month of [MONTH]. These questions should take only a few minutes:

IF ONE FALL, SKIP TO QUESTION 1.

IF MORE THAN ONE FALL:

I am going to ask you a series of questions about each fall you reported. First, I would like to ask you some questions about your most recent fall, which occurred on [DATE OF MOST RECENT FALL].

GO TO QUESTION 1.

[FOR EACH SUBSEQUENT FALL USE A NEW SURVEY FORM (MOVING FROM MOST RECENT TO MOST REMOTE FALL), SAY:]

We also note that you fell on [DATE OF FALL]. Now I would like to ask you about that fall.

1. Could you please describe to me, what happened when you fell on [DATE OF FALL].

[RECORD R'S RESPONSE VERBATIM.]

[Proceed to administer PROBES 1A-1E on an AS NEEDED basis.]

Probe 1A. What were you doing (when you fell)?

[RECORD R'S RESPONSE VERBATIM.]

Probe 1B. Where were you (exactly) when you fell?

[RECORD R'S RESPONSE VERBATIM.]

If R already provided you with the information that fall occurred either inside or outside, then skip Probe 1C. If R did NOT provide you with the information that fall occurred either inside or outside, then probe. Check the answer even though not read.

Probe 1C. Did the fall happen inside, or outside?

[ ] 1 Inside

[ ] 2 Outside

[ ] 8 Refused

[ ] 9 Don't know/non-valid response

Probe 1D. [IF INSIDE FALL] Was the surface of the ground (floor) that you fell on wet or dry?

[IF OUTSIDE FALL] Was the surface of the ground (floor) that you fell on wet, dry, icy, or have snow?

[RECORD R'S RESPONSE VERBATIM.]

[ ] 8 Refused

[ ] 9 Don't know/non-valid response

Probe 1E. When you fell, did you slip or trip on something (such as table leg, irregularity in floor or sidewalk surface, step, curb, ladder, clothing, or pet)? RECORD YES OR NO.

[ ] 0 No

[ ] 1 Yes

[ ] 8 Refused

[ ] 9 Don't know/non-valid response

Next, I'd like to ask you a few more specific questions about your fall. You may already have told me some of this, but I need to make sure I have everything.

2. Did you fall all the way fall to the floor, ground or other lower level when you fell?

[ ] 0 No, participant did not fall to the ground [GO TO Q3]

[ ] 1 Yes, participant fell all the way to the ground [GO TO Q3]

[ ] 8 Refused [GO TO Q3]

[ ] 9 Don't know/non-valid response [GO TO Q3]

3. What type of shoes were you wearing (if any) when you fell?

[READ CHOICES ONLY IF NEEDED. IF R ANSWERS ANY RESPONSE OTHER THAN THE SEVERAL LISTED, SELECT (14) OTHER AND RECORD ANSWER VERBATIM IN SPACE PROVIDED.]

[ ] 1 Barefoot, wasn't wearing shoes or socks

[ ] 2 Socks, stockings, nylons or hose

[ ] 3 Athletic shoes, sneakers (tied or Velcro)

[ ] 4 Keds or similar flat-sole canvas shoe (tied or Velcro)

[ ] 5 Tied oxford shoes, or other tied shoe or buckle shoes (tied or Velcro)

[ ] 6 Slip-on shoe, loafer

[ ] 7 Slippers

[ ] 8 Pumps or high-heels

[ ] 9 Sandals

[ ] 10 Work boot or other boot with shoelaces

[ ] 11 Boots (pull-on)

[ ] 12 Thongs or flip-flops

[ ] 13 Special shoe (molded, brace, Aliplast shoe)

[ ] 14 Other, specify: ____________________

[ ] 88 Refused

[ ] 99 Don't know

If the fall was OUTDOORS, GO to Q4.

ou fell? (Were you

[ ] 1 Just outside your home?

[ ] 2 Not right outside your home, but on the same block as your home? (within 400 feet)

[ ] 3 More than a block from home, but within 6 blocks (½ mile) of your home? (more than 400 feet, but less than ½ mile)

[ ] 4 More than 6 blocks (½ mile) away from your home?

[ ] 8 Refused

[ ] 9 Don't know/non-valid response

5. Was the lighting good enough for you to see well, when you fell?

[ ] 0 No

[ ] 1 Yes

[ ] 8 Refused

[ ] 9 Don't know/non-valid response

6. Did you fall because of a health, or medical problem?

[ ] 0 No [SKIP TO Q8 DIZZY]

[ ] 1 Yes

[ ] 8 Refused

[ ] 9 Don't know/non-valid response

7. [IF YES] What was the health or medical problem? [RECORD VERBATIM]

8. Were you feeling dizzy or lightheaded when you fell?

[ ] 0 No

[ ] 1 Yes

[ ] 8 Refused

[ ] 9 Don't know/non-valid response

9. Did you faint, pass out, blackout or lose consciousness?

[ ] 0 No

[ ] 1 Yes

[ ] 8 Refused

[ ] 9 Don't know/non-valid response

10. Did you hurt yourself in any way when you fell?

[ ] 0 No [SKIP TO Q15 EMERGENCY ROOM]

[ ] 1 Yes

[ ] 8 Refused

[ ] 9 Don't know

11. [If YES] Did you break or fracture a bone? [If not sure, Probe: "Were you told by a doctor, or other health professional, that you fractured a bone?"]

