Fall Prevention Awareness Day

Event Planning Form

Facility:______Contact: ______

Address: ______Cell phone #: ______

Email: ______Date confirmed: ______By: ______

Timeline for event:

Arrive & Set-up: ______Volunteers to arrive by: ______Event opens: ______Tear-down: ______

Activity / Timeline & resource / Materials needed / Responsibility
Entrance and reception area / Set up well before event to allow time for ‘trouble-shooting’ / Welcome & directional signs Easels
Table, tablecloth, brochures
Sponsorship recognition?
Microphone or PA system? / Event coordinator & planning team
Balance - Station 1
Timed Up & Go (TUG) or other balance test
(motor activity) / For information contact:
Carmen Abbott
University of Missouri Dept. of Physical Therapy
Phone:
Email: / 1 chair per station
Masking tape (need 10-ft.
of room)
1 stopwatch per station
Copies of TUG timesheets
2 Physical Therapy volunteers per station. May set up more than one station… / Volunteer contact name & cell phone #
Station #1
·  ______
·  ______
Station #2
·  ______
·  ______
Station #3
·  ______
·  ______
(Note date each is confirmed)
Fall Risk - Station 2
MAHC fall risk assess (cognitive activity)
*the questionnaire contains personal questions. Have visitors fill out form privately. Volunteers tally score and talk about fall risk. / Contact: local nursing schools
NEED LINK TO OR COPY OF RISK ASSESSMENT FORM / ____ table(s)
____ chairs(s)
Pens / Clipboards
Copies of MAHC fall risk assessment form w/ “Dear HCP” heading.
(ask nurses to bring BP cuffs & do B/P at this station as well) / Nurse volunteers contact name & cell phone #
Station #1
·  ______
Station #2
·  ______
Station #3
·  ______
(Note date each is confirmed)
Medication Review -Station 3
Medication review
(verbal activity) / Contact: Paul Perniciaro
Perniciaro & Associates
Missouri Pharmacy Assn.
Phone: 636-931-7555
Email:

(Consider pharmacy students) / _____table(s)
_____chairs
Pens / Clipboards
Copies of med sheet & “Dear Pharmacist” letter / Pharmacy volunteers name & cell phone #
Station #1
·  ______
Station #2
·  ______
Station #3
·  ______
(Note date each is confirmed)
Activity / Timeline & resource / Materials / Responsibility
Exercise Demo - Station 4
Chair Yoga / Stretch/ Exercise/Tai Chi Demo
(motor activity) / Yoga or Tai Chi instructor for seniors (?) / Check with contact for needed materials and space / Volunteer contact name & cell phone #
Station #1
·  ______
(Note date each is confirmed)
Vision Screening - Station 5
Vision screening
(visual activity) / Contact: LeeAnn Barrett
Missouri Optometric Assn.
Phone: Email:
Optometrist(s) / _____table(s)
_____chairs
Check with contact for needed materials / Volunteer contact name & cell phone #
Station #1
·  ______
Station #2
·  ______
Station #3
·  ______
(Note date each is confirmed)
Written Materials - Station 6 / _____table(s)
_____chairs
MO Falls by County
www.dhss.mo.gov/showmefallsfreemissouri/ShowMeFallsFreeMissouri.pdf / MO falls map by county / Make into poster?
CDC – posters & brochures
www.cdc.gov/HomeandRecreationalSafety/Falls/fallsmaterial.html / What you can do
Home safety checklist
What you can do / 100 brochures
100 brochures
Set of 4 posters
Other resources available at: www.dhss.mo.gov/showmefallsfreemissouri/ShowMeFallsFreeMissouri.pdf

TRACKING

(Please submit this data to:______)

Number Done / Notes
Total Attendance
Timed Up & Go Screenings / ç Number indicating risk
MAHC Fall Risk Assessments / ç Number indicating risk
Blood Pressure Readings / ç Number requiring follow-up
Medication Reviews / ç Number requiring follow-up
Vision Screenings / ç Number requiring follow-up
Exercise demo participants
Written Materials / Start# / - End# / = Distribution / Notes
List each brochure here
What you can do brochure / 125 / -25 / 100
Home safety checklist

Communication / PR

Media / # of pieces / Audience / Estimated reach
Local Newspaper / 500 word article / County residents / 600 residents
Church bulletin / Small ad / Seniors / 150

Contacts

Organization / Contact / Activity / Donation (Y/N) date recieved

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Original from Cyndee Howell, edited with permission