Form 17 Att.20 AARP PA questions

Attachment 20

NIH-AARP physical activity questions	OMB#: ####-#### EXP.DATE: ##/##/####
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN
Public reporting burden for this collection of information is estimated to average 10 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 (####-####).

1. During the past 12 months, approximately how much time per week did you participate in each of the following activities? (FOR EACH ACTIVITY MARK ONLY ONE RESPONSE.)

ACTIVITY	AVERAGE TOTAL TIME PER WEEK
	None	5 min	15 min	30 min	1 hr	1 hr and 30 min	2-3 hrs	4-6 hrs	7-10 hrs	More than 10 hrs
a. Light household chores (for example, cooking, cleaning up, laundry, dusting, etc.)										
b. Moderate to vigorous household chores (for example, vacuuming, sweeping, etc.)										
c. Moderate outdoor chores (for example, weeding, raking, mowing the lawn, etc.)										
d. Vigorous outdoor chores (for example, digging, carrying lumber, snow shoveling, etc.)										
e. Home repairs (for example, painting, plumbing, replacing carpeting, etc.)										
f. Caring for children (for example, pushing a stroller, playing, lifting, etc.)										
g. Caring for another adult (for example, lifting, pushing a wheelchair, etc.)										
h. Walking for exercise										
i. Walking for other daily (but not leisure time) activities, such as shopping, getting to and from work, etc.										
j. Jogging or running										
k. Playing tennis, squash, or racquetball										
l. Playing golf										
m. Swimming laps										
n. Bicycling (including riding a stationary bike)										
o. Other aerobic exercise (for example, aerobic class, exercise machines, etc.)										
p. Weight training or lifting (include free weights and machines)										

2. In a typical 24-hour period during the past 12 months, how many hours per day did you spend: (MARK ONLY ONE RESPONSE PER ACTIVITY.)	AVERAGE NUMBER OF HOURS PER DAY
	None	Less than 3 hours	3 to 4 hours	5 to 6 hours	7 to 8 hours	9 to 10 hours	11 to 12 hours	More than 12 hours
Sitting watching television, video, or DVD?								
Sitting or driving in a car, bus, or train?								
Other sitting (reading, knitting, using a computer)?								
Sleeping at night or napping during the day?								

3. What is your normal walking pace?

(MARK ONLY ONE RESPONSE)

 Easy (less than 2 miles per hours)

 Normal, average (2 to 2.9 miles per hour)

 Brisk (3 to 3.9 miles per hour)

 Very brisk, striding (4 miles per hour or faster)

 Unable to walk

<<if participant completed the 1996 baseline questionnaire, ask the following>>

4. Have you ever had a job that required physically demanding work (that is, one that required you to do very heavy labor, such as carry heavy loads, walk long distances, or dig)?

 No → GO TO QUESTION 7

 Yes

5. How many physically demanding jobs have you ever held?

 1 to 2 jobs

 3 to 5 jobs

 6 or more jobs

6. What is the total number of years that you have worked in these physically demanding jobs (that is, jobs that required you to do very heavy labor, such as carry heavy loads, walk long distances, or dig)? Sum the years spent in jobs counted in Question 5.

 Less than 1 year

 1 to 2 years

 3 to 5 years

 6 to 9 years

 10 or more years

7. Have you ever had a job in which you walked or biked (pedaled) to work for most days of the week?

 No

 Yes → What was the total number of years you had job(s) in which you walked or biked to work for most days of the week?

 Less than 1 year

 1 to 2 years

 3 to 5 years

 6 to 9 years

 10 or more years

8. Read the list of examples of light activities in the box below.

EXAMPLES OF LIGHT ACTIVITIES
Bowling Golf (riding in a cart) Table tennis	Slow walking Slow dancing Light calisthenics Light gardening	Fishing Horseshoes/croquet Light housework

Think back to the ages and time listed in the table below. Mark the circles that best describe how often you participated in light activities at the ages and time listed. DO NOT INCLUDE ACTIVITIES THAT YOU REPORTED IN QUESTIONS 4 – 7.

How often did you participate in light activities at the following ages and time?	HOW OFTEN (MARK ONLY ONE RESPONSE)
	Never	Rarely	Weekly, but less than 1 hr per week	1-3 hrs per week	4-7 hrs per week	More than 7 hrs per week
15-18 years old						
19-29 years old						
35-39 years old						
40-49 years old						
50-59 years old						
In the past 10 yrs						

9. Read the list of examples of moderate and vigorous activities in the box below.

EXAMPLES OF MODERATE AND VIGOROUS ACTIVITIES
Tennis Golf (walking) Biking Swimming Heavy gardening Weight lifting	Basketball/baseball Football/soccer Cheerleading/drill team Handball/racquetball Hiking/climbing mountains	Fast walking Fast dancing Rowing Jogging/running Heavy housework

Think back to the ages and time listed in the table below. Mark the circles that best describe how often you participated in moderate and vigorous activities at the ages and time listed. DO NOT INCLUDE ACTIVITIES THAT YOU REPORTED IN QUESTIONS 4 – 7.

How often did you participate in moderate and vigorous activities at the following ages and time?	HOW OFTEN (MARK ONLY ONE RESPONSE)
	Never	Rarely	Weekly, but less than 1 hr per week	1-3 hrs per week	4-7 hrs per week	More than 7 hrs per week
15-18 years old						
19-29 years old						
35-39 years old						
40-49 years old						
50-59 years old						
In the past 10 yrs						