National-Scale Activity Survey - Activity Dairy

OMB Control Number 2060-xxxx

Approval Expires xx/xx/xxxx

base: all respondents

In this survey, we are asking you to fill out a “diary” of various activities that you did on INSERT DATE. It may be hard to remember what you did and when, but it is important to this research project for you to give us the most accurate information possible. The information from your diary and the other people taking these surveys will be used for studies of activity patterns.

Please be assured that any information you provide will be kept strictly confidential. Your name will not be provided to anyone outside Knowledge Networks and you answers will never be linked to your name.

Remember that you will earn **** points/dollars for taking this survey and **** if you fill out all seven days of diary surveys we will send you.

Let’s begin.

base: respONDENTS WHO ENTERED SURVEY AFTER 48 HOURS OF INVITATION

[if more than 48 hours since INSERT DATE] Unfortunately the deadline for filling out this diary has passed. Diaries need to be filled out within 48 hours of when we send you the invitation. Please keep checking for additional opportunities to fill out up to 7 diaries in total.

base: ALL QUALIFIED RESPONDENTS

Q1: What time did you wake up on INSERT DATE?

01 12:00 A.M

…

02 6:00 A.M.

03 6:15 A.M.

04 6:30 A.M.

05 6:45 A.M.

06 7:00 A.M.

07 7:15 A.M.

08 7:30 A.M.

09 7:45 A.M.

10 8:00 A.M.

11 8:15 A.M.

…

59 11:45 P.M.

base: ALL QUALIFIED RESPONDENTS

Q2: When you got woke up on INSERT DATE, where were you?

Indoors at

1. Home

2. Work or school

3. Other's home

4. Indoors other [go to Q2.1]    

Outdoors at

1. Home or near home

2. Work or school

3. Other's home

4. A parking lot/garage

5. A park or natural area

6. Outdoors other [go to Q2.1]    

In a vehicle

1. A private vehicle (for example, car, truck, taxi)

2. A public vehicle (for example, bus, train, airplane)

3. Other vehicle

Q2.1 [if chose “other”] What other place were you? _________________

base: ALL QUALIFIED RESPONDENTS

Q3: Now think about the first thing you did immediately after waking up at [programmer note: insert response from q3]. Please pick the type of activity from the following list or tell us what you did by choosing the “other” category.

1. Shower, bathe, personal hygiene

2. Eat

3. Sleep/Nap

4. Work (any paid work)

5. Childcare

6. Caregiving for an adult

7. General household activities

8. General leisure activities

9. Shop, run errands

10. Attend classes

11. Exercise, participate in sports

12. Travel to another destination [skip to Q4.2]

99. Other

Q3.1 [if chose other 99] What other activity did you do?____________

Q3.2 [if activity is “travel”] Method of travel

1. Car

2. Hybrid car

3. Minivan

4. Full-size Passenger Van

5. SUV

6. Motorcycle

7. Pickup truck

8. Walking/Running to destination

9. Riding on a bus,

10. Riding on a train, subway or light rail

11. Commercial vehicle

12. Bicycle, Skate, etc. to destination

13. Airplane

14. Boat

99. Other method

Q3.3 [if chose other 99] What other method of travel did you use?____________

base: ALL QUALIFIED RESPONDENTS

Q4: What was your level of activity? Please select the level of activity from the list below.

Activity	Description	Energy Level
Sleep	Sleeping	Very Low	□
Sedentary	For example, sitting	Low	□
Light	For example, standing	Low active	□
Moderate	Moderate activities cause only light sweating or a slight to moderate increase in breathing or heart rate. Some examples are brisk walking, bicycling for pleasure, golf, or dancing.	Moderate	□
Vigorous	Vigorous activities cause moderate sweating or large increases in breathing or heart rate. An example is jogging.	Heavy/vigorous	□
Maximal exertion	Maximal exertion activities cause heavy sweating or large increases in breathing or heart rate. An example is running hard.	Maximal exertion	□

base: ALL QUALIFIED RESPONDENTS

The table below lists all your activities so far. If you need to change one of your responses, please click on the item you need to change and use the drop down list to select the correct response.

Time	Activity	Location or Method of travel	Activity Level
Before Q1	Wake up and get out of bed	Q2	Sleep
Q1	Q3	Q2	Q4

base: ALL QUALIFIED RESPONDENTS

Q5 What time did you finish [insert Q3]?

