Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/xxxx
Student Survey: Non-PYFP Schools
Please note that you do not have to participate in this survey. It is voluntary. If you decide not to participate, this will not impact your grade in PE.
Public reporting burden of this collection of information is estimated to average 15 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)
ICF International is working with the Centers for Disease Control and Prevention (CDC) and the President’s Youth Fitness Program (PYFP) to learn more about physical education and physical activity opportunities for middle schoolers.
You are being asked to take this survey because your class was picked by your school. We would like to know more about student physical activity and fitness attitudes and habits. Your answers are very valuable to us. The survey is short – it should take no more than 15-20 minutes of your time. You do not have to do the survey if you do not want to, and you may skip any question you do not wish to answer. All your responses will be kept private.
Please let the school liaison know if you have any questions while taking the survey. Once you have finished, please turn the survey in to the school liaison who gave out the survey.
For the two questions below think about an average week at school (no holidays, days-off or special events when PE might be cancelled).
In an average week when you are in school, on how many days do you go to PE class?
a. 0 days
b. 1 day
c. 2 days
d. 3 days
e. 4 days
f. 5 days
How long is your PE class (in minutes)? ______ Minutes
Think about a typical PE or gym class and the physical activities you may have done, things that got your body moving like sports, physical games or playing actively with your friends. How long do you usually spend doing physical activities in PE or gym class?
Number of minutes:_____
Physical Activity Opportunities in School
The next series of questions are about physical activity opportunities at school.
What does your school provide for students to be physically active/to get exercise? (check all that apply)
a. Intramurals
b. After school sports
c. Additional physical education classes
d. After school clubs
e. In-class physical activity breaks
f. Other (please describe) ________________________
Do classroom teachers encourage you to be physically active?
Yes/ No
As you read the statement below think about whether this is true at your school or in your physical education (PE) class and check the response option that matches what you think.
I think my school provides enough opportunities for all students to be physically active.
a. No, definitely not
b. No, not really
c. Yes, sort of
d. Yes, definitely
e. Not sure
During this semester of physical education (PE), did your PE teacher address the following physical activity topics in your physical education class?
Answer “Yes”, “No” or “Not sure” for each of the responses below
a. Benefits of physical activity including reducing risks for chronic disease?
b. Cardiovascular endurance?
c. Muscular endurance?
d. Muscular strength?
e. Flexibility?
f. Body composition?
g. Phases of a workout (warm-up, workout, and cool down)?
h. Goals for physical activity?
i. Goals for fitness (such as increased strength, flexibility or aerobic capacity)
j. Developing an individualized physical activity plan?
How many days each week do you think you should exercise or be active? Think about things that get your body moving like sports, physical activity lessons or playing actively with your friends.
_____ days per week
How many minutes do you think you should exercise or be active each day for good health?
_____ minutes per day
For each of the statements below please answer “Yes”, “No” or “not sure”.
a. I enjoy my PE class
b. I learn how to be fit in my PE class
c. Setting fitness goals is important
d. I learn about intensity in PE class so that I can apply it when I’m active
e. I learn in PE class about setting goals to improve my fitness assessment scores
f. In my PE class, I am moving more than half the time
g. I am active outside of class because I want to improve my skills
h. I am active outside of class because I want to increase my fitness
i. I am following a plan outside of class to achieve my fitness goals
Did you complete a fitness assessment this year?
Yes/ No/ Not sure
In your PE class this semester, did your teacher give:
a. Written tests
i. Yes
ii. No
iii. Not Sure
b. Skill performance tests related to PE (for example, basketball skills or soccer skills)
i. Yes
ii. No
iii. Not sure
When did you complete the written tests?
