Form 2 Survey

Survey Questions

OMB No.: 0925-0645

Expiration Date: 12/31/2014

Collection of this information is authorized by The Public Health Service Act, Section 411 (42 USC 285a). Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be kept private to the extent provided by law. Names and other identifiers will not appear in any report of the study. Information provided will be combined for all study participants and reported as summaries. You are being contacted by advertisement and have chosen to contact us to complete this instrument so that we can explore motivations for engaging in physical activity.

Public reporting burden for this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing 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 currently 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 (0925-0645). Do not return the completed form to this address.

Before we begin the focus groups, we ask that you complete this brief survey so that we have a better understanding of participants in this focus group study. The survey should take no more than 3 minutes to complete. The focus group will begin shortly.

1. About how tall are you without shoes? ___ Feet ___ Inches

2. About how much do you weigh without shoes? ___ pounds

3. In a typical week, how many days do you do any physical activity or exercise of at least moderate intensity, such as brisk walking, bicycling at a regular pace, and swimming at a regular pace?

   1. None

   2. 1 Day

   3. 2 Days

   4. 3 Days

   5. 4 Days

   6. 5 Days

   7. 6 Days

   8. 7 Days

4. On the days that you do any physical activity or exercise of at least moderate intensity, how long do you typically do these activities?

__________ Minutes _____________ Hours

5. In a typical week, outside of your job or work around the house, how many days do you do leisure-time physical activities specifically designed to strengthen your muscles such as lifting weights or circuit training (do not include cardio exercise such as walking, biking, or swimming)?

   1. None

   2. 1 Day

   3. 2 Days

   4. 3 Days

   5. 4 Days

   6. 5 Days

   7. 6 Days

   8. 7 Days

6. Using the scale below, please indicate how much each statement about physical activity is true for you:

1 2 3 4 5

Not at all Neutral Very true

True

_____	I don't want to be physically active (exercise) on a regular basis.
_____	I would be physically active (exercise) on a regular basis because others want me to.
_____	I would be physically active (exercise) on a regular basis because I would feel bad about myself if I did not.
_____	I would be physically active (exercise) on a regular basis because I have carefully thought about it and I believe it is very important for me to be physically active (exercise).
_____	I would be physically active (exercise) on a regular basis because being physically active (exercising) is consistent with other goals and things that are important in my life.

7. What is your age?

1. 20-35

2. 36-50

3. 51-65

4. OVER 65

8. Which of these best describes your ethnicity (choose one)?

   1. Hispanic or Latino

   2. Not Hispanic or Latino

9. Which of these best describes your race (choose one or more)?

   1. American Indian or Alaska Native

   2. Asian

   3. Black or African American

   4. Native Hawaiian or Other Pacific Islander

   5. White

10. What is the highest level of school you have completed or the highest degree you have received?

    1. Less than 12^th grade

    2. High school graduate or GED

    3. Some college but no college degree

    4. Associate’s degree

    5. Bachelor’s degree (i.e., B.A., B.S.)

    6. Graduate or Professional school degree (M.D., J.D., D.D.S.)

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