Community Post-Stocktake Survey (Mail)

							[PDF for Phase 4 materials]
                              STAY ON YOUR FEET® COMMUNITY STOCKTAKE SURVEY
                                               (Post-program)

As you would know, Stay On Your Feet® is a five yearYou probably know by now that STAY ON YOUR FEET is a 5-year program that aimsing
to reduce falls among people aged 60 years and over living in the [local area] community 60 and over, who live in the communities of the Wide
Bay-Burnett - the only Queensland area selected for this major falls-prevention project. What we learn from this project will be shared At the
end of this year, 2006, the things we have learned during the project will be shared to help older people all overin the rest of Australia.

To assess improvements and changes since Stay On Your Feet began, the Stay On Your Feet team needs to find out abo ut activities and
programs that are happening in your community to help older people stay on their feetto “Stay On Their Feet”.

We initially sent out this survey in [date] and are now asking you answer the questions again to provide factual evidence about what has been
achieved in the community over the duration of the project, and guide future strategies to address falls. Four years ago, in February 2002, and
again 18 months ago, we sent out this short survey.

THIS SURVEY YOU ARE HOLDING NOW IS MOST IMPORTANT FOR THE STAY ON YOUR FEET PROJECT. It will give us factual
evidence about the advances and successes in communities in the past four years. It will help us to scientifically compare 2002 with 2 006, and
help to guide future strategies.

Please complete this survey as soon as possible We know that many surveys come your way – but we hope you can complete these
            questions AS SOON AS YOU ARE ABLE and return to us in the Reply-Paid envelope by [return deadline]
            using the Reply Paid envelope provided or by fax to [fax number].Monday 13th February, or fax to 4120 6009



Stay On Your Feet® is a partnership project between Queensland Health’s [local]of the Wide Bay Population Health Unit and [partners]. If you
have any queries, please contact [name and details]. Any questions? Please ring 4120 6011


                        This information is confidential to the Stay On Your Feet project at Wide Bay Population Health Unit




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                                    Stay On Your Feet®
                          falls prevention stocktake post-survey
                              This information will remain confidential to the Stay On Your Feet® project.


1. 1. WHAT ARE YOUR CONTACT DETAILS?                                                                             Formatted: Bullets and Numbering


Organisation nameRGANISATION NAME (if applicable)you are representing an
organisation):……………………………………………………………………………………………………………………………….

Contact personYOUR
NAME:………………………………………………………………………..………………………………………………………………………….…

Postal addressPOSTAL
ADDRESS:…………………………………………………………………………………………………………………………………………………………
…………..… PostCode:………..

PhoneHONE: ……………………………….. FaxAX: ………………………..…………………………..
EmailMAIL::…………………………………………………………………………………………………………………..


  2. ROLE/OCCUPATIONWHAT DO YOU, OR YOUR ORGANISATION, DO?
Please tick the box which best matches your situationanswer.

      Community organisation representing (older people)
      eg.examples: Senior Citizens Club, 60 & Better, Pensioners and& Superannuants’ League
      Community oOrganisation (general)
      eg.examples: pProgress aAssociation, Lions Club, QCWA Branch, cChurch
      Health pProfessional (gHealth – General)
      eEg.xamples: cCommunity hHealth, hHospital, cCommunity hHealth nNurse
      Health pProfessional (medical or Haealth – Medical, Allied hHealth)
      egxamples:. General Practitioner , pPhysiotherapist, pPodiatrist, oOptometrist



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         Fitness/sport and recreation pProfessional (Fitness/ Sport & Recreation)
          egxamples:. fFitness iInstructor, sSwimming iInstructor, Tai Chi iInstructor
         Local gGovernment (cCouncil)
         Community sService
          egx.amples: Bluecare, Home Assist Secure, HACC coordinator
         Individual Person
         Other (please explainPlease write detail here)
         ……………………………………………………………………………………………………………………………………………………………..
If you are not sure what box to tick, please write your answer here………………………………………………………………………………………...



3. ACTIVITIES or PROGRAMS or FACILITIES IN YOUR LOCAL AREA
We would appreciate if you could fill in this table to the best of your ability. Stay On Your Feet® is interested in activities/ programs/ facilities
which older people can access in your community, which focus on one or more of the following factors in this box:

           Lack of awareness and                         Not enough physical                        Unsafe footwearFOOTWEAR                              Formatted: Bullets and Numbering
            knowledgeAWARENESS &                           activityPHYSICAL ACTIVITY
            KNOWLEDGE about preventing falls
           Some Using                                    Unsafe home environmentsHOME               Unsafe public                                        Formatted: Bullets and Numbering
            medicationMEDICATIONS                          ENVIRONMENTS                                environmentsPUBLIC
                                                                                                       ENVIRONMENTS
           Problems with eyesightVISION                  Not enough healthy                                                                               Formatted: Bullets and Numbering
                                                           eatingHEALTHY EATING


 Name of activity,      Brief description              Who is thisit aimed at?       Do you or /your organisation provide         Is there a fee
 program or,                                           (Please tick)                 thise activity/program/facility?             charged?
 facility                                                                            (Please tick)                                (Please tick)
                                                       Older people    General       Yes     No                                   Yes     No    Don’t
                                                                       community             (Do you know who does provide?)                    know




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4. WHAT COULD BE DONE BETTER?

Could any of these factors be better addressed in your community?
Please tick any factors you think could be better addressed in your communityyour answer/s (More than one response is fineOK)

           Awareness and& information about falls prevention
           Physical activity
           Medication
           Vision
           Feet and& footwear
           Public safety
           Home safety
           Calcium and& healthy eating
           Other (please specify)…………………………………………………………………………………………………………………………………

5. ARE THERE ANY OTHER COMMENTS YOU WOULD LIKE TO MAKE?
………………………………………………………………………………………………………………………………………………………………………
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                              Thank you for taking the time to answer these questions.
                  Your feedback is much appreciated. The results of this survey will be reported in the
                    Stay On Your Feet® newsletter and presented to a community meeting in [date].

                                       PLEASE RETURN THIS SURVEY BEFORE
                                               [RETURN DEADLINE]
                                    USING THE REPLY PAID ENVELOPE PROVIDED
                                                        OR
                                              FAX TO: [FAX NUMBER]

                              If you have any questions, please contact [name and details].


PLEASE RETURN THIS SURVEY BEFORE MONDAY 13 FEBRUARY 2006 either in the enclosed Reply-Paid envelope, or by
faxing to 4120 6009. Any questions? Please ring the Stay On Your Feet team on 4120 6011

THANK YOU FOR TAKING THE TIME TO ANSWER THESE QUESTIONS!
The results of this survey will be part of the Stay On Your Feet Evaluation Report which will be presented to community
meetings in August 2006 and summarised in the Stay On Your Feet newsletter.




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