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 C:
Consumer Survey
(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 15 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
Have you seen, heard, or read anything about government physical activity guidelines?
Yes
No
What best describes what typically happens during moderate-intensity physical activity?
Your heart beats about the same as usual, and you can sing while doing the activity.
Your heart beats somewhat faster than usual, and you can talk while doing the activity. [CODE AS CORRECT]
Your heart beats much faster than usual, and you can’t say more than a few words without pausing for a breath.
Choose the activity below that is typically considered moderate-intensity.
Jogging
Brisk walking [CODE AS CORRECT]
Fast swimming
Playing competitive basketball
What best describes what typically happens during vigorous-intensity physical activity?
Your heart beats about the same as usual, and you can sing while doing the activity.
Your heart beats somewhat faster than usual, and you can talk while doing the activity.
Your heart beats much faster than usual, and you can’t say more than a few words without pausing for a breath. [CODE AS CORRECT]
Choose the activity below that is typically considered vigorous-intensity.
Running [CODE AS CORRECT]
Walking the dog
Gardening
Washing the dishes
What is the minimum amount of moderate-intensity physical activity the government recommends for adults to get big health benefits?
20 minutes a day, 3 or more days a week
100 minutes spread out over a week
30 minutes a day, 5 or more days a week
60 minutes a day, 7 days a week
150 minutes spread out over a week [CODE AS CORRECT]
Don’t know / Not sure
What is the minimum amount of vigorous-intensity physical activity the government recommends for adults to get big health benefits?
15 minutes a day, 3 or more days a week
75 minutes spread out over a week [CODE AS CORRECT]
15 minutes a day, 5 or more days a week
30 minutes a day, 3 or more days a week
100 minutes spread out over a week
Don’t know / Not sure
How many days a week of muscle-strengthening activity does the government recommend for adults to get big health benefits?
At least 1 day a week
At least 2 days a week [CODE AS CORRECT]
At least 3 days a week
At least 4 days a week
Don’t know / Not sure
Current Amount/Type of Physical Activity
The next set of questions is about the amounts and types of physical activity that you currently do. Physical activity is anything that gets your body moving.
During the past 30 days, did you participate in any physical activities? (Some examples are walking, running, dancing, golf, and gardening.)
Yes
No
[SKIP TO QUESTION 15]
Aerobic physical activity (also known as cardio) means moving your body’s large muscles in the same way over a continuous period of time. During the past 30 days, what type of typically aerobic physical activity did you spend the most time doing?
[DROP DOWN MENU with open text box option to write in an answer that is not included]
Walking
Dancing
Swimming
Water aerobics
Jogging
Running
Basketball
Hiking
Taking a “cardio” exercise class at a gym
Doing a video-based or self-directed “cardio” exercise program at home
Bicycling
Yard work
Playing with my kids
Tennis
Golf (without a cart)
Other, please specify: __________
About how many days did you take part in [QUESTION 10 ANSWER] during the past 30 days?
[___]
days during the past 30 days
When you took part in [QUESTION 10 ANSWER], for how many minutes or hours did you usually keep at it each day?
[__] hours and [__] minutes
During the past 30 days, what type of typically muscle-strengthening physical activity did you spend the most time doing?
[DROP DOWN MENU with open text box option to write in an answer that is not included]
Lifting weights or using weight machines
Taking a strengthening exercise class at a gym
Doing a video-based or self-directed strengthening exercise program at home
Doing body weight exercises (like push-ups or lunges)
Using rubber tubing or resistance bands
Being physically active as part of my job (like lifting or carrying heavy objects)
Lifting heavy household items
Rock climbing
Other, please specify: __________
About how many days per week did you take part in [QUESTION 13 ANSWER] during the past 30 days?
[___] days per week
When you took part in [QUESTION 13 ANSWER], for how many minutes or hours did you usually keep at it each day?
[__] hours and [__] minutes
Desired Amount/Type of Physical Activity
The next set of questions is about the amounts and types of physical activity that you’d like to do. When answering these questions, please think about amounts and types of physical activity that are realistic for you.
How many days a week would you like to get physical activity?
0 days a week
1 day a week
2-3 days a week
4-5 days a week
6 days a week
7 days a week
On those days, how many minutes would you like to be physically active?
Less than 10 minutes a day
10-20 minutes a day
21-30 minutes a day
31-40 minutes a day
41-50 minutes a day
51-60 minutes a day
Over one hour a day
Which of these typically aerobic activities would you like to spend the most time doing?
