Study / Date Completed / Assessor / Subject ID / Study ID
M / M / D / D / Y / Y / Y / Y / # / # / # / # / # / # / # / # / # / # / # / # / # / # / # / #
SURVEY OF ACTIVITIES AND FEAR OF FALLING IN THE ELDERLY (SAFFE)
A. Do you currently: / 1. Go to the store? sastore / 2. Prepare simple meals? sameals1. NO0 2. YES1 / 1. NO0 2. YES1
↓ ↓
GO TO C GO TO B / ↓ ↓
GO TO C GO TO B
B. When you [ACTIVITY], how worried are you that / 1. Very worried / 1. Very worried
you might fall? / 2. Somewhat worried / 2. Somewhat worried
3. A little worried, or / 3. A little worried, or
4. Not at all worried / 4. Not at all worried
GO TO F sastfa / GO TO F samefa
C. Do you not [ACTIVITY] because you are...... that you might fall? / 1. Very worried If 1,2,3, GO TOD
2. Somewhat worried / 1. Very worried If 1,2,3, GO TOD
2. Somewhat worried
3. A little worried,or / 3. A little worried, or
4. Not at all worried →GO TO E / 4. Not at all worried →GO TO E
sastact / sameact
D. Are there other reasons that you do / 1. NO 0 sastrea / 1. NO0 samerea
not [ACTIVITY]? / 2. YES1→ SPECIFY:______/ 2. YES1→ SPECIFY:______
______/ ______
______/ ______
GO TO F sastrsp / GO TO F samesp
E. What are the reasons that you do not [ACTIVITY]? / SPECIFY :______/ SPECIFY:______
______/ ______
______/ ______
GO TO F sastsp / GO TO F samersp
F. Compared to 5 years ago, would you say / 1. More than you used to, / 1. More than you used to,
that you [ACTIVITY] …. / 2. About the same, or / 2. About the same., or
3. Less than you used to.
sastcom / 3. Less than you used to.
samecom
A. Do you currently: / 3. Take a tub bath? sabath / 4. Get out of bed? sabed
1. NO0 2. YES1 / 1. NO0 2. YES1
↓ ↓
GO TO C GO TO B / ↓ ↓
GO TO C GO TO B
B. When you [ACTIVITY], how / 1. Very worried / 1. Very worried
worried are you that / 2. Somewhat worried / 2. Somewhat worried
you might fall? / 3. A little worried, or / 3. A little worried, or
4. Not at all worried / 4. Not at all worried
GO TO F sabawor / GO TO F sabewor
C. Do you not [ACTIVITY] because you are…….. / 1. Very worried If 1,2,3, GO TOD
2. Somewhat worried / 1. Very worried If 1,2,3, GO TOD
2. Somewhat worried
thatyou might fall? / 3. A little worried or / 3. A little worried or
4. Not at all worried → GO TO E / 4. Not at all worried →GO TO E
sabatact / sabeact
D. Are there other reasons that you do / 1. NO0 sabatrea / 1. NO0 sabedr
not [ACTIVITY]? / 2. YES 1→ SPECIFY:______/ 2. YES1 → SPECIFY:______
______/ ______
______/ ______
GO TO F sabatrsp / GO TO F sabedsp
E. What are the reasons that you / SPECIFY:______/ SPECIFY:______
do not [ACTIVITY]?
______/ ______
______/ ______
GO TO F sabtsp / GO TO F sabedrsp
F. Compared to 5 years ago, / 1. More than you used to, / 1. More than you used to,
would you say that / 2. About the same, or / 2. About the same, or
you [ACTIVITY] …. / 3. Less than you used to.
sabtcom / 3. Less than you used to.
sabedcom
A. Do you currently: / 5. Take a walk for exercise? sawalk / 6. Go out when it is slippery? saslip
1. NO0 2. YES 1 / 1. NO0 2. YES1
↓ ↓
GO TO C GO TO B / ↓ ↓
GO TO C GO TO B
B. When you {ACTIVITY], how worried are you / 1. Very worried / 1. Very worried
that you might fall? / 2. Somewhat worried / 2. Somewhat worried
3. A little worried, or / 3. A little worried, or
4. Not at all worried / 4. Not at all worried
GO TO F sawawor / GO TO F saslwor
C. Do you not [ACTIVITY] because you are...... that you might fall? / 1. Very worried If 1,2,3, GO TOD
2. Somewhat worried / 1. Very worried If 1,2,3, GO TOD
2. Somewhat worried
3. A little worried or / 3. A little worried or
4. Not at all worried → GO TO E / 4. Not at all worried → GO TO E
sawaact / saslact
D. Are there other reasons that you do / 1. NO0 sawaor / 1. NO 0 saslor
not [ACTIVITY]? / 2. YES 1→ SPECIFY:______/ 2. YES1→ SPECIFY:______
______/ ______
______/ ______
GO TO F sawasp / GO TO F saslsp
E. What are the reasons that you donot / SPECIFY:______/ SPECIFY:______
[ACTIVITY]?
