Mentee Pre-Assessment

Form Approved OMB No. 0990-XXXX Exp. Date XX/XX/2018

I Can Do It, You Can Do It!

Mentee Pre-Assessment Form

Instructions:

The following questions will help us understand our program participants better and help us improve our programs. As discussed in the informed consent form, we are not asking for any names. All of your information and answers to the questions will be kept private to the extent permitted by law. You may fill out the form by yourself if you are 18 or older. If you are under 18, ask another person who is 18 or older to help you. This person should not be your ICDI mentor or an ICDI representative. People who help fill out the form should make every effort to allow you to give your own answers to questions. This survey will take about 20 minutes to complete. Thank you for participating in I Can Do It!

Who is filling out this form?

• The program participant (mentee)

• Not the participant (an adult age 18 or older) Please describe relationship: _____________

Section I: Participant (Mentee) Information:

1. What is your age? ________

2. What is your gender?

• Male

• Female

3. What is your race or ethnicity?

• American Indian or Alaska Native

• Asian

• Black or African-American

• Hispanic or Latino

• Native Hawaiian or Pacific Islander

• White

4. A disability is any condition of the body or mind that makes it more difficult to do certain activities where you live, learn, work, and play. What is your disability? Please select all that apply.

• Hearing difficulty (e.g., deaf or having serious difficulty hearing)

• Vision difficulty (e.g., blind or having serious difficulty seeing, even when wearing glasses)

• Cognitive difficulty (e.g., because of a physical, mental, or emotional problem, having difficulty remembering, concentrating, or making decisions)

• Ambulatory difficulty (e.g., having serious difficulty walking or climbing stairs)

• Self-care difficulty (e.g., having difficulty bathing, dressing, eating, or toileting)

• Independent living difficulty (e.g., because of a physical, mental, or emotional problem, having difficulty doing errands alone, such a visiting a doctor’s office or shopping)

How did you hear about this ICDI program?

5. Why did you join this program?

• I enjoy being physically active

• I need to be more physically active

• I was encouraged to join

• Other, please specify:

6. Have you ever participated in an I Can Do It, You Can Do It! program before?

• Yes

• No

Section II: Physical Activity

In this section, we will ask you about physical activity.  “Physical activity” is how your body moves and how that makes you healthier.  “Exercise” is a form of physical activity. In exercise, you make a specific plan and do it regularly to meet your goals.  When you exercise, you are being physically active.  However, just because you are being active doesn’t always mean you are exercising.

7. Do you participate in physical activity every day?

• Yes

• No

8. Light physical activity includes slowly walking/rolling/pushing, light household chores, bowling, hunting/fishing, therapeutic exercise (physical or occupational therapy, stretching, use of a standing frame), etc. On average, how many days of the week do you participate in light physical activity?

Number of days: _______

9a. On average, how much time each day do you spend doing light physical activity?

• Under 30 minutes

• Between 30-60 minutes

• More than 60 minutes

9. Moderate physical activity includes brisk walking/rolling/pushing, hiking, gardening/yard work, dancing, golf while walking and carrying clubs, slow bicycling, softball, muscle strengthening with resistance bands, etc. On average, how many days of the week do you participate in moderate physical activity?

Number of days: _______

10a. On average, how much time each day do you spend doing moderate physical activity?

• Under 30 minutes

• Between 30-60 minutes

• More than 60 minutes

10. Vigorous physical activity includes running/jogging, wheelchair racing, off road pushing, bicycling more than 10 miles per hour, swimming freestyle laps, aerobics, heavy yard work, singles tennis, arm cranking, weight lifting, competitive basketball, etc. On average, how many days of the week do you participate in vigorous physical activity?

Number of days: _______

11a. On average, how much time each day do you spend doing vigorous physical activity?

• Under 30 minutes

• Between 30-60 minutes

• More than 60 minutes

Please select how much you agree or disagree with the statements in questions 12 – 25. 1 = Strongly Disagree and 5 = Strongly Agree in the scale.