Time [PROGRAMMER NOTE: SHOW CHOICES FROM Q1, Starting with Q1.]

01 12:00 A.M

…

02 6:00 A.M.

03 6:15 A.M.

04 6:30 A.M.

05 6:45 A.M.

06 7:00 A.M.

07 7:15 A.M.

08 7:30 A.M.

09 7:45 A.M.

10 8:00 A.M.

11 8:15 A.M.

…

59 11:45 P.M.

Q6 Now think about the next thing you did. Please pick the type of activity from the following list or tell us what you did by choosing the “other” category.

1. Shower, bathe, personal hygiene

2. Eat

3. Sleep/Nap

4. Work (any paid work)

5. Childcare

6. Caregiving for an adult

7. General household activities

8. General leisure activities

9. Shop, run errands

10. Attend classes

11. Exercise, participate in sports

12. Travel to another destination [skip to Q9]

99. Other

Q6.1 [if chose other 99] What other activity did you do? _______________

Q7: Where were you?

Indoors at

1. Home [skip to 8 or 10 as appropriate]

2. Work or school

3. Other's home

4. Indoors other        

Outdoors at

1. Home or near home[skip to 8 or 10 as appropriate]

2. Work or school

3. Other's home

4. A parking lot/garage

5. A park or natural area

6. Outdoors other

Q7.1 [if chose other] What other place were you? _____________________

Q8: (if change from own home to other place or back with no travel): (if change from own home to other place with no travel): During your last activity, you were [insert location from last activity] and now you are [insert location from current activity]. Is this correct?

01 Yes

02 No [return to Q7]

Q8.1 How did you get from Q2 to Q7?

1. Car

2. Hybrid car

3. Minivan

4. Full-size Passenger Van

5. SUV

6. Motorcycle

7. Pickup truck

8. Walking/Running to destination

9. Riding on a bus,

10. Riding on a train, subway or light rail

11. Commercial vehicle

12. Bicycle, Skate, etc. to destination

13. Airplane

14. Boat

99. Other method

Q8.2 [if chose other 99] What other method of travel did you use?____________

Q9 [if activity is “travel”] Method of travel

1. Car

2. Hybrid car

3. Minivan

4. Full-size Passenger Van

5. SUV

6. Motorcycle

7. Pickup truck

8. Walking/Running to destination

9. Riding on a bus,

10. Riding on a train, subway or light rail

11. Commercial vehicle

12. Bicycle, Skate, etc. to destination

13. Airplane

14. Boat

99. Other method

Q9.1 [if chose other 99] What other method of travel did you use?____________

Q10: What was you level of activity?

Activity	Description	Energy Level
Sleep	Sleeping	Very Low	□
Sedentary	For example, sitting	Low	□
Light	For example, standing	Low active	□
Moderate	Moderate activities cause only light sweating or a slight to moderate increase in breathing or heart rate. Some examples are brisk walking, bicycling for pleasure, golf, or dancing.	Moderate	□
Vigorous	Vigorous activities cause moderate sweating or large increases in breathing or heart rate. An example is jogging.	Heavy/vigorous	□
Maximal exertion	Maximal exertion activities cause heavy sweating or large increases in breathing or heart rate. An example is running hard.	Maximal exertion	□

base: ALL QUALIFIED RESPONDENTS

The table below lists all your activities so far. If you need to change one of your responses, please click on the item you need to change and use the drop down list to select the correct response.

Time	Activity	Location or Method of travel	Activity Level

CONTINUE UNTIL CYCLE THROUGH 24 HOURS

Q11 On [insert date], did you leave [insert name of city]?

1. Yes

2. No [skip to 13]

Q12 [if yes] Below is a table of your activities on [insert date] that took place away from your home. Please type in the name of the city where the activity took place if it took place in another city.

Q13 You indicated that some of the activities took place at “work or school” Do you know the address of the building where the work took place or where you go to school?

1. Yes, the address is _________________ [skip to Q15]

2. No

Q13.1 [if no] Do you know the name of the nearest major intersection?

3. Yes

4. No

Q13.2 If you were to drive from your house to this location, how long would it take?

