42.4 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Physical Activity Monitor Set-Up Instrument, Phase 2g

OMB Specification

Physical Activity Monitor Set-Up Instrument

Event Category:	Time-Based
Event:	36M, 48M, 60M
Administration:	N/A
Instrument Target:	Child
Instrument Respondent:	Primary Caregiver
Domain:	Environmental
Document Category:	Sample Collection
Method:	Data Collector Administered
Mode (for this instrument*):	In-Person, CAI
OMB Approved Modes:	In-Person, CAI
Estimated Administration Time:	10 minutes
Multiple Child/Sibling Consideration:	Per Child
Special Considerations:	N/A
Version:	1.0
MDES Release:	4.0

*This instrument is OMB-approved for multi-mode administration, but this version of the instrument is designed for administration in this/these mode(s) only.

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Physical Activity Monitor Set-Up Instrument

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

PHYSICAL ACTIVITY MONITOR SET-UP 3

GPS MONITOR SET-UP 6

PHYSICAL ACTIVITY AND GPS MONITOR WEAR LOG DISTRIBUTION 9

PHYSICAL ACTIVITY AND GPS MONITOR SHIPPING INSTRUCTIONS 10

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Physical Activity Monitor Set-Up Instrument

GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:

DATA ELEMENT FIELDS	MAXIMUM CHARACTERS PERMITTED	DATA TYPE	PROGRAMMER INSTRUCTIONS
ADDRESS AND EMAIL FIELDS	100	CHARACTER
UNIT AND PHONE FIELDS	10	CHARACTER
_OTH AND COMMENT FIELDS	255	CHARACTER	Limit text to 255 characters
FIRST NAME AND LAST NAME	30	CHARACTER	Limit text to 30 characters
ALL ID FIELDS	36	CHARACTER
ZIP CODE	5	NUMERIC
ZIP CODE LAST FOUR	4	NUMERIC
CITY	50	CHARACTER
DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)	10	NUMERIC CHARACTER	DISPLAY AS MM/DD/YYYY STORE AS YYYY-MM-DD HARD EDITS: MM MUST EQUAL 01 TO 12 DD MUST EQUAL 01 TO 31 YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.
TIME VARIABLES	TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION	NUMERIC	HARD EDITS: HOURS MUST BE BETWEEN 00 AND 12; MINUTES MUST BE BETWEEN 00 AND 59

Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).

POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.

A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.

PHYSICAL ACTIVITY MONITOR SET-UP

(TIME_STAMP_PAM_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• PRELOAD PARTICIPANT ID (P_ID) FOR CHILD AND RESPONDENT ID (R_P_ID) FOR CAREGIVER.

• PRELOAD CHILD’SFIRST NAME (C_FNAME) AND DISPLAY NAME FOR “C_FNAME” THROUGHOUT DOCUMENT.

• USE “the child” IN APPROPRIATE FIELDS THROUGHOUT THE INSTRUMENT IF CHILD’S NAME IS REFUSED.

• IF CHILD_SEX IN PVST INSTRUMENT = 1, DISPLAY “his”, “he”, OR “himself” IN APPROPRIATE FIELDS THROUGHOUT INSTRUMENT.

• IF CHILD_SEX IN PVST INSTRUMENT = 2, DISPLAY “her”, “she”, OR “herself” IN APPROPRIATE FIELDS THROUGHOUT INSTRUMENT.

• PRELOAD MULT_CHILD AND CHILD_NUM (IF MULT_CHILD = 1), FROM PVST INSTRUMENT.

• IF MULT_CHILD = 1, PRELOAD CHILD_QNUM

PAM01000/(STAFF_ID). ENTER STAFF ID

___________________________________________

STAFF ID

PAM02000. PHYSICAL ACTIVITY MONITOR BROCHURE AND WEAR LOG DISTRIBUTION

DATA COLLECTOR INSTRUCTIONS

• DISTRIBUTE THE PHYSICAL ACTIVITY BROCHURE AND PHYSICAL ACTIVITY AND GPS MONITOR WEAR LOG IN ACCORDANCE WITH THE PHYSICAL ACTIVITY MEASUREMENT SOP.

PAM03000/(MMS_SETUP_OKAY ). We would like to place this physical activity monitor on {C_FNAME/the child}’s wrist. The monitor should stay on for a week. It is waterproof so it can be worn in the shower or tub or when swimming. It does not need to be recharged. Is that okay?

Label	Code	Go To
YES	1	PAM06000
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health & Nutrition Examination Survey (NHANES) (Modified)

PAM04000/(MMS_REFUSE). RECORD REASON FOR REFUSAL.

Label	Code	Go To
NONE GIVEN	1	MMS_SETUP_COMMENTS
NOT INTERESTED IN PHYSICAL ACTIVITY MONITORING	2	MMS_SETUP_COMMENTS
DOES NOT WANT EQUIPMENT PUT ON CHILD	3	MMS_SETUP_COMMENTS
OTHER	-5

PAM05000/(MMS_REFUSE_OTH). SPECIFY: _________________________________

PROGRAMMER INSTRUCTIONS

• GO TO MMS_SETUP_COMMENTS

PAM06000. PHYSICAL ACTIVITY MONITOR PLACEMENT INSTRUCTIONS

DATA COLLECTOR INSTRUCTIONS

• PLACE THE MONITOR ON THE SELECTED WRIST IN ACCORDANCE WITH THE PHYSICAL ACTIVITY MEASUREMENT SOP.

PAM07000/(MMS_SETUP). WERE YOU ABLE TO PLACE THE PHYSICAL ACTIVITY MONITOR ON THE CHILD’S WRIST?

Label	Code	Go To
YES	1	SAMPLE_ID
NO	2

PAM08000/(MMS_NOT_SETUP). WHY WERE YOU NOT ABLE TO PLACE THE PHYSICAL ACTIVITY MONITOR ON THE CHILD’S WRIST?

Label	Code	Go To
SUPPLIES/EQUIPMENT NOT AVAILABLE	1	MMS_SETUP_COMMENTS
EQUIPMENT PROBLEM	2	PAM10000
RAN OUT OF TIME	3	MMS_SETUP_COMMENTS
CHILD UNCOOPERATIVE	4	MMS_SETUP_COMMENTS
REFUSAL	5	MMS_SETUP_COMMENTS
OTHER	-5

PAM09000/(MMS_NOT_SETUP_OTH). SPECIFY: ________________________________

PROGRAMMER INSTRUCTIONS

• GO TO MMS_SETUP_COMMENTS

PAM10000. PHYSICAL ACTIVITY MONITOR PROBLEM

DATA COLLECTOR INSTRUCTIONS

• COMPLETE THE ENVIRONMENTAL EQUIPMENT PROBLEM LOG.

PROGRAMMER INSTRUCTIONS

• GO TO MMS_SETUP_COMMENTS.

PAM11000/(SAMPLE_ID). PHYSICAL ACTIVITY MEASUREMENT SAMPLE ID

|E|__|__|__|__|__|__|__|__|-MT01

PHYSICAL ACTIVITY MEASUREMENT SAMPLE ID

PROGRAMMER INSTRUCTIONS

• ID MUST BE FORMATTED WITH TWO ALPHA 7 NUMERIC DASH MT01.

PAM12000/(EQUIP_ID). PHYSICAL ACTIVITY MONITOR ID

___________________________________________

DATA COLLECTOR INSTRUCTIONS

• ENTER THE EQUIPMENT ID OF THE PHYSICAL ACTIVITY MONITOR

PAM13000. PHYSICAL ACTIVITY MONITOR SET-UP DATE

(MMS_SET_DATE_MM) MONTH:|___|___|

                 M    M

(MMS_SET_DATE_DD) DAY:       |___|___|

                 D     D

(MMS_SET_DATE_YYYY) YEAR:     |___|___|___|___|

                   Y    Y    Y    Y

PROGRAMMER INSTRUCTIONS

• DISPLAY HARD EDIT IF MM, DD OR YYYY ARE OUTSIDE OF THE CRITERIA DEFINED IN GENERAL PROGRAMMER INSTRUCTIONS.

PAM14000. PHYSICAL ACTIVITY MONITOR SET-UP TIME

(MMS_SET_TIME) |___|___| : |___|___|              

  H    H         M    M

(MMS_SET_TIME_UNIT)

Label	Code	Go To
AM	1
PM	2

PAM16000/(MMS_SETUP_COMMENTS). RECORD ANY COMMENTS ABOUT THE PHYSICAL ACTIVITY MONITOR PLACEMENT.

COMMENTS: __________________________________________________

(TIME_STAMP_PAM_ET).

PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP

GPS MONITOR SET-UP

(TIME_STAMP_GMS_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

GMS01000/(GPS_SETUP_OKAY). We would also like to place this GPS monitor on {C_FNAME/the child}’s waist. The monitor should be worn for a week. It is not waterproof so it cannot be worn in the shower, tub, or while swimming. Please take it off and set it near the child when {he/she} is in water or when {he/she} is sleeping. The monitor needs to be recharged every evening. Is that okay?

Label	Code	Go To
YES	1	GMS04000
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health & Nutrition Examination Survey (NHANES) (Modified)

GMS02000/(GPS_REFUSE). RECORD REASON FOR REFUSAL.

Label	Code	Go To
NONE GIVEN	1	GPS_SETUP_COMMENTS
NOT INTERESTED IN GPS MONITORING	2	GPS_SETUP_COMMENTS
DOES NOT WANT EQUIPMENT PUT ON CHILD	3	GPS_SETUP_COMMENTS
OTHER	-5

GMS03000/(GPS_REFUSE_OTH). SPECIFY:  _________________________________

PROGRAMMER INSTRUCTIONS

• GO TO GPS_SETUP_COMMENTS

GMS04000. GPS MONITOR PLACEMENT INSTRUCTIONS

DATA COLLECTOR INSTRUCTIONS

• PLACE THE GPS MONITOR ON THE SELECTED WAIST LOCATION IN ACCORDANCE WITH THE PHYSICAL ACTIVITY MEASUREMENT SOP.

GMS05000/(GPS_SETUP). WERE YOU ABLE TO PLACE THE GPS MONITOR ON THE CHILD’S WAIST?

Label	Code	Go To
YES	1	SAMPLE_1_ID
NO	2

GMS06000/(GPS_NOTSET_UP). WHY WERE YOU NOT ABLE TO PLACE THE GPS MONITOR ON THE CHILD’S WAIST?

Label	Code	Go To
SUPPLIES/EQUIPMENT NOT AVAILABLE	1	GPS_SETUP_COMMENTS
EQUIPMENT FAILURE	2	GMS08000
RAN OUT OF TIME	3	GPS_SETUP_COMMENTS
CHILD UNCOOPERATIVE	4	GPS_SETUP_COMMENTS
REFUSAL	5	GPS_SETUP_COMMENTS
OTHER	-5

GMS07000/(GPS_NOTSET_UP_OTH). SPECIFY: ________________________________

PROGRAMMER INSTRUCTIONS

• GO TO GPS_SETUP_COMMENTS

GMS08000. GPS MONITOR PROBLEM

DATA COLLECTOR INSTRUCTIONS

• COMPLETE THE ENVIRONMENTAL EQUIPMENT PROBLEM LOG.

PROGRAMMER INSTRUCTIONS

• GO TO GPS_SETUP_COMMENTS.

GMS09000/(SAMPLE_1_ID). GPS MEASUREMENT SAMPLE ID

|E|__|__|__|__|__|__|__|__|-GP01

GPS MEASUREMENT SAMPLE ID

PROGRAMMER INSTRUCTIONS

• ID MUST BE FORMATTED WITH TWO ALPHA 7 NUMERIC DASH GP01.

GMS10000/(EQUIP_1_ID). GPS MONITOR ID

___________________________________________

DATA COLLECTOR INSTRUCTIONS

• ENTER THE EQUIPMENT ID OF THE GPS MONITOR

GMS11000. GPS MONITOR SET-UP DATE

(GPS_SET_DATE_MM) MONTH:|___|___|

                 M    M

(GPS_SET_DATE_DD) DAY:       |___|___|

                 D     D

(GPS_SET_DATE_YYYY) YEAR:     |___|___|___|___|

                  Y   Y      Y     Y

PROGRAMMER INSTRUCTIONS

• DISPLAY HARD EDIT IF MM, DD, OR YYYY ARE OUTSIDE OF THE CRITERIA DEFINED IN GENERAL PROGRAMMER INSTRUCTIONS.

GMS12000. GPS MONITOR SET-UP TIME

(GPS_SET_TIME)  |___|___| : |___|___|              

   H    H         M    M

(GPS_SET_TIME_UNIT)

Label	Code	Go To
AM	1
PM	2

GMS14000/(GPS_SETUP_COMMENTS). RECORD ANY COMMENTS ABOUT THE GPS MONITOR PLACEMENT:

COMMENTS:____________________________

(TIME_STAMP_GMS_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• IF MMS_SETUP=2 AND GPS_SETUP = 2, GO TO TIME_STAMP_MSI_ET.

• OTHERWISE, GO TO TIME_STAMP_PAA_ST.

PHYSICAL ACTIVITY AND GPS MONITOR WEAR LOG DISTRIBUTION

(TIME_STAMP_PAA_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

PAA01000. PHYSICAL ACTIVITY AND GPS MONITOR WEAR LOG DISTRIBUTION

DATA COLLECTOR INSTRUCTIONS

• DISTRIBUTE AND EXPLAIN THE PHYSICAL ACTIVITY ANDGPS MONITOR WEAR LOG IN ACCORDANCE WITH THE PHYSICAL AVTIVITY MONITOR SOP.