______/ ______
______/ ______
GO TO F sawarsp / GO TO F saslrsp
F. Compared to 5 years ago,would you say that / 1. More than you used to, / 1. More than you used to,
you [ACTIVITY] …. / 2. About the same, or / 2. About the same., or
3. Less than you used to.
sawacom / 3. Less than you used to.
saslcom
A. Do you currently: / 7. Visit a friend or relative? savisit / 8. Reach for something over your head? sareach
1. NO0 2. YES 1 / 1. NO 0 2. YES 1
↓ ↓ / ↓ ↓
GO TO C GO TO B / GO TO C GO TO B
B. When you[ACTIVITY], how / 1. Very worried / 1. Very worried
worried are you that / 2. Somewhat worried / 2. Somewhat worried
you might fall? / 3. A little worried, or / 3. A little worried, or
4. Not at all worried / 4. Not at all worried
GO TO F saviwor / GO TO F sarewor
C. Do you not [ACTIVITY] because you are...... / 1. Very worried If 1,2,3, GO TOD
2. Somewhat worried / 1. Very worried If 1,2,3, GO TOD
2. Somewhat worried
that you might fall? / 3. A little worried or / 3. A little worriedor
4. Not at all worried → GO TO E / 4. Not at all worried → GO TO E
saviact / sareact
D. Are there other reasons that you / 1. NO0 savior / 1. NO 0 sareor
do not [ACTIVITY]? / 2. YES 1→SPECIFY:______/ 2. YES 1→SPECIFY:______
______/ ______
______/ ______
GO TO F saviorsp / GO TO F sareosp
E. What are the reasons that you / SPECIFY:______/ SPECIFY:______
do not [ACTIVITY]?
______/ ______
______/ ______
GO TO F saviresp / GO TO F sareacsp
F. Compared to 5 years ago, would / 1. More than you used to, / 1. More than you used to,
you say that you / 2. About the same, or / 2. About the same, or
[ACTIVITY]….. / 3. Less than you used to.
savicom / 3. Less than you used to.
sareacom
A. Do you currently: / 9. Go to a place with crowds? sacrowd / 10. Walk several blocks outside?
sablock
1. NO 0 2. YES 1 / 1. NO 0 2. YES 1
↓ ↓
GO TO C GO TO B / ↓ ↓
GO TO C GO TO B
B. When you[ACTIVITY], how / 1. Very worried / 1. Very worried
worried are you that / 2. Somewhat worried / 2. Somewhat worried
you might fall? / 3. A little worried, or / 3. A little worried, or
4. Not at all worried / 4. Not at all worried
GO TO F sacrowor / GO TO F sablowor
C. Do you not [ACTIVITY] because you are...... / 1. Very worried If 1,2,3, GO TOD
2. Somewhat worried / 1. Very worried If 1,2,3, GO TOD
2. Somewhat worried
that you might fall? / 3. A little worried or / 3. A little worried or
4. Not at all worried → GO TO E / 4. Not at all worried → GO TO E
sacrowac / sablocac
D. Are there other reasons that you / 1. NO 0 sacrore / 1. NO 0 sablocor
do not[ACTIVITY]? / 2. YES 1→ SPECIFY:______/ 2. YES 1→ SPECIFY:______
______/ ______
______/ ______
GO TO F sacrosp / GO TO F sablosp
E. What are the reasons that you do / SPECIFY:______/ SPECIFY:______
not[ACTIVITY]?
______/ ______
______/ ______
GO TO F sacrowsp / GO TO F sablrsp
F. Compared to 5 years ago, would you say / 1. More than you used to, / 1. More than you used to,
that you[ACTIVITY]…. / 2. About the same, or / 2. About the same., or
3. Less than you used to.
sacrocom / 3. Less than you used to.
sablocom
A. Do you currently: / 11. Bend down to get something?
sabend
1. NO 0 2. YES1
↓ ↓
GO TO C GO TO B
B. When you[ACTIVITY], how / 1. Very worried
worried are you that / 2. Somewhat worried
you might fall? / 3. A little worried, or
4. Not at all worried → GO TO F
sabenwor
C. Do you not [ACTIVITY] because you are...... / 1. Very worried If 1,2,3, GO TOD
2. Somewhat worried
that you might fall? / 3. A little worried or
4. Not at all worried → GO TO E
sabenact
D. Are there other reasons that you / 1. NO0 sabenor
do not[ACTIVITY] …… / 2. YES 1→SPECIFY:______
______
______
GO TO F sabensp
E. What are the reasons that you do / SPECIFY:______
not?
______
______
GO TO F sabenres
F. Compared to 5 years ago, would you say / 1. More than you used to,
that you[ACTIVITY]….. / 2. About the same, or
3. Less than you used to.
sabencom
SAFFE / Form 6 Page 1 of 6 Primary Entered by: ______Date: ____/____/____ Version 4, 7/6/05
Secondary Entered by: ______Date: ____/____/____
PepperStudy / Date Completed / Assessor / Subject ID / Study ID
M / M / D / D / Y / Y / Y / Y / # / # / # / # / # / # / # / # / # / # / # / # / # / # / # / #
SAFFE / Form 6 Page 1 of 6 Primary Entered by: ______Date: ____/____/____ Version 4, 7/6/05
Secondary Entered by: ______Date: ____/____/____