[ ] 0 No [Skip to Q13 OTHER INJURY]

[ ] 1 Yes

[ ] 8 Refused

[ ] 9 Don't know

12. [IF YES] What bone(s) did you break or fracture? [do not read list, but check all that R mentions that doctor said fractured]

[ ] a Head/skull

[ ] b Face

[ ] c Neck or collar bone

[ ] d Ribs

[ ] e Back/ spine/ vertebrae

[ ] f Shoulder/ Upper arm

[ ] g Elbow

[ ] h Lower arm

[ ] i Wrist

[ ] j Hand/fingers

[ ] k Pelvis

[ ] l Hip

[ ] m Upper leg/ femur

[ ] n Knee

[ ] o Lower leg

[ ] p Ankle

[ ] q Foot/ toes

[ ] r Other

13. Now I am going to read, a list of some injuries, you may have had from your fall. Can you tell me, yes or no, if you had a:?

[READ ALL RESPONSES AND CHECK ANY THAT R RESPONDS YES]

[ ] a Dislocated joint?

[ ] b Sprain, pulled, or torn muscle, tendon or ligament?

[ ] c Bruise or swelling?

[ ] d Cut or Scrape?

[ ] e Another injury? [SPECIFY BELOW]

[ ] 8 Refused

[ ] 9 Don't know/non-valid response

14. [IF ANOTHER INJURY] Probe: Can you describe the injury? [RECORD VERBATIM.]

________________________________________________________

15. Did you go to the Emergency Room, or to the office of a doctor, or other health professional, because of the fall?

[ ] 0 No [next question]

If yes, Probe: Did you go to the emergency room, or doctor's office (or both)?

[ ] 1 Yes, Emergency Room

[ ] 2 Yes, Doctor's Office

[ ] 3 Yes, both the ER and the Doctor's Office

[ ] 8 Refused

[ ] 9 Don't know

16. Were you admitted for an overnight stay, or longer, in the hospital following your fall?

[ ] 0 No

[ ] 1 Yes

[ ] 8 Refused

[ ] 9 Don't know

[If only one fall or final fall reported]

That was our last question. Thank you for answering these important questions for the MOBILIZE BOSTON study.

Do you have any questions before we hang-up?

Great, be well, and thank you for continuing to participate in this important study.

OR

[IF MORE FALLS WERE REPORTED]

We are now finished with the questions for this fall: Now I'd like to move on to our next set of questions. You also recorded a fall on: [...SEE SCRIPT ON PAGE 1]

FOLLOWING SECTION (QUESTIONS 17-23 TO BE COMPLETED BY MOBILIZE BOSTON RESEARCH STAFF AFTER COMPLETING PHONE INTERVIEW WITH RESPONDENT. CODING RESPONSES BASED ON RESPONDENT'S Q1 VERBATIM DESCRIPTION OF FALL AND ANSWERS TO PROBES 1A-1E.

17. Identify the ONE response that best describes what participant was doing when s/he fell. (See Probe 1A.)[CHECK ONLY ONE RESPONSE]

[ ] 1 Stepping on, or off, a curb;

[ ] 2 Getting into, or out of, a car or other vehicle

[ ] 3 Going up stairs (including a stoop)

[ ] 4 Going down stairs (including a stoop)

[ ] 5 Getting onto, or out of, a chair, sofa, bed or toilet;

[ ] 6 Walking;

[ ] 7 Standing

[ ] 8 Sitting or lying

[ ] 9 Other (not included above)

[ ] 88 Refused

[ ] 99 Don't know/non-valid response

18. Select the ONE response that best describes the location of where the fall occurred. (See Probes 1B-1C.)[CHECK ONLY ONE RESPONSE]

[ ] 1 Inside own home

[ ] 2 Inside someone else's home

[ ] 3 Inside other building

[ ] 4 Inside, other (e.g. train, subway, bus)

[ ] 5 Outdoors [SKIP TO Q 20]

[ ] 8 Refused

[ ] 9 Don't know/non-valid response

19. [If the fall occurred INSIDE,] Identify specific location of inside fall. (See Probes 1B.)

