Form 1 6.1 Special Fitness Survey

NCI Shady Grove Fitness Survey: Special Questionaire

OMB #0925-0642
Expiration Date 5/31/2020

Public reporting burden for this collection of information is estimated to average 2 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974,
Bethesda, MD 20892-7974, ATTN: PRA (0925-0642). Do not return the completed form to this
address.

1. Are you currently a member of the Shady Grove Fitness Center?
Yes
No

2. Have you ever had a gym membership at the Shady Grove Fitness Center?
Yes
No

3. If the contractor membership costs were reduced from $30 to $20 dollars, how likely are you to sign up
for a membership?
Very likely

Unlikely

Likely

Very unlikely

Neither likely nor unlikely