Accelerometry Log - 6th Grade Students in PYFP Schools

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Accelerometry Log

Public reporting burden of this collection of information is estimated to average 30 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx)

Meter Log

Wear the movement meter for seven (7) days in a row, including weekends. In the spaces below, write down the dates, days and times which you wear it. Please also write down the times school starts and ends each day. If you take the devices off for more than 30 minutes, such as for swimming, record when they were removed and for what reason. If you are unable to wear the meter for at least 12 hours one day, please wear it one extra day. Thank you!

Please start wearing your meter on or before ___________________________.

The last full day that your meter will work is ____________________!

Day 1

(Circle Day) Mon Tues Wed Thurs Fri Sat Sun Date______________

Time Meter Put On: am / pm Time school started: am / pm

Time Meter Taken Off: : am / pm Time school ended: am / pm

Time removed during the day (e.g. 10:30-11am):

Why removed (e.g. swimming): ____________ ____________ ____________

Day 2

(Circle Day) Mon Tues Wed Thurs Fri Sat Sun Date______________

Time Meter Put On: am / pm Time school started: am / pm

Time Meter Taken Off: : am / pm Time school ended: am / pm

Time removed during the day (e.g. 10:30-11am):

Why removed (e.g. swimming): ____________ ____________ ____________

Day 3

(Circle Day) Mon Tues Wed Thurs Fri Sat Sun Date______________

Time Meter Put On: am / pm Time school started: am / pm

Time Meter Taken Off: : am / pm Time school ended: am / pm

Time removed during the day (e.g. 10:30-11am):

Why removed (e.g. swimming): ____________ ____________ ____________

Day 4

(Circle Day) Mon Tues Wed Thurs Fri Sat Sun Date______________

Time Meter Put On: am / pm Time school started: am / pm

Time Meter Taken Off: : am / pm Time school ended: am / pm

Time removed during the day (e.g. 10:30-11am):

Why removed (e.g. swimming): ____________ ____________ ____________

Day 5

(Circle Day) Mon Tues Wed Thurs Fri Sat Sun Date______________

Time Meter Put On: am / pm Time school started: am / pm

Time Meter Taken Off: : am / pm Time school ended: am / pm

Time removed during the day (e.g. 10:30-11am):

Why removed (e.g. swimming): ____________ ____________ ____________

Day 6

(Circle Day) Mon Tues Wed Thurs Fri Sat Sun Date______________

Time Meter Put On: am / pm Time school started: am / pm

Time Meter Taken Off: : am / pm Time school started: am / pm

Time removed during the day (e.g. 10:30-11am):

Why removed (e.g. swimming): ____________ ____________ ____________

Day 7

(Circle Day) Mon Tues Wed Thurs Fri Sat Sun Date______________

Time Meter Put On: am / pm Time school started: am / pm

Time Meter Taken Off: : am / pm Time school ended: am / pm

Time removed during the day (e.g. 10:30-11am):

Why removed (e.g. swimming): ____________ ____________ ____________

Day 8 (if needed)

(Circle Day) Mon Tues Wed Thurs Fri Sat Sun Date______________

Time Meter Put On: am / pm Time school started: am / pm

Time Meter Taken Off: : am / pm Time school started: am / pm

Time removed during the day (e.g. 10:30-11am):

Why removed (e.g. swimming): ____________ ____________ ____________

FOR OFFICE USE ONLY
Participant ID __________________ Recruiter __________________ Meter Number __________________	Date Initialized: __________________ Valid meter days: __________________ First Mail Day: __________________

You’re done! Please include this log in your return envelope along with the meter and belt.