Form 16 Att.19 CHAMPS Activities Questionnaire

Attachment 19

Community Healthy Activities Model Program for Seniors (CHAMPS)	OMB#: ####-#### EXP.DATE: ##/##/####
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN
Public reporting burden for this collection of information is estimated to average 15 minutes for this questionnaire, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current, valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN:PRA (####-####).

CHAMPS Activities Questionnaire for Older Adults

This questionnaire is about activities that you may have done in the past 4 weeks. The questions on the following pages are similar to the example shown below.

INSTRUCTIONS

If you DID the activity in the past 4 weeks:

Step #1 Check the YES box.

Step #2 Think about how many TIMES a week you usually did it, and write your response in the space provided.

Step #3 Circle how many TOTAL HOURS in a typical week you did the activity.

Here is an example of how Mrs. Jones would answer question #1: Mrs. Jones usually visits her friends Maria and Olga twice a week. She usually spends one hour on Monday with Maria and two hours on Wednesday with Olga. Therefore, the total hours a week that she visits with friends is 3 hours a week.

In a typical week, during the past 4 weeks, did you...	How many TOTAL hours a week did you usually do it? →
1. Visit with friends or family (other than those you live with)?          [ ] YES How many TIMES a week?      →          [ ] NO	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
If you DID NOT do the activity: • Check the NO box and move to the next question.

In a typical week, during the past 4 weeks, did you...	How many TOTAL hours a week did you usually do it?
1. Visit with friends or family (other than those you live with)?          [ ] YES How many TIMES a week?      →          [ ] NO	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
2. Go to the senior center?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
3. Do volunteer work?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
4. Attend church or take part in church activities?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
5. Attend other club or group meetings?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
6. Use a computer?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
7. Dance (such as square, folk, line, ballroom) (do not count aerobic dance here)?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
8. Do woodworking, needlework, drawing, or other arts or crafts?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
9. Play golf, carrying or pulling your equipment (count walking time only)?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
10. Play golf, riding a cart (count walking time only)?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
11. Attend a concert, movie, lecture, or sport event?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
12. Play cards, bingo, or board games with other people?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
13. Shoot pool or billiards?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
14. Play singles tennis (do not count doubles)?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
15. Play doubles tennis (do not count singles)?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
16. Skate (ice, roller, in-line)?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
17. Play a musical instrument?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
18. Read?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
19. Do heavy work around the house (such as washing windows, cleaning gutters)?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
20. Do light work around the house (such as sweeping or vacuuming)?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
21. Do heavy gardening (such as spading, raking)?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
22. Do light gardening (such as watering plants)?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
23. Work on your car, truck, lawn mower, or other machinery?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
**Please note: For the following questions about running and walking, include use of a treadmill.
24. Jog or run?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
25. Walk uphill or hike uphill (count only uphill part)?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
26. Walk fast or briskly for exercise (do not count walking leisurely or uphill?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
27. Walk to do errands (such as to/from a store or to take children to school (count walk time only)?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
28. Walk leisurely for exercise or pleasure?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
29. Ride a bicycle or stationary cycle?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
30. Do other aerobic machines such as rowing, or step machines (do not count treadmill or stationary cycle)?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
31. Do water exercises (do not count other swimming          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
32. Swim moderately or fast?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
33. Swim gently?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
34. Do stretching or flexibility exercises (do not count yoga or Tai-chi)?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
35. Do yoga or Tai-chi?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
36. Do aerobics or aerobic dancing?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
37. Do moderate to heavy strength training (such as hand-held weights of more than 5 lbs., weight machines, or push-ups)?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
38. Do light strength training (such as hand-held weights of 5 lbs. or less or elastic bands)?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
39. Do general conditioning exercises, such as light calisthenics or chair exercises (do not count strength training)?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
40. Play basketball, soccer, or racquetball (do not count time on sidelines)?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours
41. Do other types of physical activity not previously mentioned (please specify)?          [ ] YES How many TIMES a week?      →          [ ] NO	How many TOTAL hours a week did you usually do it?
	[ ] Less than 1 hour	[ ] 1-2½ hours	[ ] 3-4½ hours	[ ] 5-6½ hours	[ ] 7-8½ hours	[ ] 9 or more hours

Thank You

Scoring

Data from the questionnaire is used to determine frequency per week and estimated caloric expenditure per week from physical activity. Separate scores are derived for physical activities of moderate or greater intensity (metabolic equivalents MET ≥ 3.0) and for all specified activities including those of light and moderate or greater intensity. For each of these, scores are calculated for frequency per week and estimated caloric expenditure per week.

Estimated caloric expenditures were calculated by multiplying the estimated duration per week by the MET value for each activity and summing across all relevant activities. Frequency per week is calculated by summing the frequency per week across all relevant activities. Detailed formulas are found in Table A1.

MET values were assigned to each activity from the values reported by Ainsworth et al. 1993. If an activity did not appear in the Ainsworth et al. compendium, the activity was assigned a value based on similar activities. The MET values for CHAMPS activities appear in Table A2*.

*Table A2 may be found in the Appendix of the following source.

Stewart, A. L., Mills, K. M., King, A. C., Haskell, W. L., Gillis, D., & Ritter, P. L. (2001). CHAMPS Physical Activity Questionnaire for Older Adults: Outcomes for Interventions. Medicine and Science in Sports and Exercise, 33(7), 1126-1141.

Table A1: Revised Codebook for CHAMPS Physical Activity Measures

Variable Label	Item Numbers	Coding Algorithms
Caloric expenditure/week in all exercise related activities1	7, 9, 10, 14¿16, 19-35, 36, 40	For each activity: 1. Create new duration variables for each activity recoded as follows: 1=0.5, 2=1.75, 3=3.75, 4=5.75, 5=7.75, 6=9.75; If duration variable is not answered, score = 0. Duration is hours/week. 2. For each recoded duration variable, create new weighted duration variable for each activity by multiplying duration variable (#1) by corresponding MET value). 3. For each weighted duration variable, create caloric expenditure per week variable for each activity by multiplying weighted duration variable (#2) by 3.5 and by 60 (to convert METs/minute to METs/hour) and by (weight in kg/200). 4. Sum caloric expenditure per week variables across activities to create caloric expenditure/week.
Caloric expenditure/week in moderate intensity exercise related activities	7, 9, 14-16, 19, 21, 23-26, 29-33, 36-38, 40	Same as above, subset of activities with MET values >3.0.
Frequency/week of all exercise-related activities	7, 9, 10, 14¿16, 19-35, 36, 40	SUM frequency scores/week for each of the activities (allow those with missing data on frequency to be included in the sum).
Frequency/week of moderate intensity exercise-related activities	7, 9, 14-16, 19, 21, 23-26, 29-33, 36-38, 40	SUM frequency scores/week for each of the activities (allow those with missing data on frequency to be included in the sum).

¹Based on American College of Sports Medicine formula: kcal/minute = METs * 3.5 * (body weight in kg/200). Our formula converts this into kcal/week. American College of Sports Medicine (ACSM) Guidelines for Exercise Testing and Prescription, 5^th Edition. Baltimore: Williams & Wilkins (1995).