| No. | Question | Strongly disagree | Disagree | Neither agree or disagree | Agree | Strongly agree |
| 1 | The risk factors for falling are notified to patients and their caregivers who are at high risk of falling. | ① | ② | ③ | ④ | ⑤ |
| 2 | When getting on and off a wheelchair, make sure that the wheels are fixed when climbing and lowering the bed. | ① | ② | ③ | ④ | ⑤ |
| 3 | The patients who are at high risk of falling will be explained how to use the wheelchairs in advance. | ① | ② | ③ | ④ | ⑤ |
| 4 | Make sure that the bed railing is raised when the patients are in bed. | ① | ② | ③ | ④ | ⑤ |
| 5 | Make sure that patients at high risk of falling always hold the railing when going up and down a bed or staircase. | ① | ② | ③ | ④ | ⑤ |
| 6 | Explain that patients with high risk of falling slowly move their bodies when changing positions, and help if necessary. | ① | ② | ③ | ④ | ⑤ |
| 7 | When patients are tired or dizzy, always educate them to ask for help. | ① | ② | ③ | ④ | ⑤ |
| 8 | Encourage the patient not to run around in the patient’s room or hallway or not to walk quickly with unstable steps. | ① | ② | ③ | ④ | ⑤ |
| 9 | Instruct the patient with the high risk of falls where call lights of patient’s room and restroom are placed, and how to use the call lights. | ① | ② | ③ | ④ | ⑤ |
| 10 | Check for slippery floors in hallways, patient’s rooms, treatment rooms, and restrooms. | ① | ② | ③ | ④ | ⑤ |
| 11 | Make sure that patient at high risk of falling wears shoes that don’t slip and fit well. | ① | ② | ③ | ④ | ⑤ |
| 12 | Make sure that the lighting in the hallway, patient’s room, treatment room, and restroom is bright enough. | ① | ② | ③ | ④ | ⑤ |
| 13 | Make sure that patient is wearing a seat belt when using a wheelchair. | ① | ② | ③ | ④ | ⑤ |