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Safety First: A Detailed Fall Prevention Program Checklist Template

Safety First: A Detailed Fall Prevention Program Checklist Template

A fall prevention program checklist is derived from Preventing Falls: A Guide to Implementing Effective Community-Based Fall Prevention Program by the Centers for Disease Control and Prevention (CDC). Use this fall prevention program checklist to assess patient needs, target audience, and available resources, determine program characteristics, and set implementation and evaluation measures.

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Safety First: A Detailed Fall Prevention Program Checklist Template

A fall prevention program checklist is derived from Preventing Falls: A Guide to Implementing Effective Community-Based Fall Prevention Program by the Centers for Disease Control and Prevention (CDC). Use this fall prevention program checklist to assess patient needs, target audience, and available resources, determine program characteristics, and set implementation and evaluation measures.

Use this template
or download pdf

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Preview of the template
Fall Prevention Program Checklist
Needs Assessment, Target Audience & Available Resources
Are fall prevention activities feasible and will best serve the needs of the elderly?
Does the program fit our organization?
Does the program complement other programs already being offered?
Is the program appropriate for our target older adult population?
Are older adults in the nursing home interested in the program?
Is safe, reliable, and low-cost transportation to and from the program available?
Do we have personnel with the expertise to conduct the program or is there a system in place to train program instructors?
Are the costs and resources needed within our budget?
Program Characteristics
Does the program require specially trained instructors?
Will the program provide education about fall prevention?
Does the program promote falls self-efficacy (confidence to prevent falls) among the participants?
Are there opportunities for social interaction among the participants? (Such opportunities contribute to program retention and sustainability.)
Does the program address modifiable risk factors (e.g., exercises to improve lower body strength and balance)?
Can the program be tailored to meet the differing abilities of the participants?
Are exercises progressive (get more challenging over time)? This is a key component of an effective fall prevention exercise program.)
Can your facility provide the amount of time needed to provide the recommended intervention dose (e.g. for a total of 50 hours for a Tai Chi program)?
Does the program include strategies to reduce the possibility of activity related injuries?
Implementation
Are there program materials and training manuals available?
Can the program be implemented with fidelity in your setting?
Does the program offer strategies for linking participants and the program itself with healthcare providers as needed?
Evaluation
Does the program include methods for maintaining and monitoring fidelity and program quality over time?
Does the program include easy-to-administer pre- and post-functional tests, such as the Timed Up and Go (TUG) test, to document improvements in participants’ functional abilities?
Completion
Additional Recommendation
Nursing Home Supervisor Name & Signature
Worker Name & Signature
This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.