11. I am able to participate in physical activity:

Strongly disagree 1	Disagree 2	Neutral 3	Agree 4	Strongly Agree 5
○	○	○	○	○

12. I am able to learn new types of physical activity and sports:

Strongly disagree 1	Disagree 2	Neutral 3	Agree 4	Strongly Agree 5
○	○	○	○	○

13. I am motivated to participate in physical activity and sports:

Strongly disagree 1	Disagree 2	Neutral 3	Agree 4	Strongly Agree 5
○	○	○	○	○

14. I enjoy participating in physical activity:

Strongly disagree 1	Disagree 2	Neutral 3	Agree 4	Strongly Agree 5
○	○	○	○	○

15. I enjoy participating in sports (e.g., basketball, baseball or softball, soccer, tennis, volleyball, etc.):

Strongly disagree 1	Disagree 2	Neutral 3	Agree 4	Strongly Agree 5
○	○	○	○	○

16. I feel my self-confidence and self-esteem are barriers to my participation in physical activity:

Strongly disagree 1	Disagree 2	Neutral 3	Agree 4	Strongly Agree 5
○	○	○	○	○

17. I feel my gender is a barrier to my participation in physical activity:

Strongly disagree 1	Disagree 2	Neutral 3	Agree 4	Strongly Agree 5
○	○	○	○	○

18. I feel my disability is a barrier to my participation in physical activity:

Strongly disagree 1	Disagree 2	Neutral 3	Agree 4	Strongly Agree 5
○	○	○	○	○

19. I feel transportation is a barrier to my participation in my physical activity:

Strongly disagree 1	Disagree 2	Neutral 3	Agree 4	Strongly Agree 5
○	○	○	○	○

20. I feel time is a barrier to my participation in physical activity:

Strongly disagree 1	Disagree 2	Neutral 3	Agree 4	Strongly Agree 5
○	○	○	○	○

21. I feel my enjoyment of physical activity is a barrier to my participation:

Strongly disagree 1	Disagree 2	Neutral 3	Agree 4	Strongly Agree 5
○	○	○	○	○

22. I feel there are opportunities outside of this program for me to participate in physical activity and play sports:

Strongly disagree 1	Disagree 2	Neutral 3	Agree 4	Strongly Agree 5
○	○	○	○	○

23. I value the benefits of physical activity and exercise:

Strongly disagree 1	Disagree 2	Neutral 3	Agree 4	Strongly Agree 5
○	○	○	○	○

24. It’s important to me to be physically active and exercise regularly:

Strongly disagree 1	Disagree 2	Neutral 3	Agree 4	Strongly Agree 5
○	○	○	○	○

Section III: Nutrition

In this section, we will ask you about nutrition.  “Nutrition” is eating food that helps you grow and makes you healthier.  “Healthy eating” is a form of nutrition. In healthy eating, you eat a variety of food groups at each meal. 

25. What do you feel your biggest barrier to eating healthy foods is?

26. Before the I Can Do It, You Can Do It! program, have you ever set a healthy eating goal to…

	Yes	No
Eat more whole fruit?	□	□
Vary the vegetables you eat?	□	□
Vary the protein you eat?	□	□
Make more of the grains you eat whole grains?	□	□
Move towards consuming more low-fat and fat-free dairy?	□	□
Drink more water instead of sugary drinks?	□	□
Select foods to eat with less sodium?	□	□
Limit the amount of added sugars you consume?	□	□
Replace saturated fats with unsaturated fats among the foods you consume?	□	□

Please select how much you agree or disagree with the statements in questions 28 – 33. 1 = Strongly Disagree to 5 = Strongly Agree in the scale.

27. I know how to eat healthy:

Strongly disagree 1	Disagree 2	Neutral 3	Agree 4	Strongly Agree 5
○	○	○	○	○

28. I am able to eat healthy foods and have a nutritious diet:

Strongly disagree 1	Disagree 2	Neutral 3	Agree 4	Strongly Agree 5
○	○	○	○	○

29. I am interested in eating healthy and having good nutrition:

Strongly disagree 1	Disagree 2	Neutral 3	Agree 4	Strongly Agree 5
○	○	○	○	○

30. I am motivated to eat healthy and have good nutrition.

Strongly disagree 1	Disagree 2	Neutral 3	Agree 4	Strongly Agree 5
○	○	○	○	○

31. I feel that my enjoyment of eating healthy is a barrier to having better nutrition:

Strongly disagree 1	Disagree 2	Neutral 3	Agree 4	Strongly Agree 5
○	○	○	○	○

32. I feel there are opportunities outside of this program for me to eat healthy and nutritious foods:

Strongly disagree 1	Disagree 2	Neutral 3	Agree 4	Strongly Agree 5
○	○	○	○	○

Section IV: General Information

In this section, we ask about your overall health.

33. In general, how healthy do you think you are?

• Very healthy, almost never get sick

• A little healthy, sometimes get a little sick

• A little unhealthy, sometimes get sick

• Very unhealthy, almost always get sick

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-XXXX . The time required to complete this information collection is estimated to average 20 minutes per response. 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.