At the end of the PE semester
At both the beginning and end of the PE semester
Multiple times throughout the PE semester
I did not complete written tests this semester as part of my PE class
I am not sure if I completed written tests this year as part of my PE class
**The survey questions below will be only asked if students indicate that they have completed a fitness assessment this school year. Otherwise, students will skip this section**
Did your PE teacher provide you with an explanation of what fitness assessment scores meant?
a. Yes
b. No
Did your PE teacher share your fitness scores with your parents?
a. Yes
b. No
c. Don’t know
Did your PE teacher ask you to develop a plan for being physically active?
a. Yes
b. No
Did you use your fitness assessment scores to help develop a plan for being physically active?
a. Yes
b. No
Did your PE teacher provide you with feedback on a physical activity plan?
a. Yes
b. No
Did your PE teacher teach you about how to track your progress on a physical activity plan?
a. Yes
b. No
Did your PE teacher ask you to keep a log of your physical activities outside of PE class?
a. Yes
b. No
Have you had your body mass index (BMI) [BMI: measurements of a student’s height and weight] measured at during the past school year?
a. Yes
b. No
Were you embarrassed by having the body mass index (BMI) measurements taken?
a. Yes
b. No
If yes to question 22 above, was it for any of the following reasons?
a. The BMI measurement was done in front of others
b. I do not want my peers knowing my weight
c. I do not want my PE teacher to know my weight
d. Other (please explain) _______________________
During this past school year, did your PE teacher recognize achievement of fitness goals?
a. [If yes] Were you recognized for achieving fitness goals or for fitness assessment scores?
b. [If yes] Please indicate if you Agree a lot, agree, disagree, or disagree a lot with the following statement: Receiving recognition for achieving fitness goals motivates me to be physically active.
i. Agree a lot
ii. Agree
iii. Disagree
iv. Disagree a lot
[If yes to questions 2 above] On a scale from 0 to 10, to what extent has student recognition motivated you to increase your own fitness levels?
1 (no motivation) – 10 (extreme motivation)
For the following statements, please note if you disagree or agree on a scale from 1 (disagree a lot) to 4 (agree a lot)
If I were to be physically active on most days:
|
Disagree a lot |
Disagree |
Agree |
Agree a lot |
It would help me deal with stress |
1 |
2 |
3 |
4 |
It would help me make new friends |
1 |
2 |
3 |
4 |
It would get or keep me in shape |
1 |
2 |
3 |
4 |
It would make me more attractive |
1 |
2 |
3 |
4 |
It would give me more energy |
1 |
2 |
3 |
4 |
It would make me better in sports, dance and other activities |
1 |
2 |
3 |
4 |
It would be painful |
1 |
2 |
3 |
4 |
It would be difficult |
1 |
2 |
3 |
4 |
It would be embarrassing |
1 |
2 |
3 |
4 |
It would make me feel uncomfortable |
1 |
2 |
3 |
4 |
It would make me tired |
1 |
2 |
3 |
4 |
It would make me sore |
1 |
2 |
3 |
4 |
It would be too much work |
1 |
2 |
3 |
4 |
It would take too much time |
1 |
2 |
3 |
4 |
During the last 7 days, on how many days were you physically active for a total of at least 60 minutes per day? (Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard some of the time)
a. 0 days
b. 1 day
c. 2 days
d. 3 days
e. 4 days
f. 5 days
g. 6 days
h. 7 days
On an average school day, how many hours do you watch TV?
a. I do not watch TV on an average school day
b. 1 hour per day
c. 2 hours per day
d. 3 hours per day
e. 4 hours per day
f. 5 or more hours per day
On an average school day, how many hours do you play video or computer games or use a computer for something that is not school work (count time spent on things such as Xbox, playstation, an ipod, an ipad or other tablet, a smartphone, youtube, facebook or other social networking tools and the internet).
a. I do not play video or computer games or use a computer for something that is not schools work
b. Less than 1 hour per day
c. 1 hour per day
d. 2 hours per day
e. 3 hours per day
f. 4 hours per day
g. 5 or more hours per day
How old are you?
a. 10 years old or younger
b. 11 years old
c. 12 years old
d. 13 years old
e. 14 years old or older
What grade are you in?
a. 6th grade
b. 7th grade
c. 8th grade
d. Other __________________
Are you a girl or a boy?
a. Girl
b. Boy
How do you describe yourself?
a. American Indian or Alaska Native
b. Asian
c. Black or African American
d. Native Hawaiian or Other Pacific Islander
e. White
f. Other_________________
Are you Hispanic or Latino?
Yes/ No
Thank you very much for taking the time to do this survey. Please turn your survey in to the school liaison who gave out the survey at the start of your class. Have a wonderful day!
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |