Form 42.1 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Physical Activity Monitor SAQ, Phase 2g

OMB Specification

Physical Activity Monitor 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:	9 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 SAQ

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

INSTRUCTIONS 3

GPS MONITOR (TO BE COMPLETED BY THE DATA COLLECTOR) 4

PHYSICAL ACTIVITY MONITORING SAQ 6

PHYSICAL ACTIVITY MONITOR (TO BE COMPLETED BY THE DATA COLLECTOR) 8

WEAR LOG AND SHIPPING 10

FOR DATA COLLECTOR USE ONLY: 13

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Physical Activity Monitor 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.

INSTRUCTIONS

INS00000. Please use a black or blue pen to complete this form. Do not use a felt-tip pen or pencil.

Mark X to indicate your answer.

To change your answer, draw a line through the box next to the answer you wish to change, and put an ‘X’ in the box next to the answer options you wish to select. 

Your answers are important. Please print clearly using uppercase, block letters (for example, “WEDNESDAY”).

Please follow the instructions in your booklet when completing this questionnaire.

PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP

GPS MONITOR (TO BE COMPLETED BY THE DATA COLLECTOR)

GPS01000. Monitoring period:

Start Date (Day of):

SOURCE

New

(GPS_START_MM) |___|___| 

  M     M      

SOURCE

New

(GPS_START_DD) |___|___|

   D    D

(GPS_START_YYYY)  20 |___|___|

 Y Y    Y     Y

GPS01100/(GPS_START_DAY). Start Day:

Label	Code	Go To
Monday	1
Tuesday	2
Wednesday	3
Thursday	4
Friday	5
Saturday	6
Sunday	7

SOURCE

New

GPS02000. End Date (Evening of):

SOURCE

New

(GPS_END_MM) |___|___|

  M     M

(GPS_END_DD) |___|___|

   D     D

(GPS_END_YYYY) 20|___|___|

YY  Y     Y

GPS03000/(GPS_END_DAY). End Day:

Label	Code	Go To
Monday	1
Tuesday	2
Wednesday	3
Thursday	4
Friday	5
Saturday	6
Sunday	7

SOURCE

New

PHYSICAL ACTIVITY MONITORING SAQ

PAS01000. The GPS monitor should be removed from the child's waist in the evening of the last day of the monitoring period. Enter the date the GPS monitor was last worn by the child.

SOURCE

New

(GPS_REMOVE_MM) |___|___|

  M     M

(GPS_REMOVE_DD) |___|___|

  D     D

(GPS_REMOVE_YYYY) 20|___|___|

YY   Y     Y

PAS02000/(GPS_LAST_WORN_DAY). Mark the day of the week the GPS monitor was last worn by the child.

Label	Code	Go To
Monday	1
Tuesday	2
Wednesday	3
Thursday	4
Friday	5
Saturday	6
Sunday	7

SOURCE

New

PAS03000. Enter the time the GPS monitor was last worn by the child.

SOURCE

New

(GPS_LAST_WORN_TIME) TIME: |___|___|:|___|___|

           H     H       M     M

(GPS_LAST_WORN_TIME_UNIT)

Label	Code	Go To
AM	1
PM	2

PAS04000/(GPS_PROBLEMS). Were there any problems with the GPS monitor? Please check all that apply.

Label	Code	Go To
No problems	1
Problems with charging	2
Not able to turn on	3
Waistband/Pouch damaged	4
Monitor damaged	5
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you selected "Other" and any other response, go to PAS05000.

• If you did not select "Other," go to PAS06000.

PAS05000/(GPS_PROBLEMS_OTH). SPECIFY: _________________________________________

SOURCE

New

PAS06000/(GPS_COMMENTS). Enter any comments about the GPS monitoring of your child

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SOURCE

New

PHYSICAL ACTIVITY MONITOR (TO BE COMPLETED BY THE DATA COLLECTOR)

PAM01000. Monitoring period:

Start Date (Day of):

SOURCE

New

(PA_START_MM) |___|___| 

 M     M        

(PA_START_DD) |___|___|

   D     D

(PA_START_YYYY) 20|___|___|

YY   Y     Y

PAM02000/(PA_START_DAY). Start Day:

Label	Code	Go To
Monday	1
Tuesday	2
Wednesday	3
Thursday	4
Friday	5
Saturday	6
Sunday	7

SOURCE

New

PAM03000. End Date (Morning of):

SOURCE

New

(PA_END_MM) |___|___|

   M     M

(PA_END_DD) |___|___|

  D     D

(PA_END_YYYY) 20|___|___|

YY   Y    Y

PAM04000/(PA_END_DAY). End Day:

Label	Code	Go To
Monday	1
Tuesday	2
Wednesday	3
Thursday	4
Friday	5
Saturday	6
Sunday	7

SOURCE

New

WEAR LOG AND SHIPPING

WLA01000. The physical activity monitor should be removed from the child's wrist on the morning after the last day of the monitoring period. Enter the date the physical activity monitor was removed.