[DROP DOWN MENU with open text box option to write in an answer that is not included]
Walking
Dancing
Swimming
Water aerobics
Jogging
Running
Basketball
Hiking
Taking a “cardio” exercise class at a gym
Doing a video-based or self-directed “cardio” exercise program at home
Bicycling
Yard work
Playing with my kids
Tennis
Golf (without a cart)
Other, please specify: __________
Which of these typically muscle-strengthening activities would you like to spend the most time doing?
[DROP DOWN MENU with open text box option to write in an answer that is not included]
Lifting weights or using weight machines
Taking a strengthening exercise class at a gym
Doing a video-based or self-directed strengthening exercise program at home
Doing body weight exercises (like push-ups or lunges)
Using rubber tubing or resistance bands
Being physically active as part of my job (like lifting or carrying heavy objects)
Lifting heavy household items
Rock climbing
Other, please specify: __________
[If the participant is a parent of a child 12 to 17 years old, ask questions in this section. Otherwise, skip to next section.]
The next set of questions is about the amount and type of physical activity your child age 12 to 17 gets. If you have more than one child in this age range, please answer the questions for your least physically active child.
Within the next month, do you plan to encourage your child to get more physical activity than he or she does now?
Yes [SKIP REMAINDER OF ADOLESCENT SECTION] [CODE: PREPARATION STAGE]
No
Within the next 6 months, do you plan to encourage your child to get more physical activity than he or she does now?
Yes [CODE: CONTEMPLATION STAGE]
No [SKIP REMAINDER OF ADOLESCENT SECTION] [CODE: PRECONTEMPLATION OR MAINTENANCE STAGES]
How often does your child get physical activity for at least 1 hour a day?
Never (0 days a week)
Rarely (1 a week)
Sometimes (2-3 days a week)
Often (4-5 days a week) [SKIP REMAINDER OF ADOLESCENT SECTION] [CODE: ACTION/MAINTENANCE STAGE]
Almost always (6 days a week) [SKIP REMAINDER OF ADOLESCENT SECTION] [CODE: ACTION/MAINTENANCE STAGE]
Always (7 days a week) [SKIP REMAINDER OF ADOLESCENT SECTION] [CODE: ACTION/MAINTENANCE STAGE]
What is your child’s age?
[text box]
What sex was your child assigned at birth?
Male
Female
Is your child deaf or do they have serious difficulty hearing?
Yes
No
Don’t know / Not sure
Prefer not to answer
Is your child blind or do they 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, does your child have serious difficulty concentrating, remembering, or making decisions?
Yes
No
Don’t know / Not sure
Prefer not to answer
Does your child have serious difficulty walking or climbing stairs?
Yes
No
Don’t know / Not sure
Prefer not to answer
On how many of the past 7 days did your child do exercises to strengthen or tone their muscles, such as push-ups, sit-ups, or weight lifting?
0 days
1 day
2-3 days
4-5 days
6 days
7 days
What makes it harder to be physically active? (Choose your top 3.)
When the weather bothers me
When I am bored by the activity
When I feel pain when exercising
When I have to be active alone
When I don’t enjoy the activity
When I’m too busy with other things
When I feel tired
When I feel stressed
When I feel depressed
Other
(please specify):________
What makes it easier to be physically active? (Choose your top 3.)
When the weather is good
When I am excited by the activity
When my body feels good when exercising
When I can be active with friends or family
When I enjoy the activity
When I have time
When I feel rested
When I feel like things are under control
When I feel happy
Other (please specify):________
Have you used mobile health tools to help you be more physically active? (Some examples are apps like MapMyRun, websites like MyFitnessPal, or trackers like FitBit.)
Yes
No
[SKIP TO QUESTION 34]
What mobile health tools have you used to help you be more physically active? (Check all that apply.)
Fitness tracker (like Fitbit, Garmin, Apple Watch, or pedometer)
Website where I can log my activity (like MyFitnessPal, RunKeeper, or SparkPeople)
App where I can track my activity (like MapMyRun)
App that coach me through exercises (like Sworkit or Touchfit)
Heart rate monitor
Other (please specify): ____________
Are you interested in using mobile health tools in the future?
Yes
No
What features in physical activity-related mobile health tools are or would be most helpful for you? (Choose your top 2.)
Reminder notifications
Goal-setting
Tracking my progress
Seeing how well I’m doing compared to others
Instructions on how to do a physical activity or stretch
Sharing my progress with others
Getting congratulated for accomplishments
Earning points or prizes
Other: _________________
List up to 3 websites that you visit most often. These websites can be about anything (they don’t need to be about health or physical activity).
[text box]
[text box]
[text box]
I don’t use websites.
What social media platform do you use most?
[Drop down menu with option to write in an answer]
Tumblr
Snapchat
Other: _________________
I don’t use social media sites.
Do you ever look online for information about how to stay healthy?
Yes
No [SKIP TO QUESTION 40]
I don’t seek out this information online, but it shows up in my social media or news feeds. [SKIP TO QUESTION 40]
List up to 3 websites that you visit most often to get information about how to stay healthy.
[text box]
[text box]
[text box]
I don’t use websites to get health information.
Where do you typically get information on how to stay healthy? (Choose your top 3.)
[CODE AS DIGITAL]
Social media [name favorite site: _____]
Websites (besides social media) [name favorite site: ____]
Internet searches
Video-sharing sites [name favorite site: ______]
Emails or listservs [name favorite listserv: ______]
Blogs [name favorite blog: _____]
Mobile or tablet apps [name favorite app: _____]
[CODE AS OTHER MEDIA]
Radio [name favorite station or show: ______]
TV [name favorite station or show: _______]
Newspapers or magazines [name favorite source: _____]
Books [name favorite book: _______]
[CODE AS SOCIAL]
Family and friends
Work or co-workers
Health coach or personal trainer
Doctor or medical professional
[CODE AS COMMUNITY]
Community health center
Grocery/corner store
Billboard
Library
Place of worship
Other:
________________
In the past 30 days, where have you seen, read, or heard information about physical activity? (Choose your top 3.)
[CODE AS DIGITAL]
Social media [name favorite site: _____]
Websites (besides social media) [name favorite site: ____]
Internet searches
Video-sharing sites [name favorite site: ______]
Emails or listservs [name favorite listserv: ______]
Blogs [name favorite blog: _____]
Mobile or tablet apps [name favorite app: _____]
[CODE AS OTHER MEDIA]
Radio [name favorite station or show: ______]
TV [name favorite station or show: _______]
Newspapers or magazines [name favorite source: _____]
Books [name favorite book: ______]
[CODE AS SOCIAL]
Family and friends
Work or co-workers
Health coach or personal trainer
Doctor or medical professional
[CODE AS COMMUNITY]
Community health center
Grocery/corner store
Billboard
Library
Place of worship
Other:
________________
What type of health-related information are you most likely to share with friends or family members?
Images or photos
Videos
Motivational quotes
Blog entries
News articles
Success stories
None of the above
Other:_________________
Do you ever watch videos to get information about a topic?
Yes
No [SKIP TO QUESTION 46]
Where do you usually find these videos?
Snapchat
YouTube
Email lists
Other:__________________
When you watch one of these videos, how long do you usually watch?
Less than 1 minute
1-2 minutes
3-5 minutes
6-10 minutes
Longer than 10 minutes
How often do you sign up to receive email newsletters from organizations, groups, or companies?
Never [SKIP TO QUESTION 48]
Rarely
Sometimes
Often
For these email newsletters, what kind of information do you find most useful?
[text box]
What kinds of information would motivate you to be more physically active? (Choose your top 2.)
Tips on how to be physically active with a friend or family member
Examples of physical activity I could do in my home or at the office
Having clear instructions about what types of physical activity I should do
Having clear instructions about how much physical activity I should do
Seeing pictures or videos of someone like me being physically active
Tips on how to sneak physical activity into my usual routine
Other: _________________
[If the participant is a parent of a child 12 to 17 and was prompted to answer ALL questions in the Adolescent Physical Activity section, ask questions in this section.]
The next set of questions is about the ways your child age 12 to 17 gets information. If you have more than one child in this age range, please answer the questions for your least physically active child.
List up to 3 websites that your child visits most often. These websites can be about anything (they don’t need to be about health or physical activity).
[text box]
[text box]
[text box]
My child doesn’t use websites.
What social media platform does your child use most?
[Drop down menu with option to write in an answer]
Tumblr
Snapchat
Other: _________________
My child doesn’t use social media.
List up to 3 websites that your child visits most often to get information about how to stay healthy.
[text box]
[text box]
[text box]
My child doesn’t use websites to get health information.
Where does your child typically get information about how to stay healthy? (Choose the top 3.)
[CODE AS DIGITAL]
Social media [name favorite site: _____]
Websites (besides social media) [name favorite site: ____]
Internet searches
Video-sharing sites [name favorite site: ______]
Emails or listservs [name favorite listserv: ______]
Blogs [name favorite blog: _____]
Mobile or tablet apps [name favorite app: _____]
[CODE AS OTHER MEDIA]
Radio [name favorite station or show: ______]
TV [name favorite station or show: _______]
Newspapers or magazines [name favorite source: _____]
Books [name favorite book: ______]
[CODE AS SOCIAL]
Family and friends
Coach or personal trainer
Doctor or medical professional
Teacher or school
[CODE AS COMMUNITY]
Community health center
Grocery/corner store
Billboard
Library
Place of worship
Other:
________________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Lizzie |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |