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Your Study Number Is ___ Supplementary data: Falls diary instruction pamphlet, calendar and questionnaire Thank you for participating in this study. Remember a fall is... We appreciate your time and effort in filling in the falls diary. “An unexpected event in which you come to rest on Footwear, fatigue and falls in the ground, floor or lower paediatric neuromuscular level” disease. but it is not in the normal course of sporting games Falls diary instructions where you may be knocked over by another child, or when you are playing on play Your study equipment and fall off. The Royal Children's Hospital number is E.g. Playing a game of foot- Neuromuscular Research ball and you are tackled to Neuromuscular Assessment Room Specialty Clinic A3 (next door to the Meerkats) __________ Ground Floor the ground or a fall from the The Royal Children’s Hospital 50 Flemington Rd, monkey bars is not a fall Parkville, 3052 Tripping over on uneven Phone: 03 9345 4287 ground or your legs giving E-mail: [email protected] way on the steps is a fall Footwear, fatigue and falls in paediatric neuromuscular disease. HREC number 33272 Version 2, January 8th, 2014. Falls diary recording We would like to find out about Did you fall today? If you have no falls in a falls in children and adolescents month please tick the star with neuromuscular diseases. box “I had no falls this Yes No month!!!” on the Monthly falls You will be provided with either calendar. electronic or paper copies of: Do nothing! Please return the Monthly falls Monthly falls calendar calendar to us – either by email or in a replied paid envelope Fall of the day questionnaire Place a mark in the Monthly falls calendar . Mark up with any paper copies of the to four falls a day. Fall of the day questionnaire(s) Six reply paid envelopes if you that you may have filled in. are posting your paper copies back to us. Once a month we will contact you either by phone or an email, For your worst fall of the day please fill in a Fall of the whichever you choose, to check day questionnaire - either on the paper copy or online. The electronic link utilises secure how you are going with filling out online data collection software the diary and to answer any called REDCap. We use REDCap questions you may have. for secure data entry and storage. More than six falls in a month? Yes If you require more paper copies If you choose to fill this in elec- of the Monthly falls calendar tronically, you will be emailed a and / or Fall of the day ques- Monthly falls calendar to fill in tionnaire please let us know and and send back to us and the elec- we will be send them to you. tronic link for the Fall of the day Stop filling in the Fall of the day questionnaire for that questionnaire. This link can be month only. accessed from any internet con- However, if you have a fall that is bad enough to seek Any questions? Please contact Rachel Kennedy medical attention, we would like you to fill in another nected device. Phone: 03 9345 4287 Fall of the day questionnaire so that we can find out E-mail: [email protected] about that fall too. MONTHLY FALLS CALENDAR Study number:_________ Month 1 2 3 4 5 6 Date commenced:______________ Date completed:_______________ Please place a tick or a sticker for each fall (up to four a day) in the appropriate date box below. If no falls for the month please tick the star below. For your worst fall of the day please fill in a Falls diary record form – either electronically or paper. March 2014 Sunday Monday Tuesday Wednesday Thursday Friday Saturday 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 I had no falls this month!!! Please return this “Monthly Falls Calendar” sheet and any “Fall of the day questionnaire” sheets that you have filled in this month in the replied paid envelope or by email. Thanks! Study Name: Footwear, fatigue and falls in paediatric neuromuscular disease. Protocol Number: 33272 Version & date: version 3, dated 8/1/2014 Fall of the day questionnaire – please complete one of these sheets for the worst fall of the day. Your study number is:___________ Page 1 of 2 Date of your fall. _______________________ What time did you fall? Morning Afternoon Evening Where were you located when you fell? Home School In community Where did you fall? Inside on flat surface Walking upstairs Walking downstairs Outside on flat surface Outside on uneven surface Up / down kerb/gutter Playground Other Please specify________________________________ What type of shoes were you wearing? Athletic runner / shoe Boot School shoe (oxford/mary jane/T bar/other) Slipper / moccasin Thong Sandal Crocs / slip on type flip flop Ballerina flat Canvas shoe Ugg boot Other Please specify_________________________________ No shoes – bare feet How are your shoes done up? Laces Buckle Velcro Elastic Other Please specify_________________________________ Not applicable (my shoes don’t have a fastener) Were your shoes done up when you Yes fell? No Not applicable (my shoes don’t have a fastener) Study Name: Footwear, fatigue and falls in paediatric neuromuscular disease. Protocol Number: 33272 Version & date: version 3, dated 8/1/2014 Page 2 of 2 How did you fall? Tripped Legs gave way Over balanced Other Please specify_________________________________ Were you injured? Yes No How were you injured? Bruised Cut /grazes Broken bones Other Please specify__________________________________ Did you require medical attention for Yes your injury? No Any other comments… Fall of the day questionnaire either paper form or identical electronic form via a REDCap link provided to the families Study Name: Footwear, fatigue and falls in paediatric neuromuscular disease. Protocol Number: 33272 Version & date: version 3, dated 8/1/2014.
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