Attachment 19
Community Healthy Activities Model Program for Seniors (CHAMPS) |
OMB#: ####-#### EXP.DATE: ##/##/#### |
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN |
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Public reporting burden for this collection of information is estimated to average 15 minutes for this questionnaire, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review 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 current, 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 (####-####). |
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CHAMPS Activities Questionnaire for Older Adults
This questionnaire is about activities that you may have done in the past 4 weeks. The questions on the following pages are similar to the example shown below.
INSTRUCTIONS
If you DID the activity in the past 4 weeks:
Step #1 Check the YES box.
Step #2 Think about how many TIMES a week you usually did it, and write your response in the space provided.
Step #3 Circle how many TOTAL HOURS in a typical week you did the activity.
Here is an example of how Mrs. Jones would answer question #1: Mrs. Jones usually visits her friends Maria and Olga twice a week. She usually spends one hour on Monday with Maria and two hours on Wednesday with Olga. Therefore, the total hours a week that she visits with friends is 3 hours a week.
In a typical week, during the past 4 weeks, did you... |
How many TOTAL hours a week did you usually do it? → |
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1. Visit with friends or family (other than those you live with)? [ ] YES How many TIMES a week? → [ ] NO |
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If you DID NOT do the activity: • Check the NO box and move to the next question. |
In a typical week, during the past 4 weeks, did you... |
How many TOTAL hours a week did you usually do it? |
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1. Visit with friends or family (other than those you live with)? [ ] YES How many TIMES a week? → [ ] NO |
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2. Go to the senior center? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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3. Do volunteer work? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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4. Attend church or take part in church activities? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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5. Attend other club or group meetings? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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6. Use a computer? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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7. Dance (such as square, folk, line, ballroom) (do not count aerobic dance here)? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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8. Do woodworking, needlework, drawing, or other arts or crafts? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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9. Play golf, carrying or pulling your equipment (count walking time only)? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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10. Play golf, riding a cart (count walking time only)? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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11. Attend a concert, movie, lecture, or sport event? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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12. Play cards, bingo, or board games with other people? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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13. Shoot pool or billiards? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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14. Play singles tennis (do not count doubles)? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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15. Play doubles tennis (do not count singles)? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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16. Skate (ice, roller, in-line)? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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17. Play a musical instrument? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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[ ] Less than 1 hour |
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18. Read? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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[ ] Less than 1 hour |
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19. Do heavy work around the house (such as washing windows, cleaning gutters)? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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20. Do light work around the house (such as sweeping or vacuuming)? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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[ ] Less than 1 hour |
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21. Do heavy gardening (such as spading, raking)? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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22. Do light gardening (such as watering plants)? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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23. Work on your car, truck, lawn mower, or other machinery? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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**Please note: For the following questions about running and walking, include use of a treadmill. |
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24. Jog or run? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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25. Walk uphill or hike uphill (count only uphill part)? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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26. Walk fast or briskly for exercise (do not count walking leisurely or uphill? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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27. Walk to do errands (such as to/from a store or to take children to school (count walk time only)? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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28. Walk leisurely for exercise or pleasure? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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29. Ride a bicycle or stationary cycle? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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30. Do other aerobic machines such as rowing, or step machines (do not count treadmill or stationary cycle)? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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31. Do water exercises (do not count other swimming [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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32. Swim moderately or fast? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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33. Swim gently? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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34. Do stretching or flexibility exercises (do not count yoga or Tai-chi)? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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35. Do yoga or Tai-chi? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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36. Do aerobics or aerobic dancing? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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37. Do moderate to heavy strength training (such as hand-held weights of more than 5 lbs., weight machines, or push-ups)? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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38. Do light strength training (such as hand-held weights of 5 lbs. or less or elastic bands)? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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39. Do general conditioning exercises, such as light calisthenics or chair exercises (do not count strength training)? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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40. Play basketball, soccer, or racquetball (do not count time on sidelines)? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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41. Do other types of physical activity not previously mentioned (please specify)? [ ] YES How many TIMES a week? → [ ] NO |
How many TOTAL hours a week did you usually do it? |
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Thank You
Scoring
Data from the questionnaire is used to determine frequency per week and estimated caloric expenditure per week from physical activity. Separate scores are derived for physical activities of moderate or greater intensity (metabolic equivalents MET ≥ 3.0) and for all specified activities including those of light and moderate or greater intensity. For each of these, scores are calculated for frequency per week and estimated caloric expenditure per week.
Estimated caloric expenditures were calculated by multiplying the estimated duration per week by the MET value for each activity and summing across all relevant activities. Frequency per week is calculated by summing the frequency per week across all relevant activities. Detailed formulas are found in Table A1.
MET values were assigned to each activity from the values reported by Ainsworth et al. 1993. If an activity did not appear in the Ainsworth et al. compendium, the activity was assigned a value based on similar activities. The MET values for CHAMPS activities appear in Table A2*.
*Table A2 may be found in the Appendix of the following source.
Stewart, A. L., Mills, K. M., King, A. C., Haskell, W. L., Gillis, D., & Ritter, P. L. (2001). CHAMPS Physical Activity Questionnaire for Older Adults: Outcomes for Interventions. Medicine and Science in Sports and Exercise, 33(7), 1126-1141.
Table A1: Revised Codebook for CHAMPS Physical Activity Measures
Variable Label |
Item Numbers |
Coding Algorithms |
Caloric expenditure/week in all exercise related activities1 |
7, 9, 10, 14¿16, 19-35, 36, 40 |
For each activity: 1. Create new duration variables for each activity recoded as follows: 1=0.5, 2=1.75, 3=3.75, 4=5.75, 5=7.75, 6=9.75; If duration variable is not answered, score = 0. Duration is hours/week. 2. For each recoded duration variable, create new weighted duration variable for each activity by multiplying duration variable (#1) by corresponding MET value). 3. For each weighted duration variable, create caloric expenditure per week variable for each activity by multiplying weighted duration variable (#2) by 3.5 and by 60 (to convert METs/minute to METs/hour) and by (weight in kg/200). 4. Sum caloric expenditure per week variables across activities to create caloric expenditure/week. |
Caloric expenditure/week in moderate intensity exercise related activities |
7, 9, 14-16, 19, 21, 23-26, 29-33, 36-38, 40 |
Same as above, subset of activities with MET values >3.0. |
Frequency/week of all exercise-related activities |
7, 9, 10, 14¿16, 19-35, 36, 40 |
SUM frequency scores/week for each of the activities (allow those with missing data on frequency to be included in the sum). |
Frequency/week of moderate intensity exercise-related activities |
7, 9, 14-16, 19, 21, 23-26, 29-33, 36-38, 40 |
SUM frequency scores/week for each of the activities (allow those with missing data on frequency to be included in the sum). |
1Based on American College of Sports Medicine formula: kcal/minute = METs * 3.5 * (body weight in kg/200). Our formula converts this into kcal/week. American College of Sports Medicine (ACSM) Guidelines for Exercise Testing and Prescription, 5th Edition. Baltimore: Williams & Wilkins (1995).
File Type | application/msword |
File Title | CHAMPS Activities Questionnaire for Older Adults |
Author | Heather Bowles |
Last Modified By | Ann Truelove |
File Modified | 2011-03-07 |
File Created | 2010-12-30 |