[CHECK ONLY ONE RESPONSE]

[ ] 1 Hallway

[ ] 2 Bathroom

[ ] 3 Bedroom

[ ] 4 Living room

[ ] 5 Dining room

[ ] 6 Kitchen

[ ] 7 Basement or Cellar

[ ] 8 Stairs/Stairwell (Inside)

[ ] 9 Escalator

[ ] 10 Moving Walkways (e.g., airport walkway)

[ ] 11 In a Train/Bus

[ ] 12 Other inside location

[ ] 88 Refused

[ ] 99 Don't know/non-valid response

20. [If the fall occurred outside,] Identify specific location of outside fall.

(See Probe 1B.)

[ ] 1 Stairs/Stairwell (outside)

[ ] 2 Garden or yard

[ ] 3 Sidewalk

[ ] 4 Street

[ ] 5 Curb

[ ] 6 Parking lot

[ ] 7 Other outside location

[ ] 8 Refused

[ ] 9 Don't know/non-valid response

21. Identify the Ground/Floor Surface Condition (See Probe 1D.)

[ ] 1 Wet

[ ] 2 Dry

[ ] 3 Snowy/icy

[ ] 8 Refused

[ ] 9 Don't know/non-valid response

22. Did participant slip or trip on something (such as, a table leg, irregularity in floor or sidewalk surface, step, curb, ladder, clothing, or pet)? (See Probe 1E.)

[ ] 0 No

[ ] 1 Yes

[ ] 8 Refused

[ ] 9 Don't know/non-valid response

23. Was participant knocked down by someone or something? (See Probe 1A.)

[ ] 0 No

[ ] 1 Yes

[ ] 8 Refused

[ ] 9 Don't know/non-valid response

For more than one fall on this date or in this month, begin another form.

MONTH YEAR ID #

SUN

MON

TUES

WED

THURS

FRI

SAT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

MAIL CARD PLEASE!

PLEASE MARK AN "F" ON EACH DAY YOU HAD A FALL, AND "N" ON EACH DAY YOU DID NOT FALL.

PLEASE CIRCLE YOUR ONE BEST ANSWER.

In the past month, how much bodily pain have you had?

None      Very Mild      Mild      Moderate      Severe      Very severe

ONLY IF YOU HAD A FALL THIS MONTH, PLEASE ANSWER THE FOLLOWING QUESTIONS ABOUT THE FALL. IF YOU FELL MORE THAN ONE TIME THIS MONTH, PLEASE ANSWER THE QUESTIONS ABOUT THE FIRST FALL ONLY. [WE WILL CALL YOU TO ASK ABOUT YOUR OTHER FALLS] (Circle YES or NO)

Did you injure yourself as a result of your fall? YES NO

If YES, did you have any of the following (check all that apply):

___ hit your head hard (or head injury)

___ broken hip

___ other injury (_______________________)

Did you go to the emergency room or stay overnight in the hospital because of the fall? (Circle YES or NO)

Went to the emergency room because of the fall YES NO

Stayed overnight in the hospital because of the fall YES NO

Protocol Name from Source:

Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston (MOBILIZE Boston)

Availability:

Publicly available

Personnel and Training Required

The interviewer must be trained to conduct personal interviews with individuals from the general population. The interviewer must be trained and found to be competent (i.e., tested by an expert) at the completion of personal interviews. The interviewer should be trained to prompt respondents further if a "don't know" response is provided.

Equipment Needs
The PhenX Working Group acknowledges these questions can be administered in a computerized or noncomputerized format (i.e., paper-and-pencil instrument). Computer software is necessary to develop computer-assisted instruments. The interviewer will require a laptop computer/handheld computer to administer a computer-assisted questionnaire.
Requirements
Requirement CategoryRequired
Mode of Administration

Interviewer-administered questionnaire

Life Stage:

Participants:

Ages 70 and older

Specific Instructions:
Selection Rationale

This questionnaire was successfully administered to a large diverse elderly population in Boston, Massachusetts.

Language

Standards
StandardNameIDSource
Common Data Elements (CDE) Geriatrics Fall Assessment Questionnaire Assessment Score 6356778 CDE Browser
Derived Variables

None

Process and Review

The Expert Review Panel has yet to review this measure.

Source

Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston (MOBILIZE Boston)

General References
Protocol ID:

250601

Variables:
Export Variables
Variable NameVariable IDVariable DescriptionVersiondbGaP Mapping
Research Domain Information
Measure Name:

Falls

Release Date:

N/A

Definition

The frequency, potential causes, and outcomes of an individual's fall or falls.

Purpose

Falls are a leading cause of disability in older adult populations. By collecting details about falls, clinicians may be able to identify the causes of falls and reduce the risks.

Keywords

Fall, frail, fracture, disability, elderly, geriatrics, Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston, MOBILIZE Boston, gerontology, aging