42.3 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Physical Activity Monitor Log SAQ, Phase 2g

OMB Specification

Physical Activity Monitor Log SAQ

Event Category:	Time-Based
Event:	36M, 48M, 60M
Administration:	N/A
Instrument Target:	Child
Instrument Respondent:	Primary Caregiver
Domain:	Environmental
Document Category:	Sample Collection
Method:	Self-Administered
Mode (for this instrument*):	In-Person, PAPI
OMB Approved Modes:	In-Person, PAPI; Phone, PAPI; Web-Based, CAI
Estimated Administration Time:	14 minutes
Multiple Child/Sibling Consideration:	Per Child
Special Considerations:	N/A
Version:	1.0
MDES Release:	4.0

​​*This instrument is OMB-approved for multi-mode administration, but this version of the instrument is designed for administration in this/these mode(s) only.

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Physical Activity Monitor Log SAQ

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

ACTIVITY MONITOR AND LOG 3

FOR OFFICE USE ONLY: 24

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Physical Activity Monitor Log SAQ

GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:

DATA ELEMENT FIELDS	MAXIMUM CHARACTERS PERMITTED	DATA TYPE	PROGRAMMER INSTRUCTIONS
ADDRESS AND EMAIL FIELDS	100	CHARACTER
UNIT AND PHONE FIELDS	10	CHARACTER
_OTH AND COMMENT FIELDS	255	CHARACTER	Limit text to 255 characters
FIRST NAME AND LAST NAME	30	CHARACTER	Limit text to 30 characters
ALL ID FIELDS	36	CHARACTER
ZIP CODE	5	NUMERIC
ZIP CODE LAST FOUR	4	NUMERIC
CITY	50	CHARACTER
DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)	10	NUMERIC CHARACTER	DISPLAY AS MM/DD/YYYY STORE AS YYYY-MM-DD HARD EDITS: MM MUST EQUAL 01 TO 12 DD MUST EQUAL 01 TO 31 YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.
TIME VARIABLES	TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION	NUMERIC	HARD EDITS: HOURS MUST BE BETWEEN 00 AND 12; MINUTES MUST BE BETWEEN 00 AND 59

Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).

POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.

A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.

ACTIVITY MONITOR AND LOG

AMA01000. Activity Monitor and Log Use for:

(PA_CHILD_NAME) Name: _________________________________________

SOURCE

New

(PA_CHILD_AGE) Age: |___|___| Years

SOURCE

New

AMA02000. Please fill in the appropriate row at the end of each day.

If the monitor was removed, please note the times when it was not worn and why. You do not need to record removing the GPS from the waist at bedtime.

AMA03000/(PA_DAY1). Day of Week

Day 1 - __________________

SOURCE

New

AMA04000. Date

SOURCE

New

(PA_DATE1_MM) MONTH: |___|___|

(PA_DATE1_DD) DAY: |___|___|

(PA_DATE1_YYYY) YEAR: 20|___|___|

AMA05000. Time child got out of bed

SOURCE

New

(PA_WAKE_TIME1) |___|___|:|___|___|

(PA_WAKE_TIME1_UNIT)

Label	Code	Go To
AM	1
PM	2

AMA06000. Time child went to bed

SOURCE

New

(PA_BED_TIME1) |___|___|:|___|___|

(PA_BED_TIME1_UNIT)

Label	Code	Go To
AM	1
PM	2

AMA07000/(PA_WORE_PA1). Wore Activity Monitor Throughout the Day

Wore physical activity monitor on wrist?

Label	Code	Go To
Yes	1	PA_WORE_GPS1
No	2

SOURCE

New

AMA08000/(PA_HRS_WORN_PA1). Approx. # hrs monitor not worn as specified

|___|___|

Hours

SOURCE

New

AMA09000/(PA_NOT_WORN_PA1). Why was monitor not worn? Mark all that apply.

Label	Code	Go To
Removed by the child	1
Not allowed at daycare	2
Needed to remove it at airport	3
Monitor was damaged	4
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you answered "other" or "other" and any combination of the first four answers, go to PA_NOT_WORN_PA1_OTH.

• If you did not answer "other," go to PA_WORE_GPS1.

AMA10000/(PA_NOT_WORN_PA1_OTH). Specify reason: _____________________________________________________________

SOURCE

New

AMA11000/(PA_WORE_GPS1). Wore Activity Monitor Throughout the Day

Wore GPS monitor on waist, except at bedtime?