01 Less than 5 minutes

02 5 to 10 minutes

03 10 to 20 minutes

04 20 to 40 minutes

05 More than 40 minutes

Post-diary

base: ALL QUALIFIED RESPONDENTS

Q15 Think about the amount of time you spent indoors and outdoors compared to the amount time you usually spend indoors and outdoors on weekdays. Using the scale below, please indicate the amount of time you spent indoors or outdoors on [PROGRAMMER NOTE: INSERT DATE] compared to a typical day.

A lot more A little more Usual amount of A little more A lot more

Time indoors time indoors time indoors and time outdoors time outdoors

outdoors

1 2 3 4 5

BASE: SPENT A LOT OR A LITTLE MORE TIME INDOORS

Q16 Which of the following contributed to you spending more time indoors? Please check all that apply.

01 Your health on this day

02 The health of your child on this day

03 The health of another person you care for on this day

04 Conditions were not good outside.

05 I had previously scheduled plans to do an indoor activity.

06 No particular reason

96 Other, What other reason contributed to you spending more time indoors?

BASE: conditions outside WERE Not NICE

Q16.1 Which outdoor conditions contributed to you spending more time indoors? Please check all that apply.

01 Too hot

02 Too cool

03 Too humid

04 Poor air quality

05 Too much dust or pollen

06 Too much rain

07 Too windy

96 Other, What other reason contributed to you spending more time indoors?

BASE: SPENT A LOT OR A LITTLE MORE TIME OUTDOORS

Q17 Which of the following contributed to you spending more time outdoors? Please check all that apply.

01 Conditions outside were nice

02 I had previously scheduled plans to do an outdoor activity

03 No particular reason

96 Other, What other reason contributed to you spending more time outdoors?

BASE: conditions outside WERE NICE

Q17.1 (md6351-md6356) Which outdoor conditions contributed to your spending more time outdoors? Please check all that apply.

01 Good weather

02 Good air quality

03 Low dust or pollen

96 Other, What other reason contributed to you spending more time outdoors?

base: ALL QUALIFIED RESPONDENTS

Q18 (md6401-md64012) Did you experience any of the following symptoms on [PROGRAMMER NOTE: INSERT DATE]? <I>Please check all that apply.</I>

01 Coughing

02 Wheezing

03 Shortness of breath

04 Asthma attack

05 Runny nose or other cold symptoms

06 Nausea, stomachache

07 Fever

08 Earache

09 Sore throat

10 Chest pain

96 Other, What other symptoms did you experience?

97 I did not experience any symptoms on [PROGRAMMER NOTE: INSERT DATE].

BASE: HAVE EXPERIENCED SYMPTOMS

Q18.1 How long your [PROGRAMMER NOTE: INSERT RESPONSE FROM Q17] last?

1 All day

2 Most of the day

3 Some of the day

4 A short time

BASE: HAVE EXPERIENCED SYMPTOMS

Q18.2 How would you characterize your [PROGRAMMER NOTE: INSERT RESPONSE FROM Q17]?

1 Mild

2 Moderate

3 Severe

BASE: ALL QUALIFIED RESPONDENTS

Q19 Did you take any medication on [PROGRAMMER NOTE: INSERT DATE]? Please include prescription and over the counter medicines.

1 Yes

2 No

BASE: TOOK MEDICATION

Q20 Did you take any medication that you do not usually take every day or did you take a higher dose of a medication you usually take?

1. Yes

2. No

Q21 What medications did you take? <I>Please enter one medication per box.</I>

[TEXT BOX]

[TEXT BOX]

[TEXT BOX]

[TEXT BOX]

[TEXT BOX]

BASE: ALL QUALIFIED RESPONDENTS

Q22 Did you have your windows open between 7 a.m. and 8 p.m. on [PROGRAMMER NOTE: INSERT DATE]?

1 Yes

2 No

8 Not sure

BASE: HAD WINDOWS OPEN

Q22.1 For how long between 7 a.m. and 8 p.m. did you have your windows open?

Q19.11 Q19.12

Hours Minutes

[Range 0-13] [Range 0-59]

|__|__| |__|__|

Thank you for completing this survey. We appreciate your time and effort.

[if appropriate] You will be asked to fill out more diary surveys for the next (1/2/3) days. It is very important for this research study that we get more than 1 diary from each person and ideally that we get all 7 diaries from each person. Don’t forget that you can earn **** for completing all 7 diaries.

The public reporting and recordkeeping burden for this collection of information is estimated to average 15 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.