Grant-Required Data Elements vs. Optional Data Elements

• Grant-Required Data Elements:  Organizations funded by ACL to implement evidence-based falls prevention programs are required to use these data collection tools, which include:
  • Participant Information Form (Pre-Survey)
  • Participant Post-Program Survey Form
  • Attendance Log
  • Falls Program Information Cover Sheet
  • Host Organization Information Form
  • Falls Prevention Program Group Leader/Coach Script
• Optional Data Elements: Questions and functional assessments that organizations collect over and above the grant-required data elements. If you have a reasonable programmatic reason for doing so, you may add optional data elements to the Participant Information Form (presurvey) and Participant Post-Program surveys, after receiving approval from ACL and NCOA.

Optional Data Items Currently Available in the National Falls Prevention Database

• Monthly Household Income: Add this question if you would like to assess income. This question can also be used to estimate participants’ federal poverty level when coupled with the grant-required question ‘Living Alone (Y/N)’. It is important for grantees/program leaders to remind participants that completing survey questions, such as the income question, is entirely voluntary and participants are free to skip questions. This question is currently only available in English.
  • Question: Including yourself (and your spouse, if married), what is your combined monthly gross income now? (Consider all sources of income, including Social Security, pension, etc.)?
    • Less than $1,000
    • $1,001 - $1,499
    • $1,500 - $1,999
    • $2,000 - $2,499
    • $2,500 - $2,999
    • $3,000 -$3,499
    • $3,500 - $3,999
    • $4,000 or more
• Chronic Condition: Early Stage Dementia: The grant-required Participant Information Form (Pre-Survey) asks participants about their chronic conditions. In addition to the chronic condition answer choices on the form, you may choose to add the chronic condition “early stage dementia” to evaluate if you are reaching this high-risk population. This answer choice is available in English, Spanish, Cambodian, Chinese, Hmong, and Vietnamese.
• Caregiver for Person with Dementia: Add this question to identify if the program participant is a caregiver for a person with dementia. In some programs, caregivers for participants with dementia attend the program to assist the care recipient and/or learn how to help the care recipient prevent falls.
  • Question: Are you here as a caregiver to a person with dementia? O Yes O No
• Zip Code: Add this question to help identify which regions you are reaching or gaps where new programs could be offered. Consider cross-mapping the regions with “falls hot spots”—areas with high rates of older adult fall-related emergency room visits. (Note: Data reports from the National Falls Prevention Database will not cross-map fall hot spots in your state; grantees will need to utilize state-specific data sources and mapping tools to do so).
  • Question: What is your zip code?
• Type of Health Insurance: Add this question to identify which health insurance plan(s) program participants are enrolled in to evaluate the impact your programs have on participants in particular health plans. The answer choices can be customzied to include health insurance plans in your state. Utilize this data to develop a value proposition to health plans/payors. Take the data one step further by utilizing it to calculate the potential return on investment for health plans/payors. This question is available in English, Spanish, Cambodian, Chinese, Hmong, and Vietnamese.
  • Question: Please indicate which type of insurance you have.
    • Medicaid
    • Medicare
    • TriCare
    • Veterans Health
    • No Insurance
    • Private Insurance Not Listed Above
    • Other Private Insurance: _____________
    • [Optional: Add your list of state-specific health insurance plans here]
• Referral from Facebook Ad: Add this question if you use Facebook ads as a participant recruitment tool and are interested in tracking how many participants enroll as a result. This question is available in English, Spanish, Cambodian, Chinese, Hmong, and Vietnamese.
  • Question: Were you referred here today from a Facebook ad? O Yes O No
• Question to Assist with Tracking Participant Completion in Long-Form Programs: Add this question if you would like to better track participant completion rates across long-form programs (e.g., SAIL, Tai Ji Quan: Moving for Better Balance) that you implement across multiple workshops. For example, if you implement the Tai Ji Quan: Moving for Better Balance program as two 12 week workshops (meeting twice a week for 1 hour each), in which the participant completes a participant survey at the beginning and end of each workshop block. This question helps to more reliably match participant IDs on the backend of the database, thus resulting in a more accurate participant completion rate in data reports. This question is available in English, Spanish, Cambodian, Chinese, Hmong, and Vietnamese.
  • Question: Have you taken this falls prevention program before? O Yes O No
• Question to Assist with Tracking Participation in Other Fall Prevention Programs: This question helps to track if a participant has attended another fall prevention program before. It is especially helpful in tracking if participants engage in a continuum of programs, such as attending a moderate to high-falls risk program like A Matter of Balance and then enrolling in a lower-falls risk program like Tai Chi. This question is available in English, Spanish, Cambodian, Chinese, Hmong, and Vietnamese.
  • Question: Have you taken a falls prevention program before? O Yes O No If yes, please indicate the program name: __________ 
• Functional Measurement Assessments Overview: Add the Timed Up and Go (TUG) and/or the Chair Stand functional measurement assessments to your data collection process to assess mobility, leg strength, and endurance pre- and post- program. Collecting these measures would allow you to assess if the participant has improved, maintained, or declined in their ability after participating in the program. Data from these measures will appear in the National Falls Prevention Database “Outcomes Report." These tests are to be conducted and recorded by program leaders and/or professionals.
  • Timed Up and Go Test: Conduct this test pre- and post-program to assess the participant’s mobility. Program leaders record the number of seconds on the Participant Information Form (Pre-Survey) and Participant Post-Survey. Test administration instructions for program leaders are available here.
    • Text to Add to Pre-and Post-Program Surveys (For Program Leader Use Only): Timed Up and Go Test Number of Seconds:_____
  • Chair Stand Test: Conduct this test pre- and post-program to test the participant’s leg strength and endurance. Program leaders record the participant’s score on the Participant Information Form (Pre-Survey) and Participant Post-Survey. Test instructions for program leaders are available here.
    • Text to Add to Pre-and Post-Program Surveys (For Program Leader Use Only): Chair Stand Test Score:_____