Label	Code	Go To
Yes	1	PA_DAY2
No	2

SOURCE

New

AMA12000/(PA_HRS_WORN_GPS1). Approx. # hrs monitor not worn as specified

|___|___|

Hours

SOURCE

New

AMA13000/(PA_NOT_WORN_GPS1). Why was monitor not worn? Mark all that apply.

Label	Code	Go To
Child in water	1
Removed by the child	2
Not allowed at daycare	3
Needed to remove it at airport	4
Monitor was damaged	5
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you answered "other" or "other" and any combination of the first five answers, go to PA_NOT_WORN_GPS1_OTH.

• If you did not answer "other," go to PA_DAY2.

AMA14000/(PA_NOT_WORN_GPS1_OTH). Specify reason: ______________________________________________

SOURCE

New

AMA15000/(PA_DAY2). Day of Week

Day 2 - ____________________

SOURCE

New

AMA16000. Date

SOURCE

New

(PA_DATE2_MM) MONTH: |___|___|

(PA_DATE2_DD) DAY: |___|___|

(PA_DATE2_YYYY) YEAR: 20|___|___|

AMA17000. Time child got out of bed

SOURCE

New

(PA_WAKE_TIME2) |___|___|:|___|___|

(PA_WAKE_TIME2_UNIT)

Label	Code	Go To
AM	1
PM	2

AMA18000. Time child went to bed

SOURCE

New

(PA_BED_TIME2) |___|___|:|___|___|

(PA_BED_TIME2_UNIT)

Label	Code	Go To
AM	1
PM	2

AMA19000/(PA_WORE_PA2). Wore Activity Monitor Throughout the Day

Wore physical activity monitor on wrist?

Label	Code	Go To
Yes	1	PA_WORE_GPS2
No	2

SOURCE

New

AMA20000/(PA_HRS_WORN_PA2). Approx. # hrs monitor not worn as specified

|___|___|

Hours

SOURCE

New

AMA21000/(PA_NOT_WORN_PA2). Why was monitor not worn? Mark all that apply.

Label	Code	Go To
Removed by the child	1
Not allowed at daycare	2
Needed to remove it at airport	3
Monitor was damaged	4
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you answered "other" or "other" and any combination of the first four answers, go to PA_NOT_WORN_PA2_OTH.

• If you did not answer "other," go to PA_WORE_GPS2.

AMA22000/(PA_NOT_WORN_PA2_OTH). Specify reason: _____________________________________

SOURCE

New

AMA23000/(PA_WORE_GPS2). Wore Activity Monitor Throughout the Day

Wore GPS monitor on waist, except at bedtime?

Label	Code	Go To
Yes	1	PA_DAY3
No	2

SOURCE

New

AMA24000/(PA_HRS_WORN_GPS2). Approx. # hrs monitor not worn as specified

|___|___|

Hours

SOURCE

New

AMA25000/(PA_NOT_WORN_GPS2). Why was monitor not worn? Mark all that apply.

Label	Code	Go To
Child in water	1
Removed by the child	2
Not allowed at daycare	3
Needed to remove it at airport	4
Monitor was damaged	5
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you answered "other" or "other" and any combination of the first five answers, go to PA_NOT_WORN_GPS2_OTH.

• If you did not answer "other," go to PA_DAY3.

AMA26000/(PA_NOT_WORN_GPS2_OTH). Specify reason: _____________________________________________________________

SOURCE

New

AMA27000/(PA_DAY3). Day of Week

Day 3 - ______________________

SOURCE

New

AMA28000. Date

SOURCE

New

(PA_DATE3_MM) MONTH: |___|___|

(PA_DATE3_DD) DAY: |___|___|

(PA_DATE3_YYYY) YEAR: 20|___|___|

AMA29000. Time child got out of bed

SOURCE

New

(PA_WAKE_TIME3) |___|___|:|___|___|

(PA_WAKE_TIME3_UNIT)

Label	Code	Go To
AM	1
PM	2

AMA30000. Time child went to bed

SOURCE

New

(PA_BED_TIME3) |___|___|:|___|___|

(PA_BED_TIME3_UNIT)

Label	Code	Go To
AM	1
PM	2

AMA31000/(PA_WORE_PA3). Wore Activity Monitor Throughout the Day

Wore physical activity monitor on wrist?

Label	Code	Go To
Yes	1	PA_WORE_GPS3
No	2

SOURCE

New

AMA32000/(PA_HRS_WORN_PA3). Approx. # hrs monitor not worn as specified

|___|___|

Hours

SOURCE

New

AMA33000/(PA_NOT_WORN_PA3). Why was monitor not worn? Mark all that apply.

Label	Code	Go To
Removed by the child	1
Not allowed at daycare	2
Needed to remove it at airport	3
Monitor was damaged	4
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you answered "other" or "other" and any combination of the first four answers, go to PA_NOT_WORN_PA3_OTH.

• If you did not answer "other," go to PA_WORE_GPS3.

AMA34000/(PA_NOT_WORN_PA3_OTH). Specify reason: ____________________________________________

SOURCE

New

AMA35000/(PA_WORE_GPS3). Wore Activity Monitor Throughout the Day

Wore GPS monitor on waist, except at bedtime?

Label	Code	Go To
Yes	1	PA_DAY4
No	2

SOURCE

New

AMA36000/(PA_HRS_WORN_GPS3). Approx. # hrs monitor not worn as specified

|___|___|

Hours

SOURCE

New

AMA37000/(PA_NOT_WORN_GPS3). Why was monitor not worn? Mark all that apply.

Label	Code	Go To
Child in water	1
Removed by the child	2
Not allowed at daycare	3
Needed to remove it at airport	4
Monitor was damaged	5
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you answered "other" or "other" and any combination of the first five answers, go to PA_NOT_WORN_GPS3_OTH.

• If you did not answer "other," go to PA_DAY4.

AMA38000/(PA_NOT_WORN_GPS3_OTH). Specify reason: ___________________________________________________

SOURCE

New

AMA39000/(PA_DAY4). Day of Week

Day 4 - ___________________________

SOURCE

New

AMA40000. Date

SOURCE

New

(PA_DATE4_MM) MONTH: |___|___|

(PA_DATE4_DD) DAY: |___|___|

(PA_DATE4_YYYY) YEAR: 20|___|___|

AMA41000. Time child got out of bed

SOURCE

New

(PA_WAKE_TIME4) |___|___|:|___|___|

(PA_WAKE_TIME4_UNIT)

Label	Code	Go To
AM	1
PM	2

AMA42000. Time child went to bed

SOURCE

New

(PA_BED_TIME4) |___|___|:|___|___|

(PA_BED_TIME4_UNIT)

Label	Code	Go To
AM	1
PM	2

AMA43000/(PA_WORE_PA4). Wore Activity Monitor Throughout the Day

Wore physical activity monitor on wrist?

Label	Code	Go To
Yes	1	PA_WORE_GPS4
No	2

SOURCE

New

AMA44000/(PA_HRS_WORN_PA4). Approx. # hrs monitor not worn as specified

|___|___|

Hours

SOURCE

New

AMA45000/(PA_NOT_WORN_PA4). Why was monitor not worn? Mark all that apply.

Label	Code	Go To
Removed by the child	1
Not allowed at daycare	2
Needed to remove it at airport	3
Monitor was damaged	4
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you answered "other" or "other" and any combination of the first four answers, go to PA_NOT_WORN_PA4_OTH.

• If you did not answer "other," go to PA_WORE_GPS4.

AMA46000/(PA_NOT_WORN_PA4_OTH). Specify reason: _______________________________________

SOURCE

New

AMA47000/(PA_WORE_GPS4). Wore Activity Monitor Throughout the Day

Wore GPS monitor on waist, except at bedtime?

Label	Code	Go To
Yes	1	PA_DAY5
No	2

SOURCE

New

AMA48000/(PA_HRS_WORN_GPS4). Approx. # hrs monitor was not worn as specified

|___|___|

Hours

SOURCE

New

AMA49000/(PA_NOT_WORN_GPS4). Why was monitor not worn? Mark all that apply.

Label	Code	Go To
Child in water	1
Removed by the child	2
Not allowed at daycare	3
Needed to remove it at airport	4
Monitor was damaged	5
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you answered "other" or "other" and any combination of the first five answers, go to PA_NOT_WORN_GPS4_OTH.

• If you did not answer "other," go to PA_DAY5.

AMA50000/(PA_NOT_WORN_GPS4_OTH). Specify reason: _______________________________________

SOURCE

New

AMA51000/(PA_DAY5). Day of Week

Day 5 - ________________

SOURCE

New

AMA52000. Date

SOURCE

New

(PA_DATE5_MM) MONTH: |___|___|

(PA_DATE5_DD) DAY: |___|___|

(PA_DATE5_YYYY) YEAR: 20|___|___|

AMA53000. Time child got out of bed

SOURCE

New

(PA_WAKE_TIME5) |___|___|:|___|___|

(PA_WAKE_TIME5_UNIT)

Label	Code	Go To
AM	1
PM	2

AMA54000. Time child went to bed

SOURCE

New

(PA_BED_TIME5) |___|___|:|___|___|

(PA_BED_TIME5_UNIT)

Label	Code	Go To
AM	1
PM	2

AMA55000/(PA_WORE_PA5). Wore Activity Monitor Throughout the Day

Wore physical activity monitor on wrist?

Label	Code	Go To
Yes	1	PA_WORE_GPS5
No	2

SOURCE

New

AMA56000/(PA_HRS_WORN_PA5). Approx. # hrs not worn as specified

|___|___|

Hours

SOURCE

New

AMA57000/(PA_NOT_WORN_PA5). Why was monitor not worn? Mark all that apply.

Label	Code	Go To
Removed by the child	1
Not allowed at daycare	2
Needed to remove it at airport	3
Monitor was damaged	4
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you answered "other" or "other" and any combination of the first four answers, go to PA_NOT_WORN_PA5_OTH.

• If you did not answer "other," go to PA_WORE_GPS5.

AMA58000/(PA_NOT_WORN_PA5_OTH). Specify reason: _______________________________________

SOURCE

New

AMA59000/(PA_WORE_GPS5). Wore Activity Monitor Throughout the Day

Wore GPS monitor on waist, except at bedtime?

Label	Code	Go To
Yes	1	PA_DAY6
No	2

SOURCE

New

AMA60000/(PA_HRS_WORN_GPS5). Approx. # hrs monitor not worn as specified

|___|___|

Hours

SOURCE

New

AMA61000/(PA_NOT_WORN_GPS5). Why was monitor not worn? Mark all that apply.

Label	Code	Go To
Child in water	1
Removed by the child	2
Not allowed at daycare	3
Needed to remove it at airport	4
Monitor was damaged	5
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you answered "other" or "other" and any combination of the first five answers, go to PA_NOT_WORN_GPS5_OTH.

• If you did not answer "other," go to PA_DAY6.

AMA62000/(PA_NOT_WORN_GPS5_OTH). Specify reason: ________________________________________

SOURCE

New

AMA63000/(PA_DAY6). Day of Week

Day 6 - ________________________

SOURCE

New

AMA64000. Date

SOURCE

New

(PA_DATE6_MM) MONTH: |___|___|

(PA_DATE6_DD) DAY: |___|___|

(PA_DATE6_YYYY) YEAR: 20|___|___|

AMA65000. Time child got out of bed

SOURCE

New

(PA_WAKE_TIME6) |___|___|:|___|___|

(PA_WAKE_TIME6_UNIT)

Label	Code	Go To
AM	1
PM	2

AMA66000. Time child went to bed

SOURCE

New

(PA_BED_TIME6) |___|___|:|___|___|

(PA_BED_TIME6_UNIT)

Label	Code	Go To
AM	1
PM	2

AMA67000/(PA_WORE_PA6). Wore Activity Monitor Throughout the Day

Wore physical activity monitor on wrist?

Label	Code	Go To
Yes	1	PA_WORE_GPS6
No	2

SOURCE

New

AMA68000/(PA_HRS_WORN_PA6). Approx. # hrs monitor not worn as specified

|___|___|

Hours

SOURCE

New

AMA69000/(PA_NOT_WORN_PA6). Why was monitor not worn? Mark all that apply.

Label	Code	Go To
Removed by the child	1
Not allowed at daycare	2
Needed to remove it at airport	3
Monitor was damaged	4
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you answered "other" or "other" and any combination of the first four answers, go to PA_NOT_WORN_PA6_OTH.

• If you did not answer "other," go to PA_WORE_GPS6.

AMA70000/(PA_NOT_WORN_PA6_OTH). Specify reason: ___________________________________________

SOURCE

New

AMA71000/(PA_WORE_GPS6). Wore Activity Monitor Throughout the Day

Wore GPS monitor on waist, except at bedtime?

Label	Code	Go To
Yes	1	PA_DAY7
No	2

SOURCE

New

AMA72000/(PA_HRS_WORN_GPS6). Approx. # hrs monitor not worn as specified

|___|___|

Hours

SOURCE

New

AMA73000/(PA_NOT_WORN_GPS6). Why was monitor not worn? Mark all that apply.

Label	Code	Go To
Child in water	1
Removed by the child	2
Not allowed at daycare	3
Needed to remove it at airport	4
Monitor was damaged	5
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you answered "other" or "other" and any combination of the first five answers, go to PA_NOT_WORN_GPS6_OTH.

• If you did not answer "other," go to PA_DAY7.

