This sample checklist can help determine whether the facility’s falls risk assessment tool screens for certain risk factors associated with greater risk of falls and  falls with injury. As the falls team or staff reviews the facility’s falls risk assessment tool, evaluate and check “Yes” or “No” for each falls risk variable.

Specific instructions for use are included in the checklist, which may be downloaded for electronic entry or printed for handwritten entry. The checklist is a PDF and requires Adobe Reader to view and/or use the electronic entry feature.