 

DATE:

SOURCE

New

(PA_REMOVE_MM) |___|___|

  M     M

(PA_REMOVE_DD) |___|___|

  D     D

(PA_REMOVE_YYYY) 20|___|___|

YY   Y     Y

WLA02000/(PA_LAST_WORN_DAY). Mark the day of the week the physical activity monitor was removed from the child's wrist.

Label	Code	Go To
Monday	1
Tuesday	2
Wednesday	3
Thursday	4
Friday	5
Saturday	6
Sunday	7

SOURCE

New

WLA03000. Enter the time the physical activity monitor was removed from the child's wrist.

SOURCE

New

(PA_LAST_WORN_TIME) TIME: |___|___|:|___|___|

            H    H       M     M

(PA_LAST_WORN_TIME_UNIT)

Label	Code	Go To
AM	1
PM	2

WLA04000/(PA_PROBLEMS). Were there any problems with the physical activity monitor? Please check all that apply.

Label	Code	Go To
No problems	1
Wrist band damaged	2
Monitor damaged	3
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you selected "Other" and any other response, go to WLA05000.

• Otherwise, if you did not select "Other," go to ?WLA06000.

WLA05000/(PA_PROBLEMS_OTH). SPECIFY: ___________________________________________________

SOURCE

New

WLA06000/(PA_COMMENTS). Enter any comments about the physical activity monitor worn by your child.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SOURCE

New

WLA07000/(LOG_COMPLETED). Is the wear log completed?

Label	Code	Go To
Yes	1	PACK_MONITORS_PROB
No	2

SOURCE

New

WLA08000/(LOG_INCOMPLETE_REASON). Why is the wear log not completed?

Label	Code	Go To
Wear log missing	1	PACK_MONITORS_PROB
Instructions not clear	2	PACK_MONITORS_PROB
Ran out of time	3	PACK_MONITORS_PROB
Other	-5

SOURCE

New

WLA09000/(LOG_INCOMPLETE_REASON_OTH). SPECIFY: _______________________________________________

SOURCE

New

WLA10000/(PACK_MONITORS_PROB). Were there any problems packing up the monitors for shipping? Please check all that apply.

Label	Code	Go To
No problems	1
Shipping supplies missing	2
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you selected "Other" and any other response, go to WLA11000.

• Otherwise, if you did not select "Other," go to ?WLA12000.

WLA11000/(PACK_MONITORS_PROB_OTH). SPECIFY: ____________________________________________

SOURCE

New

WLA12000. Thank you very much for completing this questionnaire! All of your answers are very important.

 

Please help us by looking at each question again to make sure you:

• Did not incorrectly skip any questions, and

• Drew a line through the answer options you wished to change and put an 'X' next to the answer options you wished to select

 

Place this questionnaire in a resealable plastic bag and ship it with the physical activity monitor, GPS monitor and wear log to the following address: [Include the shipping address here.]

If you have any questions about your child's activity monitoring or shipping the monitors, please contact us at: [Include ROC contact information (phone number, email address, etc.) here.]

FOR DATA COLLECTOR USE ONLY:

FDC01000/(GPS_EQUIP_ID). Equipment ID of the GPS monitor

Equipment ID: _________________________________________

FDC02000/(PA_EQUIP_ID). Equipment ID of the physical activity monitor

Equipment ID: ___________________________________________

FDC03000/(SHIP_TRACK_NUM). Shipment tracking number: _____________________________________________

FDC04000/(STAFF_ID). Staff ID: _________________________________________________

FDC05000/(R_P_ID). Respondent ID: _____________________________________________

FDC06000/(P_ID). Participant ID: _____________________________________________

Public reporting burden for this collection of information is estimated to average 9 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.