Falls Prevention Toolkit Demographic Form

For aggregate reporting purposes only, please answer the following questions before accessing the Falls Prevention Toolkit.

Where do you work?

State:

County:

Age and Gender

Age:

Male Female

Race (check all that apply):

Native Hawaiian/Pacific Islander
White
Other

American Indian/Alaskan Native
Asian
Black or African American

If other, please specify:

Are you Hispanic/Latino?

Yes
No

What is your primary role?

Primary Role:

Specify Other:

Discipline

Discipline:

Specify Other:

Most advanced degree earned:

Degree:

Specify Other:

Please indicate the clinical site(s) in which you work.

Check all that apply. For each location you check, please indicate the number of patient encounters you have in an average day:

Ambulatory Care Center, #:
Assisted Living, #:
Chronic/Acute Hospital, #:
Other

Home Care, #:
Hospice, #:
Nursing Home, #:

If other, please specify: #: