OMB Control Number: 0990-0281
ODPHP Generic Information Collection Request: Prevention Communication and Formative Research
Audience Research to Inform Physical Activity Guidelines Strategic Communication
Attachment B:
Screening Questions
(Research Instrument)
April 5, 2017
Submitted to:
Sherrette Funn
Office of the Chief Information Officer
U.S. Department of Health and Human Services
Submitted by:
Frances Bevington
Strategic Communication and Public Affairs Advisor
Office of Disease Prevention and Health Promotion
U.S. Department of Health and Human Services
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 0990-0281. The time required to complete this information collection is estimated to average 5 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
You’re being asked to participate in a survey about physical activity.
We are conducting this survey on behalf of the Office for Disease Prevention and Health Promotion, part of the U.S. Department of Health and Human Services.
First, we want to see if you qualify.
We have a few simple questions to ask. At some point, the questions may end if you don’t qualify. This has nothing to do with you. We are simply looking for people who meet certain criteria.
Please
tell us a little bit about yourself.
Where do you live?
Baltimore, MD area
Chicago, IL area
Jackson, MS area
Las Vegas, NV area
None
of the above [TERMINATE]
Which best describes where you live?
City or urban area
Suburbs
Country or rural area
What is your age?
24 years old or younger [TERMINATE]
25 to 34 years old
35 to 44 years old
45 to 54 years old
55 to 64 years old
65 to 74 years old
75 years old or older [TERMINATE]
Are you comfortable answering questions in English?
Yes
No [TERMINATE]
How often do you get physical activity for at least 30 minutes a day? Physical activity is anything that gets your body moving.
Never (0 days a week)
Rarely (1 day a week)
Sometimes (2-3 days a week)
Often (4-5 days a week) [TERMINATE – ACTION/MAINTENANCE STAGES]
Almost always (6 days a week) [TERMINATE – ACTION/MAINTENANCE STAGES]
Always (7 days a week) [TERMINATE – ACTION/MAINTENANCE STAGES]
Within the next month, do you plan to start getting more physical activity than you do now?
Yes [TERMINATE – PREPARATION STAGE]
No
Within the next 6 months, do you plan to start getting more physical activity than you do now?
Yes
No [TERMINATE – PRECONTEMPLATION OR MAINTENANCE STAGES]
What sex were you assigned at birth?
Male
Female
Are you a parent of an adolescent? (Adolescent is defined as being 12 to 17 years old.)
Yes
No
[SKIP TO QUESTION 11]
How many adolescents do you have?
1
2
3 or
more
Are you of Hispanic or Latino origin?
Yes
No
Which category best describes your race?
White only
Black or African American only
American Indian or Alaska Native only
Asian or Pacific Islander only
2 or more races
Other
What is the highest level of education you have completed?
Less than high school
High school
Some college
Associates degree
4-year college
Advanced degree
Which is your total, yearly household income?
Less than $20,000
$20,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $149,999
$150,000 to $199,999
$200,000
or more
Are you deaf or do you have serious difficulty hearing?
Yes
No
Don’t know / Not sure
Prefer not to answer
Are you blind or do you have serious difficulty seeing, even when wearing glasses?
Yes
No
Don’t know / Not sure
Prefer not to answer
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
Yes
No
Don’t know / Not sure
Prefer not to answer
Do you have serious difficulty walking or climbing stairs?
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Lizzie |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |