Form 8 Wear Log Instrument (Attachment L)

ATTACHMENT L:
WEAR LOG INSTRUMENT

FLASHE Study Daily Physical Activity Log

OMB Number:0925-XXXX
Expiration Date:xx/xx/20xx

FLASHE Study
Daily Physical Activity Log
PID LABEL

Collection of this information is authorized by The Public Health Service Act, Section 411 (42 USC 285a). Rights of study
participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or
withdrawing from the study at any time. The information collected in this study will be kept private to the extent provided by law.
Names and other identifiers will not appear in any report of the study. Information provided will be combined for all study participants
and reported as summaries. You are being contacted by the National Cancer Institute (contact: FLASHEStudy@Westat.com) so we
can learn about behaviors that might prevent cancer.
Public reporting burden for this collection of information is estimated to average 5 minutes per day for a total of 35 minutes, 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.

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PID LABEL

HOW TO USE THIS ACTIVITY LOG
 The log book is divided into seven pages, one page for each day that you are to wear the
activity monitor. Complete one page for EVERY DAY that you wear the monitor.
 Start by circling the day of the week and write in the date you are wearing the activity
monitor.
 Write down the time you put the wrist monitor on. We ask that you begin wearing it at 8 PM
of the day we have designated as your first day (see letter included with this package).
 You do not need to write down anything from the device as it stores all the needed
information.
 If you remove the device, for example, when you take a bath or go swimming, please fill in
the times you take the monitor off and when you put it back on, and briefly describe the
activity.

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PID LABEL

DAY 1 of 7
Date: |__|__|/ |__|__|/|__|__|__|__|
Month

Day

Please circle the day:

Year

Mon / Tue / Wed / Thu / Fri / Sat / Sun

Time out of bed in the morning |__|__|:|__|__| AM/PM
Record the times during the day when the monitor was not worn. Briefly describe
the reason the monitor was not worn.
Time took monitor off

Time put back on

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

Time into bed for the night

Reason

|__|__|:|__|__| AM/PM

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PID LABEL

DAY 2 of 7
Date: |__|__|/ |__|__|/|__|__|__|__|
Month

Day

Please circle the day:

Year

Mon / Tue / Wed / Thu / Fri / Sat / Sun

Time out of bed in the morning |__|__|:|__|__| AM/PM
Record the times during the day when the monitor was not worn. Briefly describe
the reason the monitor was not worn.
Time took monitor off

Time put back on

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

Time into bed for the night

Reason

|__|__|:|__|__| AM/PM

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PID LABEL

DAY 3 of 7
Date: |__|__|/ |__|__|/|__|__|__|__|
Month

Day

Please circle the day:

Year

Mon / Tue / Wed / Thu / Fri / Sat / Sun

Time out of bed in the morning |__|__|:|__|__| AM/PM
Record the times during the day when the monitor was not worn. Briefly describe
the reason the monitor was not worn.
Time took monitor off

Time put back on

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

Time into bed for the night

Reason

|__|__|:|__|__| AM/PM

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PID LABEL

DAY 4 of 7
Date: |__|__|/ |__|__|/|__|__|__|__|
Month

Day

Please circle the day:

Year

Mon / Tue / Wed / Thu / Fri / Sat / Sun

Time out of bed in the morning |__|__|:|__|__| AM/PM
Record the times during the day when the monitor was not worn. Briefly describe
the reason the monitor was not worn.
Time took monitor off

Time put back on

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

Time into bed for the night

Reason

|__|__|:|__|__| AM/PM

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PID LABEL

DAY 5 of 7
Date: |__|__|/ |__|__|/|__|__|__|__|
Month

Day

Please circle the day:

Year

Mon / Tue / Wed / Thu / Fri / Sat / Sun

Time out of bed in the morning |__|__|:|__|__| AM/PM
Record the times during the day when the monitor was not worn. Briefly describe
the reason the monitor was not worn.
Time took monitor off

Time put back on

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

Time into bed for the night

Reason

|__|__|:|__|__| AM/PM

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PID LABEL

DAY 6 of 7
Date: |__|__|/ |__|__|/|__|__|__|__|
Month

Day

Please circle the day:

Year

Mon / Tue / Wed / Thu / Fri / Sat / Sun

Time out of bed in the morning |__|__|:|__|__| AM/PM
Record the times during the day when the monitor was not worn. Briefly describe
the reason the monitor was not worn.
Time took monitor off

Time put back on

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

Time into bed for the night

Reason

|__|__|:|__|__| AM/PM

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PID LABEL

DAY 7 of 7
Date: |__|__|/ |__|__|/|__|__|__|__|
Month

Day

Please circle the day:

Year

Mon / Tue / Wed / Thu / Fri / Sat / Sun

Time out of bed in the morning |__|__|:|__|__| AM/PM
Record the times during the day when the monitor was not worn. Briefly describe
the reason the monitor was not worn.
Time took monitor off

Time put back on

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

|__|__| :|__|__| am/pm

Time into bed for the night

Reason

|__|__|:|__|__| AM/PM

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