Weekly Check-In Form

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

Weekly Check-In Worksheet

PARTICIPANT USER ID
DATE
1.

Review the goal you set on the Goal Setting Worksheet - both the physical activity
you wanted to do and the amount of time you wanted to do it.

2.

Did you do this physical activity this
week?
2A.

3.
3A.

3B.

YES

NO

If you checked “yes”, for about how many minutes did
you do it over the course of the whole week?
Did you do other types of physical
activities during the week?

YES

NO

If you checked “yes” what were they?

For about how many minutes did you do it over the
course of the whole week?
Please turn in a copy of this worksheet to your mentor.

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.