Accelerometer: Activity Diary and Reminder

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

Accelerometer: Activity Diary and Reminder (WHAM) Women’s Health and Mindfulness Program

Accelerometer: Activity Diary and Reminder

INSTRUCTIONS FOR USING THE ADULT ACTIVITY DIARY

The Adult Activity Diary is a set of papers that you will use to keep track of (1) whether you wore the activity monitor, (2) where you were, and (3) the reason you walked or biked, if applicable. In the top part of the diary you will write the date, indicate if this was a work day, write the time you got out of bed in the morning, indicate whether the monitor was taken off during the day, and write the time you went to bed in the evening. In the bottom part of the diary you will circle the most appropriate response to the questions.

Please write clearly and fill out the Activity Diary the best you can.

Please make sure to fill out the Activity Diary every day—do not wait until the end of the week and try to remember your activity. If you have any questions about how to use the Activity Diary, please contact _________________________________________________________.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

We need to know if you wore the activity monitor, where you were most of the time, and if you biked or walked. If you biked or walked, we would like to know why and for how long.

• If you wore the activity monitor most of the time during the specific time of day, please circle “Yes” in the column labeled “Did you wear the monitor.”

• If a time of day is split equally between 2 options for “Most of the time, where were you?” (e.g., half at work and half at home), then select the option that occurred first.

• If you biked any time during the specified time period, please circle “Yes” for the column labeled “During this time, did you bicycle?” and indicate the reason for bicycling and how many minutes you biked during the time period.

• If you walked any time during the specified time period, please circle “Yes” for the column labeled “During this time, did you walk?” and indicate the reason for walking and how many minutes you walked during the time period.

E xample:

• You got out of bed at 7:00 in the morning (on a weekday) and started getting ready for work. You took a shower at 7:45 and put the monitor on at 8:00 in the morning.

• At 8:30 in the morning you arrived at work.

• You walked to the deli to pick up lunch (12:10–12:20).

• You left work at 5:30 in the evening.

• You had dinner at 6:30 in the evening.

• You and your child walked to the corner store from 7:30 to 7:50 in the evening.

• You did not bike at all during the day or evening.

• You went to bed at 11:30 in the evening.

• You would need to write on your Activity Diary as indicated in the example to the right.

Adult Activity Diary

D

Study ID # ____________________

ate (month / day / year) _______________ _______ __20______

1. Was this a work day? (circle one) YES NO

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

3. 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:_____________________________

4. 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 Work 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 Work 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 Work 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 Work 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 Work 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 Work 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 Work 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 Work 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

Adult Activity Diary

D

Study ID # ____________________

ate (month / day / year) _______________ _______ __20______

1. Was this a work day? (circle one) YES NO

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

3. 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:_____________________________

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

Early morning (5:01am – 9:00am)	Yes No	Home Work 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 Work 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 Work 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 Work 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 Work 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 Work 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 Work 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 Work 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

Adult Activity Diary

D

Study ID # ____________________

ate (month / day / year) _______________ _______ __20______

1. Was this a work day? (circle one) YES NO

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

3. 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:_____________________________

4. 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 Work 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 Work 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 Work 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 Work 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 Work 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 Work 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 Work 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 Work 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

Adult Activity Diary

D

Study ID # ____________________

ate (month / day / year) _______________ _______ __20______

1. Was this a work day? (circle one) YES NO

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

3. 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:_____________________________

4. 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 Work 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 Work 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 Work 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 Work 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 Work 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 Work 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 Work 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 Work 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

Adult Activity Diary

D

Study ID # ____________________

ate (month / day / year) _______________ _______ __20______

1. Was this a work day? (circle one) YES NO

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

3. 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:_____________________________

4. 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 Work 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 Work 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 Work 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 Work 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 Work 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 Work 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 Work 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 Work 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

Adult Activity Diary

D

Study ID # ____________________

ate (month / day / year) _______________ _______ __20______

1. Was this a work day? (circle one) YES NO

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

3. 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:_____________________________

4. 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 Work 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 Work 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 Work 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 Work 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 Work 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 Work 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 Work 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 Work 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

Adult Activity Diary

D

Study ID # ____________________

ate (month / day / year) _______________ _______ __20______

1. Was this a work day? (circle one) YES NO

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

3. 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:_____________________________

4. 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 Work 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 Work 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 Work 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 Work 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 Work 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 Work 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 Work 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 Work 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

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