Community Pre-Stocktake Survey (Mail)

Stay On Your Feet®

community stocktake mail survey

(pre-program)

Stay On Your Feet® is a five year program that aims to reduce falls among people aged 60 years and over living in
the [local area] community .

Commencing [date], we will be working with communities to develop local falls prevention action plans. Then, in [date],three full years of activities and programs aimed at preventing falls will begin.

But first – we need to

find out what activities and programs are already happeningFIND OUT WHAT ACTIVITIES AND PROGRAMS ARE ALREADY HAPPENING.

We also need to

find out what activities and programs need to happenFIND OUT WHAT ACTIVITIES AND PROGRAMS NEED TO HAPPEN.

We sincerely hope you can help by completing this short survey.

The information from the survey will help us toproduce a
falls prevention networking directory Falls Prevention Directory for for the [local area] community and help us to developmake the development of the local falls prevention action plans. as painless as possible!

Please complete this survey as soon as possible and return to us using the Reply Paid envelope provided by [return deadline].

Stay On Your Feet®
community stocktake mail surveyThank you for filling in this

“STAY ON YOUR FEET”

FALLS PREVENTION STOCKTAKE SURVEY

(pre-program)

This information will remain confis confidential to the Stay Oon Your Feet® project at CPHUN-WB.

1. What are your contact details?

OrganisationRGANISATION:

Contact person:

Postal aAddress:

Phone: Fax: Email:

1. What does your organisation do?

1. What geographical area do you cover? (e.g. particular towns, Local Government Area, Health Service District etc)

1. Do you provide* any programs, services, activities or resources which focus on any of the factors in the box below?:

(PleaseLEASE write your responses for Q.4 in the table on the next page.)

*(“Provide” means you/your organisation are responsible for the activity, either alone or in cooperation with other groups or individuals)

1

Name of activity/

1

5Could we include your activities in a free fFalls pPrevention networking directoryfor [local community]Wide Bay/ Burnett?  Yes  No

Would you like a copy of the directory?  Yes  No

6Are there any factors relating to falls in older people, which could be better addressed in your community? (more than one response is fineO.K )

  Awareness (falls are common but preventable)

  Information (what to do to reduce falls)

  Physical activity  Footwear

  Medications  Calcium intake

  Eyesight Home safety

  Public safety OtOther………………………………………………

7Would you/ your organisation be interested in working with us to develop a local fFalls aAction pPlan for your area?(This would be during [time period] and your involvement would depend on your availability We expect that the local plans will be developed in the period March-August 2002; your involvement would depend on your available time - you may wish to come to community meetings, comment on drafts, or maybe meet with us individually.)

 Yes  No CComments……………………………………………………….

……..………………………………………….…………………………………………

8What would be the most workable area for your local falls action plan? “local” Action Plan?

Your town only

Your towns and neighbouring towns (please specifyname them)
…………………………………………………………………………………………...

Your Health District area (please specify) i.e. North Burnett, South Burnett, Bundaberg, Fraser Coast)

…………………………….

 Your Local Government Area (please specifyname) ….……………………………….

9Are there any other comments you would like to make?

Thank you for taking the time to answer these questions. Your feedback is much appreciated!.

PLEASE RETURN THIS SURVEY BBEFORE

[RETURN DEADLINE]FRIDAY 10TH MAY 2002

USINGIN THE REPLY- PAID ENVELOPE PROVIDED

ORr

FAXax TO: [FAX NUMBER]

41977299

If you have anAny questions, please contact [name and details]? Call Sue Jones 41977255.

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[PaCM1]1Do you want to leave this in?