Form 1 YES Initiative Performance Measures: Physical Activity a

YES Initiative Performance Measures:

Physical Activity and Nutrition Survey

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this data collection is 0990-XXXX. The time required to complete this information collection is estimated at 20 minutes per response, including the time to review instructions, search existing data sources, gather data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W. Suite 336-E, Washington D.C. 20201. Attention: PRA Reports Clearance Officer Outcomes

1. Were you physically active for a total of at least 60 minutes yesterday? (Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard some of the time.)

A. Yes

B. No

C. Not sure

2. How many minutes were you physically active yesterday? (Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard some of the time.)

A. Less than 15 minutes

B. 15 minutes to 29 minutes

C. 30 minutes to 44 minutes

D. 45 minutes to 59 minutes

E. 60 minutes or more

F. Not sure

3. Did you eat fresh fruit yesterday? (Do not count fruit juice.)

A. Yes

B. No

C. Not sure

4. Did you eat vegetables such as green salad, carrots, green beans, or other vegetables yesterday? (Do not count potatoes or French Fries.)

A. Yes

B. No

C. Not sure

5. Did you drink a can, bottle, or glass of pop or soda, such as Coke, Pepsi, or Sprite yesterday? (Do not count diet pop or diet soda)

A. Yes

B. No

C. Not sure

6. Did you drink a sports drink, such as Gatorade or PowerAde yesterday? (Do not count diet sports drinks)

A. Yes

B. No

C. Not sure

7. Are you Hispanic or Latino?

A. Yes

B. No

8. What is your race? (Select one or more responses.)

A. American Indian or Alaska Native

B. Asian

C. Black or African American

D. Native Hawaiian or Other Pacific Islander

E. White

9. What is your sex?

A. Male

B. Female