National-Scale Activity Survey - Screening

OMB Control Number 2060-XXXX

Approval Expires xx/xx/xxxx

Screening Questions

Thank you for your interest in this survey. In this survey we will ask you about issues related to your quality of life. This survey is being conducted by Research Triangle Institute, a non-profit research organization.

Please first answer some questions about your situation to confirm that you are eligible to participate in the survey. If you have any problems or concerns about this survey, please contact Panel Relations at 800-782-7699, and someone will direct your questions to the appropriate researchers at Research Triangle Institute.

1. “During the past month, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise for work or for leisure?”  

   1. Yes

   2. No

2. How many people live in your household, including yourself?

   1. _______ people

3. How many children (less than 18 years old) currently live in your household?

   1. _____children

4. Are you currently living with a spouse or partner?

   1. Yes

   2. No

If “no” to Q1, then: “Thank you for your interest, but you are not eligible for today’s survey.”

The public reporting and recordkeeping burden for this collection of information is estimated to average 3 minutes per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed survey to this address.