42.3 Survey

Continuation of National Children's Study Vanguard (Pilot) Study Data Collection: Study Visits through 60-Months

PhysicalActivityMonitorLogSAQ

Physical Activity Subsample Study

OMB: 0925-0593

Document [docx]
Download: docx | pdf

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Physical Activity Monitor Log SAQ, Phase 2g

OMB Specification


Physical Activity Monitor Log SAQ


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:

Self-Administered

Mode (for this instrument*):

In-Person, PAPI

OMB Approved Modes:

In-Person, PAPI;
Phone, PAPI;
Web-Based, CAI

Estimated Administration Time:

14 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 Log SAQ



TABLE OF CONTENTS





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Physical Activity Monitor Log SAQ



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.





ACTIVITY MONITOR AND LOG


AMA01000. Activity Monitor and Log Use for:


(PA_CHILD_NAME) Name: _________________________________________


SOURCE

New


(PA_CHILD_AGE) Age: |___|___| Years


SOURCE

New


AMA02000. Please fill in the appropriate row at the end of each day.

If the monitor was removed, please note the times when it was not worn and why. You do not need to record removing the GPS from the waist at bedtime.


AMA03000/(PA_DAY1). Day of Week

Day 1 - __________________


SOURCE

New


AMA04000. Date


SOURCE

New


(PA_DATE1_MM) MONTH: |___|___|


(PA_DATE1_DD) DAY: |___|___|


(PA_DATE1_YYYY) YEAR: 20|___|___|


AMA05000. Time child got out of bed


SOURCE

New


(PA_WAKE_TIME1) |___|___|:|___|___|


(PA_WAKE_TIME1_UNIT)


Label

Code

Go To

AM

1


PM

2



AMA06000. Time child went to bed


SOURCE

New


(PA_BED_TIME1) |___|___|:|___|___|


(PA_BED_TIME1_UNIT)


Label

Code

Go To

AM

1


PM

2



AMA07000/(PA_WORE_PA1). Wore Activity Monitor Throughout the Day

Wore physical activity monitor on wrist?


Label

Code

Go To

Yes

1

PA_WORE_GPS1

No

2



SOURCE

New


AMA08000/(PA_HRS_WORN_PA1). Approx. # hrs monitor not worn as specified

|___|___|

Hours


SOURCE

New


AMA09000/(PA_NOT_WORN_PA1). Why was monitor not worn? Mark all that apply.


Label

Code

Go To

Removed by the child

1


Not allowed at daycare

2


Needed to remove it at airport

3


Monitor was damaged

4


Other

-5



SOURCE

New


PARTICIPANT INSTRUCTIONS

  • If you answered "other" or "other" and any combination of the first four answers, go to PA_NOT_WORN_PA1_OTH.

  • If you did not answer "other," go to PA_WORE_GPS1.


AMA10000/(PA_NOT_WORN_PA1_OTH). Specify reason: _____________________________________________________________


SOURCE

New


AMA11000/(PA_WORE_GPS1). Wore Activity Monitor Throughout the Day

Wore GPS monitor on waist, except at bedtime?


Label

Code

Go To

Yes

1

PA_DAY2

No

2



SOURCE

New


AMA12000/(PA_HRS_WORN_GPS1). Approx. # hrs monitor not worn as specified

|___|___|

Hours


SOURCE

New


AMA13000/(PA_NOT_WORN_GPS1). Why was monitor not worn? Mark all that apply.


Label

Code

Go To

Child in water

1


Removed by the child

2


Not allowed at daycare

3


Needed to remove it at airport

4


Monitor was damaged

5


Other

-5



SOURCE

New


PARTICIPANT INSTRUCTIONS

  • If you answered "other" or "other" and any combination of the first five answers, go to PA_NOT_WORN_GPS1_OTH.

  • If you did not answer "other," go to PA_DAY2.


AMA14000/(PA_NOT_WORN_GPS1_OTH). Specify reason: ______________________________________________


SOURCE

New


AMA15000/(PA_DAY2). Day of Week

Day 2 - ____________________


SOURCE

New


AMA16000. Date


SOURCE

New


(PA_DATE2_MM) MONTH: |___|___|


(PA_DATE2_DD) DAY: |___|___|


(PA_DATE2_YYYY) YEAR: 20|___|___|


AMA17000. Time child got out of bed


SOURCE

New


(PA_WAKE_TIME2) |___|___|:|___|___|


(PA_WAKE_TIME2_UNIT)


Label

Code

Go To

AM

1


PM

2



AMA18000. Time child went to bed


SOURCE

New


(PA_BED_TIME2) |___|___|:|___|___|


(PA_BED_TIME2_UNIT)


Label

Code

Go To

AM

1


PM

2



AMA19000/(PA_WORE_PA2). Wore Activity Monitor Throughout the Day

Wore physical activity monitor on wrist?


Label

Code

Go To

Yes

1

PA_WORE_GPS2

No

2



SOURCE

New


AMA20000/(PA_HRS_WORN_PA2). Approx. # hrs monitor not worn as specified

|___|___|

Hours


SOURCE

New


AMA21000/(PA_NOT_WORN_PA2). Why was monitor not worn? Mark all that apply.


Label

Code

Go To

Removed by the child

1


Not allowed at daycare

2


Needed to remove it at airport

3


Monitor was damaged

4


Other

-5



SOURCE

New


PARTICIPANT INSTRUCTIONS

  • If you answered "other" or "other" and any combination of the first four answers, go to PA_NOT_WORN_PA2_OTH.

  • If you did not answer "other," go to PA_WORE_GPS2.


AMA22000/(PA_NOT_WORN_PA2_OTH). Specify reason: _____________________________________


SOURCE

New


AMA23000/(PA_WORE_GPS2). Wore Activity Monitor Throughout the Day

Wore GPS monitor on waist, except at bedtime?


Label

Code

Go To

Yes

1

PA_DAY3

No

2



SOURCE

New


AMA24000/(PA_HRS_WORN_GPS2). Approx. # hrs monitor not worn as specified

|___|___|

Hours


SOURCE

New


AMA25000/(PA_NOT_WORN_GPS2). Why was monitor not worn? Mark all that apply.


Label

Code

Go To

Child in water

1


Removed by the child

2


Not allowed at daycare

3


Needed to remove it at airport

4


Monitor was damaged

5


Other

-5



SOURCE

New


PARTICIPANT INSTRUCTIONS

  • If you answered "other" or "other" and any combination of the first five answers, go to PA_NOT_WORN_GPS2_OTH.

  • If you did not answer "other," go to PA_DAY3.


AMA26000/(PA_NOT_WORN_GPS2_OTH). Specify reason: _____________________________________________________________


SOURCE

New


AMA27000/(PA_DAY3). Day of Week

Day 3 - ______________________


SOURCE

New


AMA28000. Date


SOURCE

New


(PA_DATE3_MM) MONTH: |___|___|


(PA_DATE3_DD) DAY: |___|___|


(PA_DATE3_YYYY) YEAR: 20|___|___|


AMA29000. Time child got out of bed


SOURCE

New


(PA_WAKE_TIME3) |___|___|:|___|___|


(PA_WAKE_TIME3_UNIT)


Label

Code

Go To

AM

1


PM

2



AMA30000. Time child went to bed


SOURCE

New


(PA_BED_TIME3) |___|___|:|___|___|


(PA_BED_TIME3_UNIT)


Label

Code

Go To

AM

1


PM

2



AMA31000/(PA_WORE_PA3). Wore Activity Monitor Throughout the Day

Wore physical activity monitor on wrist?


Label

Code

Go To

Yes

1

PA_WORE_GPS3

No

2



SOURCE

New


AMA32000/(PA_HRS_WORN_PA3). Approx. # hrs monitor not worn as specified

|___|___|

Hours


SOURCE

New


AMA33000/(PA_NOT_WORN_PA3). Why was monitor not worn? Mark all that apply.


Label

Code

Go To

Removed by the child

1


Not allowed at daycare

2


Needed to remove it at airport

3


Monitor was damaged

4


Other

-5



SOURCE

New


PARTICIPANT INSTRUCTIONS

  • If you answered "other" or "other" and any combination of the first four answers, go to PA_NOT_WORN_PA3_OTH.

  • If you did not answer "other," go to PA_WORE_GPS3.


AMA34000/(PA_NOT_WORN_PA3_OTH). Specify reason: ____________________________________________


SOURCE

New


AMA35000/(PA_WORE_GPS3). Wore Activity Monitor Throughout the Day

Wore GPS monitor on waist, except at bedtime?


Label

Code

Go To

Yes

1

PA_DAY4

No

2



SOURCE

New


AMA36000/(PA_HRS_WORN_GPS3). Approx. # hrs monitor not worn as specified

|___|___|

Hours


SOURCE

New


AMA37000/(PA_NOT_WORN_GPS3). Why was monitor not worn? Mark all that apply.


Label

Code

Go To

Child in water

1


Removed by the child

2


Not allowed at daycare

3


Needed to remove it at airport

4


Monitor was damaged

5


Other

-5



SOURCE

New


PARTICIPANT INSTRUCTIONS

  • If you answered "other" or "other" and any combination of the first five answers, go to PA_NOT_WORN_GPS3_OTH.

  • If you did not answer "other," go to PA_DAY4.


AMA38000/(PA_NOT_WORN_GPS3_OTH). Specify reason: ___________________________________________________


SOURCE

New


AMA39000/(PA_DAY4). Day of Week

Day 4 - ___________________________


SOURCE

New


AMA40000. Date


SOURCE

New


(PA_DATE4_MM) MONTH: |___|___|


(PA_DATE4_DD) DAY: |___|___|


(PA_DATE4_YYYY) YEAR: 20|___|___|


AMA41000. Time child got out of bed


SOURCE

New


(PA_WAKE_TIME4) |___|___|:|___|___|


(PA_WAKE_TIME4_UNIT)


Label

Code

Go To

AM

1


PM

2



AMA42000. Time child went to bed


SOURCE

New


(PA_BED_TIME4) |___|___|:|___|___|


(PA_BED_TIME4_UNIT)


Label

Code

Go To

AM

1


PM

2



AMA43000/(PA_WORE_PA4). Wore Activity Monitor Throughout the Day

Wore physical activity monitor on wrist?


Label

Code

Go To

Yes

1

PA_WORE_GPS4

No

2



SOURCE

New


AMA44000/(PA_HRS_WORN_PA4). Approx. # hrs monitor not worn as specified

|___|___|

Hours


SOURCE

New


AMA45000/(PA_NOT_WORN_PA4). Why was monitor not worn? Mark all that apply.


Label

Code

Go To

Removed by the child

1


Not allowed at daycare

2


Needed to remove it at airport

3


Monitor was damaged

4


Other

-5



SOURCE

New


PARTICIPANT INSTRUCTIONS

  • If you answered "other" or "other" and any combination of the first four answers, go to PA_NOT_WORN_PA4_OTH.

  • If you did not answer "other," go to PA_WORE_GPS4.


AMA46000/(PA_NOT_WORN_PA4_OTH). Specify reason: _______________________________________


SOURCE

New


AMA47000/(PA_WORE_GPS4). Wore Activity Monitor Throughout the Day

Wore GPS monitor on waist, except at bedtime?


Label

Code

Go To

Yes

1

PA_DAY5

No

2



SOURCE

New


AMA48000/(PA_HRS_WORN_GPS4). Approx. # hrs monitor was not worn as specified

|___|___|

Hours


SOURCE

New


AMA49000/(PA_NOT_WORN_GPS4). Why was monitor not worn? Mark all that apply.


Label

Code

Go To

Child in water

1


Removed by the child

2


Not allowed at daycare

3


Needed to remove it at airport

4


Monitor was damaged

5


Other

-5



SOURCE

New


PARTICIPANT INSTRUCTIONS

  • If you answered "other" or "other" and any combination of the first five answers, go to PA_NOT_WORN_GPS4_OTH.

  • If you did not answer "other," go to PA_DAY5.


AMA50000/(PA_NOT_WORN_GPS4_OTH). Specify reason: _______________________________________


SOURCE

New


AMA51000/(PA_DAY5). Day of Week

Day 5 - ________________


SOURCE

New


AMA52000. Date


SOURCE

New


(PA_DATE5_MM) MONTH: |___|___|


(PA_DATE5_DD) DAY: |___|___|


(PA_DATE5_YYYY) YEAR: 20|___|___|


AMA53000. Time child got out of bed


SOURCE

New


(PA_WAKE_TIME5) |___|___|:|___|___|


(PA_WAKE_TIME5_UNIT)


Label

Code

Go To

AM

1


PM

2



AMA54000. Time child went to bed


SOURCE

New


(PA_BED_TIME5) |___|___|:|___|___|


(PA_BED_TIME5_UNIT)


Label

Code

Go To

AM

1


PM

2



AMA55000/(PA_WORE_PA5). Wore Activity Monitor Throughout the Day

Wore physical activity monitor on wrist?


Label

Code

Go To

Yes

1

PA_WORE_GPS5

No

2



SOURCE

New


AMA56000/(PA_HRS_WORN_PA5). Approx. # hrs not worn as specified

|___|___|

Hours


SOURCE

New


AMA57000/(PA_NOT_WORN_PA5). Why was monitor not worn? Mark all that apply.


Label

Code

Go To

Removed by the child

1


Not allowed at daycare

2


Needed to remove it at airport

3


Monitor was damaged

4


Other

-5



SOURCE

New


PARTICIPANT INSTRUCTIONS

  • If you answered "other" or "other" and any combination of the first four answers, go to PA_NOT_WORN_PA5_OTH.

  • If you did not answer "other," go to PA_WORE_GPS5.


AMA58000/(PA_NOT_WORN_PA5_OTH). Specify reason: _______________________________________


SOURCE

New


AMA59000/(PA_WORE_GPS5). Wore Activity Monitor Throughout the Day

Wore GPS monitor on waist, except at bedtime?


Label

Code

Go To

Yes

1

PA_DAY6

No

2



SOURCE

New


AMA60000/(PA_HRS_WORN_GPS5). Approx. # hrs monitor not worn as specified

|___|___|

Hours


SOURCE

New


AMA61000/(PA_NOT_WORN_GPS5). Why was monitor not worn? Mark all that apply.


Label

Code

Go To

Child in water

1


Removed by the child

2


Not allowed at daycare

3


Needed to remove it at airport

4


Monitor was damaged

5


Other

-5



SOURCE

New


PARTICIPANT INSTRUCTIONS

  • If you answered "other" or "other" and any combination of the first five answers, go to PA_NOT_WORN_GPS5_OTH.

  • If you did not answer "other," go to PA_DAY6.


AMA62000/(PA_NOT_WORN_GPS5_OTH). Specify reason: ________________________________________


SOURCE

New


AMA63000/(PA_DAY6). Day of Week

Day 6 - ________________________


SOURCE

New


AMA64000. Date


SOURCE

New


(PA_DATE6_MM) MONTH: |___|___|


(PA_DATE6_DD) DAY: |___|___|


(PA_DATE6_YYYY) YEAR: 20|___|___|


AMA65000. Time child got out of bed


SOURCE

New


(PA_WAKE_TIME6) |___|___|:|___|___|


(PA_WAKE_TIME6_UNIT)


Label

Code

Go To

AM

1


PM

2



AMA66000. Time child went to bed


SOURCE

New


(PA_BED_TIME6) |___|___|:|___|___|


(PA_BED_TIME6_UNIT)


Label

Code

Go To

AM

1


PM

2



AMA67000/(PA_WORE_PA6). Wore Activity Monitor Throughout the Day

Wore physical activity monitor on wrist?


Label

Code

Go To

Yes

1

PA_WORE_GPS6

No

2



SOURCE

New


AMA68000/(PA_HRS_WORN_PA6). Approx. # hrs monitor not worn as specified

|___|___|

Hours


SOURCE

New


AMA69000/(PA_NOT_WORN_PA6). Why was monitor not worn? Mark all that apply.


Label

Code

Go To

Removed by the child

1


Not allowed at daycare

2


Needed to remove it at airport

3


Monitor was damaged

4


Other

-5



SOURCE

New


PARTICIPANT INSTRUCTIONS

  • If you answered "other" or "other" and any combination of the first four answers, go to PA_NOT_WORN_PA6_OTH.

  • If you did not answer "other," go to PA_WORE_GPS6.


AMA70000/(PA_NOT_WORN_PA6_OTH). Specify reason: ___________________________________________


SOURCE

New


AMA71000/(PA_WORE_GPS6). Wore Activity Monitor Throughout the Day

Wore GPS monitor on waist, except at bedtime?


Label

Code

Go To

Yes

1

PA_DAY7

No

2



SOURCE

New


AMA72000/(PA_HRS_WORN_GPS6). Approx. # hrs monitor not worn as specified

|___|___|

Hours


SOURCE

New


AMA73000/(PA_NOT_WORN_GPS6). Why was monitor not worn? Mark all that apply.


Label

Code

Go To

Child in water

1


Removed by the child

2


Not allowed at daycare

3


Needed to remove it at airport

4


Monitor was damaged

5


Other

-5



SOURCE

New


PARTICIPANT INSTRUCTIONS

  • If you answered "other" or "other" and any combination of the first five answers, go to PA_NOT_WORN_GPS6_OTH.

  • If you did not answer "other," go to PA_DAY7.


AMA74000/(PA_NOT_WORN_GPS6_OTH). Specify reason: ___________________________________


SOURCE

New


AMA75000/(PA_DAY7). Day of Week

Day 7 - ______________


SOURCE

New


AMA76000. Date


SOURCE

New


(PA_DATE7_MM) MONTH: |___|___|


(PA_DATE7_DD) DAY: |___|___|


(PA_DATE7_YYYY) YEAR: 20|___|___|


AMA77000. Time child got out of bed


SOURCE

New


(PA_WAKE_TIME7) |___|___|:|___|___|


(PA_WAKE_TIME7_UNIT)


Label

Code

Go To

AM

1


PM

2



AMA78000. Time child went to bed


SOURCE

New


(PA_BED_TIME7) |___|___|:|___|___|


(PA_BED_TIME7_UNIT)


Label

Code

Go To

AM

1


PM

2



AMA79000/(PA_WORE_PA7). Wore Activity Monitor Throughout the Day

Wore physical activity monitor on wrist?


Label

Code

Go To

Yes

1

PA_WORE_GPS7

No

2



SOURCE

New


AMA80000/(PA_HRS_WORN_PA7). Approx. # hrs monitor not worn as specified

|___|___|

Hours


SOURCE

New


AMA81000/(PA_NOT_WORN_PA7). Why was monitor not worn? Mark all that apply.


Label

Code

Go To

Removed by the child

1


Not allowed at daycare

2


Needed to remove it at airport

3


Monitor was damaged

4


Other

-5



SOURCE

New


PARTICIPANT INSTRUCTIONS

  • If you answered "other" or "other" and any combination of the first four answers, go to PA_NOT_WORN_PA7_OTH.

  • If you did not answer "other," go to PA_WORE_GPS7.


AMA82000/(PA_NOT_WORN_PA7_OTH). Specify reason: _________________________________


SOURCE

New


AMA83000/(PA_WORE_GPS7). Wore Activity Monitor Throughout the Day

Wore GPS monitor on waist, except at bedtime?


Label

Code

Go To

Yes

1

PA_DAY8

No

2



SOURCE

New


AMA84000/(PA_HRS_WORN_GPS7). Approx. # hrs monitor not worn as specified

|___|___|

Hours


SOURCE

New


AMA85000/(PA_NOT_WORN_GPS7). Why was monitor not worn? Mark all that apply.


Label

Code

Go To

Child in water

1


Removed by the child

2


Not allowed at daycare

3


Needed to remove it at airport

4


Monitor was damaged

5


Other

-5



SOURCE

New


PARTICIPANT INSTRUCTIONS

  • If you answered "other" or "other" and any combination of the first five answers, go to PA_NOT_WORN_GPS7_OTH.

  • If you did not answer "other," go to PA_DAY8.


AMA86000/(PA_NOT_WORN_GPS7_OTH). Specify reason: _______________________________________


SOURCE

New


AMA87000/(PA_DAY8). Day of Week

Day 8 - _________________


SOURCE

New


AMA88000. Date


SOURCE

New


(PA_DATE8_MM) MONTH: |___|___|


(PA_DATE8_DD) DAY: |___|___|


(PA_DATE8_YYYY) YEAR: 20|___|___|


AMA89000. Time child got out of bed


SOURCE

New


(PA_WAKE_TIME8) |___|___|:|___|___|


(PA_WAKE_TIME8_UNIT)


Label

Code

Go To

AM

1


PM

2



AMA90000. Time child went to bed


SOURCE

New


(PA_BED_TIME8) |___|___|:|___|___|


(PA_BED_TIME8_UNIT)


Label

Code

Go To

AM

1


PM

2



AMA91000/(PA_WORE_PA8). Wore Activity Monitor Throughout the Day

Wore physical activity monitor on wrist?


Label

Code

Go To

Yes

1

PA_COMMENTS

No

2



SOURCE

New


AMA92000/(PA_HRS_WORN_PA8). Approx. # hrs monitor not worn as specified

|___|___|

Hours


SOURCE

New


AMA93000/(PA_NOT_WORN_PA8). Why was monitor not worn? Mark all that apply.


Label

Code

Go To

Removed by the child

1


Not allowed at daycare

2


Needed to remove it at airport

3


Monitor was damaged

4


Other

-5



SOURCE

New


PARTICIPANT INSTRUCTIONS

  • If you answered "other" or "other" and any combination of the first four answers, go to PA_NOT_WORN_PA8_OTH.

  • If you did not answer "other," go to PA_COMMENTS.


AMA94000/(PA_NOT_WORN_PA8_OTH). Specify reason: __________________________________________


SOURCE

New


AMA94100/(PA_COMMENTS). Additional Comments - Please record any additional comments you have about wearing the devices.

__________________________________________________________________________________________


SOURCE

New



FOR OFFICE USE ONLY:


FOU01000/(P_ID). Insert participant ID? label here.


FOU02000/(R_P_ID). Insert respondent ID? label here.


FOU03000. Insert ROC contact information? label here.


Public reporting burden for this collection of information is estimated to average 14 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 (0925-0593*). Do not return the completed form to this address.

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