AMA74000/(PA_NOT_WORN_GPS6_OTH). Specify reason: ___________________________________

SOURCE

New

AMA75000/(PA_DAY7). Day of Week

Day 7 - ______________

SOURCE

New

AMA76000. Date

SOURCE

New

(PA_DATE7_MM) MONTH: |___|___|

(PA_DATE7_DD) DAY: |___|___|

(PA_DATE7_YYYY) YEAR: 20|___|___|

AMA77000. Time child got out of bed

SOURCE

New

(PA_WAKE_TIME7) |___|___|:|___|___|

(PA_WAKE_TIME7_UNIT)

Label	Code	Go To
AM	1
PM	2

AMA78000. Time child went to bed

SOURCE

New

(PA_BED_TIME7) |___|___|:|___|___|

(PA_BED_TIME7_UNIT)

Label	Code	Go To
AM	1
PM	2

AMA79000/(PA_WORE_PA7). Wore Activity Monitor Throughout the Day

Wore physical activity monitor on wrist?

Label	Code	Go To
Yes	1	PA_WORE_GPS7
No	2

SOURCE

New

AMA80000/(PA_HRS_WORN_PA7). Approx. # hrs monitor not worn as specified

|___|___|

Hours

SOURCE

New

AMA81000/(PA_NOT_WORN_PA7). Why was monitor not worn? Mark all that apply.

Label	Code	Go To
Removed by the child	1
Not allowed at daycare	2
Needed to remove it at airport	3
Monitor was damaged	4
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you answered "other" or "other" and any combination of the first four answers, go to PA_NOT_WORN_PA7_OTH.

• If you did not answer "other," go to PA_WORE_GPS7.

AMA82000/(PA_NOT_WORN_PA7_OTH). Specify reason: _________________________________

SOURCE

New

AMA83000/(PA_WORE_GPS7). Wore Activity Monitor Throughout the Day

Wore GPS monitor on waist, except at bedtime?

Label	Code	Go To
Yes	1	PA_DAY8
No	2

SOURCE

New

AMA84000/(PA_HRS_WORN_GPS7). Approx. # hrs monitor not worn as specified

|___|___|

Hours

SOURCE

New

AMA85000/(PA_NOT_WORN_GPS7). Why was monitor not worn? Mark all that apply.

Label	Code	Go To
Child in water	1
Removed by the child	2
Not allowed at daycare	3
Needed to remove it at airport	4
Monitor was damaged	5
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you answered "other" or "other" and any combination of the first five answers, go to PA_NOT_WORN_GPS7_OTH.

• If you did not answer "other," go to PA_DAY8.

AMA86000/(PA_NOT_WORN_GPS7_OTH). Specify reason: _______________________________________

SOURCE

New

AMA87000/(PA_DAY8). Day of Week

Day 8 - _________________

SOURCE

New

AMA88000. Date

SOURCE

New

(PA_DATE8_MM) MONTH: |___|___|

(PA_DATE8_DD) DAY: |___|___|

(PA_DATE8_YYYY) YEAR: 20|___|___|

AMA89000. Time child got out of bed

SOURCE

New

(PA_WAKE_TIME8) |___|___|:|___|___|

(PA_WAKE_TIME8_UNIT)

Label	Code	Go To
AM	1
PM	2

AMA90000. Time child went to bed

SOURCE

New

(PA_BED_TIME8) |___|___|:|___|___|

(PA_BED_TIME8_UNIT)

Label	Code	Go To
AM	1
PM	2

AMA91000/(PA_WORE_PA8). Wore Activity Monitor Throughout the Day

Wore physical activity monitor on wrist?

Label	Code	Go To
Yes	1	PA_COMMENTS
No	2

SOURCE

New

AMA92000/(PA_HRS_WORN_PA8). Approx. # hrs monitor not worn as specified

|___|___|

Hours

SOURCE

New

AMA93000/(PA_NOT_WORN_PA8). Why was monitor not worn? Mark all that apply.

Label	Code	Go To
Removed by the child	1
Not allowed at daycare	2
Needed to remove it at airport	3
Monitor was damaged	4
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you answered "other" or "other" and any combination of the first four answers, go to PA_NOT_WORN_PA8_OTH.

• If you did not answer "other," go to PA_COMMENTS.

AMA94000/(PA_NOT_WORN_PA8_OTH). Specify reason: __________________________________________

SOURCE

New

AMA94100/(PA_COMMENTS). Additional Comments - Please record any additional comments you have about wearing the devices.

__________________________________________________________________________________________

SOURCE

New

FOR OFFICE USE ONLY:

FOU01000/(P_ID). Insert participant ID? label here.

FOU02000/(R_P_ID). Insert respondent ID? label here.

FOU03000. Insert ROC contact information? label here.

Public reporting burden for this collection of information is estimated to average 14 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 (0925-0593*). Do not return the completed form to this address.