Youth Activity Diary

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Youth Activity Diary

Public reporting burden of this collection of information is estimated to average 10 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx)

1. D

   Study ID # _____________________________

   ate (month / day / year) ____/__ _/20________

2. Was this a school day? (circle one) YES NO

3. What time did you get out of bed in the morning? ____ ____ : ____ ____

4. Did you take off the monitor during the day? (circle one) YES NO
   If yes, when (time) ____ ____ : ____ ____ and why (circle one) Swim Shower Other, specify:_____________________________

5. What time did you get into the bed in the evening? ____ ____ : ____ ____

Time of day	Did you wear the Monitor? (circle one)	Most of the time, where were you? (circle one)	During this time, did you bicycle? (circle Yes or No; if Yes, specify activity time(s)) By “transportation” we mean going from place to place to do errands, shop, go to work or school	During this time, did you walk? (circle Yes or No; if Yes, specify activity time(s)) By “transportation” we mean going from place to place to do errands, shop, go to work or school
Early morning (5:01am – 9:00am)	Yes No	Home School Other, specify: _______________	Yes - for leisure __ __ min - for transportation __ __ min - for other reason __ __ min No	Yes - for leisure __ __ min - for transportation __ __ min - for other reason __ __ min No
Morning (9:01am – 11:00am)	Yes No	Home School Other, specify: _______________	Yes - for leisure __ __ min - for transportation __ __ min - for other reason __ __ min No	Yes - for leisure __ __ min - for transportation __ __ min - for other reason __ __ min No
Lunch time (11:01am – 1:00pm)	Yes No	Home School Other, specify: _______________	Yes - for leisure __ __ min - for transportation __ __ min - for other reason __ __ min No	Yes - for leisure __ __ min - for transportation __ __ min - for other reason __ __ min No
Afternoon (1:01pm – 5:00pm)	Yes No	Home School Other, specify: _______________	Yes - for leisure __ __ min - for transportation __ __ min - for other reason __ __ min No	Yes - for leisure __ __ min - for transportation __ __ min - for other reason __ __ min No
Dinner time (5:01pm – 8:00pm)	Yes No	Home School Other, specify: _______________	Yes - for leisure __ __ min - for transportation __ __ min - for other reason __ __ min No	Yes - for leisure __ __ min - for transportation __ __ min - for other reason __ __ min No
After dinner (8:01pm – 10:00pm)	Yes No	Home School Other, specify: _______________	Yes - for leisure __ __ min - for transportation __ __ min - for other reason __ __ min No	Yes - for leisure __ __ min - for transportation __ __ min - for other reason __ __ min No
Bed time (10:01pm – midnight)	Yes No	Home School Other, specify: _______________	Yes - for leisure __ __ min - for transportation __ __ min - for other reason __ __ min No	Yes - for leisure __ __ min - for transportation __ __ min - for other reason __ __ min No
Middle of the night (12:01pm – 5:00am)	Yes No	Home School Other, specify: _______________	Yes - for leisure __ __ min - for transportation __ __ min - for other reason __ __ min No	Yes - for leisure __ __ min - for transportation __ __ min - for other reason __ __ min No