PPTA members are asked to complete this form during or shortly after completion of Fall Prevention Awareness Day (FPAD) events/activities so we can report our successes internally and externally fully and accurately. Please answer all questions as completely and accurately as possible. 

Why is this important to do?  We want to celebrate our successes and objectively demonstrate strong PPTA support for this important national initiative to the PA Department of Aging/PA Falls Coalition and the National Council on Aging (NCOA). The NCOA collects this data and publishes it in an annual report available to the public and national stakeholders.

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* 1. Member Name:

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* 2. Please Input Your Email Address:

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* 3. APTA Membership Number:

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* 5. Type of setting your FPAD advocacy events/activities took place (choose all that apply):

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* 6. City/town of FPAD advocacy events/activities:

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* 7. Date(s) of FPAD advocacy events/activities:

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* 8. Did you use any of the materials in the PPTA FPAD Resource Toolkit to support your efforts?

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* 9. What type of events/activities did you provide in support of FPAD (choose all that apply):

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* 10. Approximately how many physical therapy professionals (PTs/PTAs) were involved in carrying out your 2018 FPAD activities?

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* 11. Approximately how many physical therapy students (PT/PTA students) were involved in carrying out your 2018 FPAD activities? 

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* 12. Approximately how many older adults did you reach overall with FPAD activities?

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* 13. Approximately how many family or professional caregivers of at risk older adults were reached by your FPAD activities?

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* 14. Approximately how many clients were recommended for physical therapy services as a result of FPAD outreach activities?

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* 15. What was the greatest success of the event/activity?

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* 16. What would you do differently next time, if anything?

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* 17. Please specify any additional resources or information that would be helpful to you in planning and conducting these efforts in the future:

If you have an individual success story, please consider uploading your photos and the appropriate completed consent form below. If you have more than three photos and consent forms to submit, please email them directly to Janita Kilgore.

If you have a video you would like to share, please contact Janita Kilgore at the PPTA Office for instructions.

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* 18. Photo upload:

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* 19. Completed consent form upload:

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* 20. Photo upload:

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* 21. Completed consent form upload:

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* 22. Photo upload:

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* 23. Completed consent form upload:

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Thank You For Your Time!

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