Form 1 Screening Questions

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 B:

Screening Questions

(Research Instrument)

March 28, 2019

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

Screening Questions

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 5 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

Q1 Welcome

You’re being asked to participate in a survey about physical activity. We are conducting this survey on behalf of the Office for Disease Prevention and Health Promotion, part of the U.S. Department of Health and Human Services. 

Q2 Screener Questions

First, we want to see if you qualify. We have a few simple questions to ask. At some point, the questions may end if you don’t qualify. This has nothing to do with you. We are simply looking for people who meet certain criteria. Please tell us a little bit about yourself.

Q3 What is your 5-digit zip code?

• Jackson, MS area codes (1)

• Southern Nevada area codes (2)

• None of the above (3)  Terminate

Q4 Which best describes where you live?

• City or urban area (1)

• Suburbs (2)

• Country or rural area (3)

Q5 What is your age?

• 24 years old or younger (1)  Terminate

• 25 to 34 years old (2)

• 35 to 44 years old (3)

• 45 to 54 years old (4)

• 55 to 64 years old (5)

• 65 to 74 years old (6)

• 75 years old or older (7)  Terminate

Q6 Are you comfortable answering questions in English?

• Yes (1)

• No (2)  Terminate

Q7 How often do you get physical activity for at least 30 minutes a day? Physical activity is anything that gets your body moving.

• Never (0 days a week) (1)

• Rarely (1 day a week) (2)

• Sometimes (2–3 days a week) (3)

• Often (4–5 days a week) (4)  Skip to Q9

• Almost always (6 days a week) (5)  Skip to Q9

• Always (7 days a week) (6)  Skip to Q9

Q8 How likely are you to become more physically active in the next month?

• Extremely likely (1)  Skip to Q11 [Preparation]

• Somewhat likely (2)  Skip to Q11 [Preparation]

• Somewhat unlikely (4)  Skip to Q10

• Extremely unlikely (5)  Skip to Q10

Q9 You noted you’ve been getting physical activity regularly — for at least 30 minutes a day, at least 4 days a week. Have you been getting at least this much physical activity for the past 6 months?

• Yes (1)  Terminate [Maintenance]

• No (2)  Skip to Q11 [Action]

Q10 How likely are you to become more physically active in the next 6 months? 

• Extremely likely (1) [Contemplation]

• Somewhat likely (2) [Contemplation]

• Somewhat unlikely (4)  Terminate [Precontemplation]

• Extremely unlikely (5)  Terminate [Precontemplation]

Q11 What sex were you assigned at birth?

• Male (1)

• Female (2)

Q12 Are you a parent or guardian of at least 1 child who lives with you and is under the age of 18?

• Yes (1)

• No (2)

Q13 Are you of Hispanic or Latino origin?

• Yes (1)

• No (2)

Q14 Which category or categories best describe your race? [Select 1 or more.]

• White (1)

• Black or African American (2)

• American Indian or Alaska Native (3)

• Asian (4)

• Native Hawaiian or Other Pacific Islander (5)

Q15 What is the highest level of education you have completed?

• Less than high school (1)

• High school (2)

• Some college (3)

• Associates degree (4)

• 4-year college (5)

• Advanced degree (6)

Q16 Which is your total, yearly household income?

• Less than $20,000 (1)

• $20,000 to $34,999 (2)

• $35,000 to $49,999 (3)

• $50,000 to $74,999 (4)

• $75,000 to $99,999 (5)

• $100,000 to $149,999 (6)

• $150,000 to $199,999 (7)

• $200,000 or more (8)

Q17 Are you deaf or do you have serious difficulty hearing? 

• Yes (1)

• No (2)

• Don't know / Not sure (3)

• Prefer not to answer (4)

Q18 Are you blind or do you have serious difficulty seeing, even when wearing glasses?

• Yes (1)

• No (2)

• Don't know / Not sure (3)

• Prefer not to answer (4)

Q19 Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

• Yes (1)

• No (2)

• Don't know / Not sure (4)

• Prefer not to answer (5)

Q20 Do you have serious difficulty walking or climbing stairs?

• Yes (1)

• No (2)

• Don't know / Not sure (4)

• Prefer not to answer (5)