Mentee Post- Assessment

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

I Can Do It, You Can Do It!

Mentee Post-Assessment Form

Instructions:

The following questions will help us understand our program participants better and help us improve our programs. Remember, as discussed in the informed consent form, we are not asking for any names. 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 should make every effort to allow you to give your own answers to questions. This survey will take about 25 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)

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.

5. Do you participate in physical activity every day?

• Yes

• No

6. 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: _______

6a. 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

7. 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: _______

7a. 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

8. 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: _______

8a. 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 9 – 22. 1 = Strongly Disagree and 5 = Strongly Agree in the scale.

9. I am able to participate in physical activity:

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

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

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

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

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

12. I enjoy participating in physical activity:

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

13. 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
○	○	○	○	○

14. 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
○	○	○	○	○

15. 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
○	○	○	○	○

16. 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
○	○	○	○	○

17. 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
○	○	○	○	○

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

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

19. 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
○	○	○	○	○

20. 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
○	○	○	○	○

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

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

22. 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. 

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

24. After the I Can Do It, You Can Do It! program, will you set a healthy eating goal to or continue 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 25 – 30. 1 = Strongly Disagree to 5 = Strongly Agree in the scale.

25. I know how to eat healthy:

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

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

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

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

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

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

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

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

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

30. 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 how you feel about your overall health.

31. 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

Section V: Program Evaluation

In this section, we ask about the I Can Do It! program that you participated in.

32. Did you earn the Presidential Active Lifestyle Award (PALA+) as part of the I Can Do It, You Can Do It! program?

• Yes

• No

33. Did you find it difficult to complete the I Can Do It, You Can Do It! program?

• Yes (Please answer question 33a)

• No (Please skip ahead to question 34)

33a. Why did you find it difficult to complete the I Can Do It, You Can Do It! program?

34. Would you encourage your friends to participate in an I Can Do It, You Can Do It! program?

• Yes

• No

35. If the opportunity is available, would you like to continue to participate in an I Can Do It, You Can Do It! program?

• Yes

• No

36. Did the I Can Do It, You Can Do It! program motivate you to be physically active?

• Yes

• No

37. Did the I Can Do It, You Can Do It! program motivate you to eat healthy?

• Yes

• No

38. How do you feel about the I Can Do It, You Can Do It! program?

• I really liked it

• I somewhat liked it

• I did not like or dislike it

• I somewhat disliked it

• I really disliked it

For question 39 & 40, please select how strongly you agree with the following statement using a scale of 1 = Strongly Disagree to 5 = Strongly Agree.

39. It was easy for me to set and track my weekly goals using the Goal Setting Handbook.

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

39a. Please provide any comments you have about the Goal Setting Handbook.

40. The PALA+ Goal Resources provide informative, easy to understand physical activity and healthy eating goal information.

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

40a. Please provide any comments you have about the PALA+ Goal Resources.

Please tell us how often the statement in question 41 and 42 was true for you.

41. How often did you meet with your mentor in-person?

• More than once a day

• About once a day

• A few times each week

• Once a week

• Less than once a week

42. How often did you talk with your mentor (phone, computer contact)?

• More than once a day

• About once a day

• A few times each week

• Once a week

• Less than once a week

43. Now that the I Can Do It, You Can Do It! program is complete, what will you do next? Please select all that apply.

• Participate in another I Can Do It, You Can Do It! program with a mentor.

• Continue doing physical activity, but on my own or with a group, please describe:

• Encourage my friends to participate in the I Can Do It, You Can Do It! program.

• Continue practicing good nutrition and eating healthy. Please describe:

• Physical activity is not important to me and I am not going to work on it anymore.

• Nutrition is not important to me and I am not going to work on it anymore.

• Other, please describe:

44. Please share any other comments you have about the I Can Do It, You Can Do It! program.

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 25 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.