14 Physical Activity

ID NUMBER:

FORM CODE: PAE VERSION: A 7/24/07

Contact Occasion

SEQ #

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 05 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

H

OMB#: 0925-XXXX

Exp. XX/XXXX

CHS/SOL Physical Activity Questionnaire

ID NUMBER:

FORM CODE: PAE VERSION: A 7/24/07

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date: // 0b. Staff ID:

Month Day Year

Instructions: For each question, mark the appropriate response. Unless instructed, mark ONLY one response.

I am going to ask you about the time you spend doing different types of physical activity in a typical week. Please answer these questions even if you do not consider yourself to be a physically active person. Think first about the time you spend doing work. Think of work as the things that you have to do such as paid or unpaid work, study/training, household chores, harvesting food/crops, fishing or hunting for food, seeking employment. (Insert other examples if needed)

In answering the following questions, ‘vigorous-intensity activities’ are activities that require hard physical effort and cause large increases in breathing or heart rate, ’moderately-intensity activities’ are activities that require moderate physical effort and cause small increases in breathing or heart rate.

1. Does your work involve vigorous intensity activity that causes large increases in breathing or heart rate like [carrying or lifting heavy loads, digging or construction work] for at least 10 minutes continuously?

No 0  GO TO QUESTION 4

Yes 1

2. In a typical week, on how many days do you do vigorous-intensity activities as part of your work?

Days a week

3. How much time do you spend doing vigorous-intensity activities at work on a typical day?

Hr. Min.

4. Does your work involve moderate-intensity activity that causes small increases in breathing or heart rate such as brisk walking [or carrying light loads] for at least 10 minutes continuously?

(Insert examples and use showcard)

No 0  GO TO QUESTION 7

Yes 1

5. In a typical week, on how many days do you do moderate-intensity activities as part of your work?

Days a week

6. How much time do you spend doing moderate-intensity activities at work on a typical day?

Hr. Min.

The next questions exclude the physical activities at work that you have already mentioned. Now I would like to ask you about the usual way you travel to and from places, for example to work, for shopping, to market, to place of worship. (Insert other examples if needed)

7. Do you walk or use a bicycle (pedal cycle) for at least 10 minutes continuously to get to and from places?

No 0  GO TO QUESTION 10

Yes 1

8. In a typical week, on how many days do you walk or bicycle for at least 10 minutes continuously to get to and from places?

Days a week

9. How much time do you spend walking or bicycling for travel on a typical day?

Hr. Min.

The next questions exclude the work and transport activities you have already mentioned. Now I would like to ask you about sports, fitness, and recreational (leisure) activities.

10. Do you do any vigorous-intensity sports, fitness or recreational (leisure) activities that cause large increases in breathing or heart rate such as running or football for at least 10 minutes continuously? (Insert examples and use showcard)

No 0  GO TO QUESTION 14

Yes 1

11. What are some of those activities? (Mark all that apply)

(Give examples if needed)

a. American football

b. Basketball

c. Boxing

d. Fencing

e. Handball

f. Hockey (ice or field)

g. Lacrosse

h. Lap swimming

i. Racquetball

j. Running k. Soccer/football

l. Tennis (singles or doubles)

m. Volleyball (competitive)

n. Water Polo

o. Weight lifting p. Other

Please specify: ________________

12. In a typical week, on how many days do you do vigorous-intensity sports, fitness or recreational (leisure) activities?

Days a week

13. How much time do you spend doing vigorous-intensity sports, fitness or recreational activities on a typical day?

Hr. Min.

14. Do you do any moderate-intensity sports, fitness or recreational (leisure) activities that cause small increases in breathing or heart rate such as brisk walking [cycling, swimming, volleyball] for at least 10 minutes continuously? (Insert examples and use showcard)

No 0  GO TO QUESTION 18

Yes 1

15. What are some of those activities? (Mark all that apply)

(Give examples if needed)

a. Aerobic dance/Step/Taibo

b. Baseball/softball

c. Brisk walking

d. Canoeing/kayaking

e. Coaching sports

f. Cricket

g. Cycling (including stationary)

h. Dance

i. Exercise machines

j. Frisbee play k. Hunting and fishing

l. Jai alai

m. Karate/judo/other martial arts

n. Rock climbing

o. Skating (roller or ice)/Roller

blading

p. Skin/Scuba diving q. Surfing

r. Swimming

s. Table tennis

t. Tai chi

u. Volleyball (includes beach

volleyball)

v. Other

Please specify: ________________

16. In a typical week, on how many days do you do moderate-intensity sports, fitness or recreational (leisure) activities?

Days a week

17. How much time do you spend doing moderate-intensity sports, fitness or recreational activities on a typical day?

Hr. Min.

The following question is about sitting or reclining at work, at home, getting to and from places, or with friends including time spent (sitting at a desk, sitting with friends, traveling in a car, bus, train, reading, playing cards or watching television), but do not include time spent sleeping.

(Insert examples and use showcard)

18. How much time do you usually spend sitting or reclining on a typical day?

Hr. Min.

Physical Activity Form (PAE) Page 0 of 4