PAA02000/(MLG_LOG_OKAY). We would like to leave this log with you. It will come back with the physical activity monitors. Is that okay?

Label	Code	Go To
YES	1	MLG_LOG_COMMENTS
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

New

PAA03000/(MLG_LOG_REFUSE). RECORD REASON FOR REFUSAL.

Label	Code	Go To
NONE GIVEN	1	MLG_LOG_COMMENTS
DOES NOT WANT TO FILL OUT A LOG	2	MLG_LOG_COMMENTS
OTHER	-5

PAA04000/(MLG_LOG_REFUSE_OTH). SPECIFY:  _________________________________

PAA05000/(MLG_LOG_COMMENTS). RECORD ANY COMMENTS ABOUT THE PHYSICAL ACTIVITY AND GPS MONITOR WEAR LOG DISTIBUTION ACTIVITY.

COMMENTS: ____________________________

(TIME_STAMP_PAA_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

PHYSICAL ACTIVITY AND GPS MONITOR SHIPPING INSTRUCTIONS

(TIME_STAMP_MSI_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

MSI01000/(MSI_PARTICIPANT_MAILBACK). AT THIS VISIT, WILL THE PARTICIPANT BE ASKED TO MAIL BACK THE PHYSICAL ACTIVITY MONITORS AND LOG?

DATA COLLECTOR INSTRUCTIONS

• CHECK ROC EVENT SPECIFICATIONS.

Label	Code	Go To
YES	1
NO	2	TIME_STAMP_MSI_ET

MSI02000. PHYSICAL ACTIVITY MONITOR SAQ AND SHIPPING INSTRUCTIONS DISTRIBUTION

DATA COLLECTOR INSTRUCTIONS

• DISTRIBUTE THE PHYSICAL ACTIVITY MONITOR SAQ AND PHYSICAL ACTIVITY AND GPS MONITOR SHIPPING INSTRUCTIONS IN ACCORDANCE WITH THE PHYSICAL ACTIVITY MONITOR SOP.

MSI03000/(MSI_PARTICIPANT_MAILBACK_OKAY). At the end of the week, we would like you to send the monitors, questionnaire, and log back to us. We have a kit with a pre-paid shipper to help you with that. Is that okay?

Label	Code	Go To
YES	1	SHIPMENT_TRACKING_NUM
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

New

MSI04000/(MSI_PART_MAILBACK_REFUSE). RECORD REASON FOR REFUSAL.

Label	Code	Go To
NONE GIVEN	1	KIT_DISTRIB_COMMENTS
WANTS DATA COLLECTOR TO PICK UP	2	KIT_DISTRIB_COMMENTS
TOO MUCH TROUBLE TO MAIL BACK	3	KIT_DISTRIB_COMMENTS
OTHER	-5

MSI05000/(MSI_PART_MAILBACK_REFUSE_OTH). SPECIFY:  _________________________________

PROGRAMMER INSTRUCTIONS

• GO TO KIT_DISTRIB_COMMENTS

MSI06000/(SHIPMENT_TRACKING_NUM). SHIPMENT TRACKING NUMBER:

TRACKING NUMBER:______________________________

DATA COLLECTOR INSTRUCTIONS

• DISTRIBUTE THE PHYSICAL ACTIVITY MONITOR SHIPPING KIT IN ACCORDANCE WITH THE PHYSICAL ACTIVITY MEASUREMENT SOP.

• ENTER THE SHIPMENT TRACKING NUMBER THAT IS PRINTED ON THE SHIPPING LABEL INCLUDED IN THE KIT.

MSI07000. RECORD THE EXPECTED SHIPMENT DATE FOR THE MONITORS:

(TARGET_SHIP_DATE_MM) MONTH:|___|___|

                 M    M

(TARGET_SHIP_DATE_DD) DAY:       |___|___|

                 D     D

(TARGET_SHIP_DATE_YYYY) YEAR:     |___|___|___|___|

                  Y    Y      Y    Y

PROGRAMMER INSTRUCTIONS

• DISPLAY HARD EDIT IF MM, DD OR YYYY ARE OUTSIDE CRITERIA DEFINED IN GENERAL PROGRAMMER INSTRUCTIONS.

MSI08000/(KIT_DISTRIB_COMMENTS). RECORD ANY COMMENTS ABOUT DISTRIBUTING THE MONITOR SHIPMENT KIT.

COMMENTS:  ______________________________

(TIME_STAMP_MSI_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for 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 (0925-0593*). Do not return the completed form to this address.