Goal Setting Worksheet (Program Participant/Mentee

Form Approved OMB No. 0990-XXXX Exp. Date XX/XX/XX11

Goal Setting Worksheet

Participant ID: __________________________________________

1.

Setting Your Goal
In the next eight weeks, my main goal(s) is/are: (check all that apply)
❏ Lose weight (# of lbs:_______)

❏ Get more strength

❏ Exercise more often

❏ Get more energy

❏ Make better eating choices

❏ Achieve the PALA*

❏ Be more physically active

❏ Other (describe)
___________________________

*(PALA) requires participation in physical activity 1 hour per day, 5 days per week for 6 weeks

2.

Choosing Activities To Meet Your Goal
In choosing activities, remember that:

• You don’t necessarily need to spend lots of money on exercise equipment or

memberships in gyms — lots of physical activity can be done by yourself with
things you already have handy.

• You can choose an organized sport (e.g., join a team), but you can also do activities associated with a sport by yourself.

• You should work with your mentor to choose the most appropriate physical activities for you.

Some examples of activities you can do either on your own or with others include:
Bicycling using either legs or an arm cycle
Chair Aerobics
Baseball or Softball
Water Exercise
Weightlifting (weights, canned goods, bricks)
Walking or Jogging

Gardening
Soccer
Golfing
Swimming
Yoga
Wheeling

Arm dancing
Dancing
Basketball
Bowling

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 information collection is 0990- XXXX. The time required to complete this
information collection is estimated to average XX hours or xx minutes per response, including the time to review instructions, search existing
data resources, gather the 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,
ASRT/OCIO/PRA, 200 Independence Ave., S.W., Suite 531-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.

A. In the box below, write down specific physical activity goals you would like to
achieve in the next eight weeks.

B.

Which days each week would I like to do my physical activity?
(check days) (PALA requires 5 days per week)
❏ Sunday

❏ Thursday

❏ Monday

❏ Friday

❏ Tuesday

❏ Saturday

❏ Wednesday
C.

How much time will I spend to work on my goal on the days I selected?
(check one) (PALA requires 60 minutes per day for 5 days)
❏ 20 minutes

❏ 50 minutes

❏ 30 minutes

❏ 60 minutes

❏ 40 minutes

❏ Other: ____________________