Survey Type: Fidelity Tool Session 4

Assessor: ______

Date: ______Class size (# of attendees): ______

Location of Fidelity Check: ______

Leader: ______

2nd Trained Leader (if applicable):______

Peer Leader: ______

Event / Check to indicate whether or not event occurred / Rate Leader’s quality
on scale
0 = Not done at all
1 = Not satisfactory
2 = Satisfactory
3 = Excellent / Rate 2nd Trained Leader’s quality on scale if applicable
0 = Not done at all
1 = Not satisfactory
2 = Satisfactory
3 = Excellent
SESSION 4
  1. Class was welcomed and agenda was disseminated and discussed.
/ Occurred
Did not occur
  1. Balance and strength exercises were practiced concentrating on those with which people had trouble.
/ 0 1 2 3 / 0 1 2 3
  1. Leader encouraged advancing exercises as able with class practice.
/ 0 1 2 3 / 0 1 2 3
  1. Leader offered and encouraged weights with session exercise practice.
/ 0 1 2 3 / 0 1 2 3
  1. Leader facilitated stories on how to fit exercises into daily routine.
/ 0 1 2 3 / 0 1 2 3
  1. Homework (home fall hazards) was reviewed and discussed with each participant.
/ 0 1 2 3 / 0 1 2 3
  1. Exercise Plan was passed out.
/ Occurred
Did not occur
  1. Exercise Plan was collected.
/ Occurred
Did not occur
  1. Vision expert was introduced.
/ Occurred
Did not occur
  1. Leader prompted for questions for vision expert.
/ 0 1 2 3 / 0 1 2 3
  1. Leader monitored the vision discussion and kept it on topic.
/ 0 1 2 3 / 0 1 2 3
  1. Vision expert covered all topic areas.
/ Occurred
Did not occur
  1. Leader reviewed key messages from vision expert.
/ 0 1 2 3 / 0 1 2 3
  1. Leader passed out Vision and Falling handout and any handouts provided by the vision expert after the discussion and before the break.
/ Occurred
Did not occur
  1. Leader passed out handouts: Shoe Audit, What is a Safe Comfortable Shoe? and Safe Footwear for the group activities.
/ Occurred
Did not occur
  1. Leader demonstrated and passed around inappropriate shoes.
/ Occurred
Did not occur
  1. Participants performed a shoe audit.
/ Occurred
Did not occur
  1. Leader introduced the community safety expert.
/ Occurred
Did not occur
  1. Leader prompted for questions for the community safety expert.
/ 0 1 2 3 / 0 1 2 3
  1. Leader monitored the community safety discussion and kept it on topic.
/ 0 1 2 3 / 0 1 2 3
  1. Community safety expert covered all topic areas.
/ Occurred
Did not occur
  1. Leader reviewed key messages from the community safety expert.
/ 0 1 2 3 / 0 1 2 3
  1. Leader passed out Strategies to Increase Personal Safety handout.
/ Occurred
Did not occur
  1. Strategies to Increase Personal Safety handout was discussed.
/ Occurred
Did not occur
  1. Leader offered Moving about Safely handout.
/ Occurred
Did not occur
  1. Leader assigned homework to do a shoe audit or apply something they learned from the community mobility talk.
/ Occurred
Did not occur
  1. Leader outlined next week’s session on medication management and sleeping better and asked participants to bring in their supplements that contain Vitamin D.
/ Occurred
Did not occur
  1. Leader and peer leader appeared to work well together.
/ 0 1 2 3 / 0 1 2 3
Process:
  1. Leader established welcoming environment.
/ 0 1 2 3 / 0 1 2 3
  1. Pace was comfortable (not rushed).
/ 0 1 2 3 / 0 1 2 3
  1. Leader demonstrated good knowledge of fall prevention topics necessary for session.
/ 0 1 2 3 / 0 1 2 3
  1. Leader invited feedback throughout.
/ 0 1 2 3 / 0 1 2 3
  1. Leader used plain language throughout.
/ 0 1 2 3 / 0 1 2 3
  1. Leader used optimism and positive talk.
/ 0 1 2 3 / 0 1 2 3
  1. Leader demonstrated skill at story telling.
/ 0 1 2 3 / 0 1 2 3
  1. Leader demonstrated skill at using reflective listening.
/ 0 1 2 3 / 0 1 2 3
  1. Participants told falls or safety strategy stories.
/ 0 1 2 3 / 0 1 2 3
  1. Leader used prevention framework.
/ 0 1 2 3 / 0 1 2 3
  1. Leader facilitated engagement of all members of the group.
/ 0 1 2 3 / 0 1 2 3
  1. Break was offered and used effectively to answer questions, point out items on the display table and help participants to interact with the guest expert.
/ Occurred
Did not occur
  1. Peer leader role modeled how to be an active participant.
/ Occurred
Did not occur
  1. Did it appear that the participants could see/hear what was being presented?
/ Occurred
Did not occur

Comments:Consider adult learning principles, programmatic aspects, exercise, advancing exercise, the leader’s role and skills and the role of the peer leader in your comments.

1. What went well in this session?

2. Were there any items from today’s agenda that were omitted, moved to a later session or included from a previous session? Please explain.

3. How was the time managed?

4. What, if anything, could have been done better?

5. Please note here anything of concern:

FOLLOW-UP Recommendation for Leader #1

Name of Leader: ______

Please check only ONE of the following action items:

A. Follow-up recommended in 2 years. (This Leader DOES NOT need another

coaching session this year. Minimal, if any, improvements needed and discussed.)

B. Areas needing improvement were identified and discussed during coaching 

session with successful response by Leader. (Follow-up recommended within

one year.)

C. Leader had some SIGNIFICANT areas needing improvement and should have

follow-up fidelity coaching at next workshop. (Fidelity Coach should ask Statewide

Coordinator to initiate and conduct a conversation with Leader and local coordinator.)

D. Leader should be removed by Statewide Coordinator. (This Leader has had 

repeated significant areas of needed improvements with no improvements to date.)

Comments:

FOLLOW-UP Recommendation for Leader #2

Name of Leader: ______

Please check only ONE of the following action items:

A. Follow-up recommended in 2 years. (This Leader DOES NOT need another

coaching session this year. Minimal, if any, improvements needed and discussed.)

B. Areas needing improvement were identified and discussed during coaching 

session with successful response by Leader. (Follow-up recommended within

one year.)

C. Leader had some SIGNIFICANT areas needing improvement and should have

follow-up fidelity coaching at next workshop. (Fidelity Coach should ask Statewide

Coordinator to initiate and conduct a conversation with Leader and local coordinator.)

D. Leader should be removed by Statewide Coordinator. (This Leader has had 

repeated significant areas of needed improvements with no improvements to date.)

Comments:

Session 4 Fidelity Tool