Baseline Interim Behavioral Assessment Month

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20X

Interim Behavioral Assessment Month 1 (WHAM) Women’s Health and Mindfulness Program

The interim behavioral assessment consists of a sub-set of questions related to physical activity and nutrition from the Evaluation Questionnaire, Section 3: Questions 3.1-3.21. These questions will be administered through a web-based survey.

We are interested in finding out about the kinds of physical activities that people do as part of their everyday lives. The questions will ask you about the time you spent being physically active in the last 7 days. Please answer each question even if you do not consider yourself to be an active person. Please think about the activities you do at work, as part of your house and yard work, to get from place to place, and in your spare time for recreation, exercise or sport.

SHOW PARTICIPANT PHYSICAL ACTIVITY IMAGE CARD.

Think about all the vigorous activities that you did in the last 7 days. Vigorous physical activities take hard physical effort and make you breathe much harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time.

1. *During the last 7 days, on how many days did you do vigorous physical activities like heavy lifting, digging, aerobics, or fast bicycling?

_____ days in the last week  if 0, skip to 3.3

2. *How much time did you usually spend doing vigorous physical activities on one of those days?

_____1 Hour(s) per day

_____2 Minutes per day

_____3 Don’t know/not sure

Think about all the moderate activities that you did in the last 7 days. Moderate activities take moderate physical effort and make you breathe somewhat harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time.

3. *During the last 7 days, on how many days did you do moderate physical activities like carrying light loads, bicycling at a regular pace, or doubles tennis? Do not include walking.

_____ days in the last week  if 0, skip to 3.5

4. *How much time did you usually spend doing moderate physical activities on one of those days?

_____1 Hour(s) per day

_____2 Minutes per day

_____3 Don’t know/not sure

Now, think about the time you spent walking in the last 7 days. This includes at work and at home, walking to travel from place to place, and any other walking that you might do solely for recreation, sport, exercise, or leisure.

5. *During the last 7 days, on how many days did you walk for at least 10 minutes at a time?

_____ days in the last week  if 0, skip to 3.7

6. *How much time did you usually spend walking on one of those days?

_____1 Hour(s) per day

_____2 Minutes per day

_____3 Don’t know/not sure

The last question is about the time you spent sitting on weekdays during the last 7 days. Include time spent at work, at home, while doing course work and during leisure time. This may include time spent sitting at a desk, visiting friends, reading, or sitting or lying down to watch television.

7. *During the last 7 days, how much time did you spend sitting on a week day?

_____1 Hour(s) per day

_____2 Minutes per day

_____3 Don’t know/not sure

The next section is about the foods you ate or drank during the past 30 days, including meals and snacks. Remember to include any sweetened beverages used as a mixer for cocktails.

8. *During the past 30 days, how often did you drink regular soda or pop that contains sugar? Do not include diet soda.

_____1 Times per day

_____2 Times per week

_____3 Times per month

_____4 Never

9. *During the past 30 days, how often did you drink diet soda or pop that contains artificial sweeteners?

_____1 Times per day

_____2 Times per week

_____3 Times per month

_____4 Never

10. *During the past 30 days, how often did you drink sports or energy drinks such as Gatorade, Red Bull or Vitamin Water. Remember to use include sports or energy drinks used as a mixer? Do not include diet or sugar-free kinds.

_____1 Times per day

_____2 Times per week

_____3 Times per month

_____4 Never

11. *During the past 30 days, how often did you drink sweetened fruit drinks such as Kool-aid, cranberry drink or lemonade? Include fruit drinks you made at home and added sugar to. Do not include 100% fruit juices and drinks with things like Splenda or Equal.

_____1 Times per day

_____2 Times per week

_____3 Times per month

_____4 Never

12. *During the past 30 days, how often did you drink coffee or tea with sugar or honey added? Do not include drinks with things like Splenda or Equal. Include pre-sweetened tea and coffee drinks such as Arizona Iced Tea and Frappuccino.

_____1 Times per day

_____2 Times per week

_____3 Times per month

_____4 Never

13. *During the past 30 days, how often did you drink water (including tap, bottled, and carbonated water)?

_____1 Times per day

_____2 Times per week

_____3 Times per month

_____4 Never

14. *Each time you drank water, how much did you usually drink?

_____1 Less than 6 fl oz (3/4 oz)

_____2 8 fl oz (1 cup)

_____3 12 fl oz (1-1/2 cups)

_____4 16 fl oz (2 cups)

_____5 More than 20 fl oz (2-1/2 cups)

15. *During the past 30 days, how many times per day, week or month did you drink 100% PURE fruit juices? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to. Only include 100% juice.

_____1 Times per day

_____2 Times per week

_____3 Times per month

_____4 Never

16. *During the past 30 days, not counting juice, how many times per day, week or month did you eat fruit? Count fresh, frozen or canned fruit.

_____1 Times per day

_____2 Times per week

_____3 Times per month

_____4 Never

17. *During the past 30 days, how many times per day, week or month did you eat cooked or canned beans, such as refried, black, garbanzo beans, beans in soup, soybeans, edamame, tofu or lentils. Do NOT include long green beans.

_____1 Times per day

_____2 Times per week

_____3 Times per month

_____4 Never

18. *During the past 30 days, how many times per day, week or month did you eat dark green vegetables for example broccoli or dark leafy greens including romaine, chard, collard greens or spinach?

_____1 Times per day

_____2 Times per week

_____3 Times per month

_____4 Never

19. *During the past 30 days, how many times per day, week or month did you eat orange colored vegetables such as sweet potatoes, pumpkin, winter squash or carrots?

_____1 Times per day

_____2 Times per week

_____3 Times per month

_____4 Never

20. *Not counting these last questions on fruits and vegetables, during the past 30 days, about how many times per day, week or month did you eat OTHER vegetables? Examples of other vegetables include tomatoes, tomato juice or V-8 juice, corn, eggplant, lettuce, cabbage and white potatoes that are not fried such as baked or mashed potatoes.

_____1 Times per day

_____2 Times per week

_____3 Times per month

_____4 Never

21. *How many servings of fruits and vegetables do you usually have per day? (1 serving = 1 medium piece of fruit; ½ cup fresh, frozen or canned fruits/vegetables; ¾ cup fruit/vegetable juice; 1 cup salad greens; or ¼ cup dried fruit).

____0 servings per day

____1-2 servings per day

____3-4 servings per day

____5 or more servings per day

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-xxxx . The time required to complete this information collection is estimated to average 4 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:  U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201,   Attention: PRA Reports Clearance Officer

Version 0.4: February 10, 2013