3 Parent Physical Activity Survey and Checklist

Questionnaire Cognitive Interviewing and Pretesting (NCI)

Attach 4A-2 FLASHE Parent PA Survey and Activity Checklist

Sub-study #4: Cognitive Testing of the Family Life, Activity, Sun, Health, and Eating (FLASHE) Survey

OMB: 0925-0589

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0925-0589 can be found here:

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ATTACHMENT 4A-2: FLASHE PARENT PHYSICAL ACTIVITY SURVEY
Thank you for taking the Family Life, Activity, Sun, Health and Eating (FLASHE) Survey. This
survey asks about your attitudes and opinions about your physical activities, as well as other
related factors. It is important that you answer the survey questions carefully and accurately,
since your answers will help us understand more about people’s physical activities and
lifestyles.

Survey Instructions
This information will help you answer the FLASHE Survey questions.
u

For the FLASHE Survey, the term “physical activity” means any play, game, sport, exercise or
transportation (like walking or biking to school or work) that gets you moving and breathing harder.

In the first part of the survey we will ask questions about you. In the second part, we will ask questions
about your teenager, {FILL TEENAGER’S NAME}.

You’ll need about 15 minutes to do the survey.

Read all the answers before marking a box. Please mark only the box that best describes you or your
family. There aren’t any right or wrong answers.

Try to answer all the questions. The more questions you answer, the more we’ll learn. If any question
makes you uncomfortable, it’s okay to skip it.

Follow the arrows to move through the survey. Some arrows point you to the next question. Other arrows
come with a note telling you which question to answer next. They might tell you to skip over some
questions. Here are some examples:

Example Survey Items
1a. Have you ever answered a mail survey questionnaire before?
No

0
1

GO TO QUESTION 2

Yes

1b.

When was the last time you
answered a mail survey
questionnaire?
1
2
3

1-5 months ago
6-12 months ago
More than 12 months ago

Have you ever answered a telephone survey questionnaire before?
0

No
Yes
1

OMB No.: 0925-0642
Expiration Date: 9/30/2014
Collection of this information is authorized by The Public Health Service Act, Section 411 (42 USC 285a). Rights of study participants are protected by
The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to
participate will not affect your benefits in any way. The information collected in this study will be kept private under the Privacy Act. Names and other
identifiers will not appear in any report of the study. Information provided will be combined for all study participants and reported as summaries. You are
being contacted by telephone to complete this instrument so that we can identify potential sources of measurement or response error. The purpose of
this instrument is to examine psychosocial, generational, and environmental correlates of cancer preventive behaviors.
Public reporting burden for this collection of information is estimated to average 40 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.

FLASHE Physical Activity Survey: Parent
Section 1. Physical Activity
This first section asks different questions having to do with physical activity. Physical activity in this
survey means any play, game, sport, exercise or transportation (like walking or biking to work) that
gets you moving and breathing harder.
1. When you were growing up, which best describes your overall physical activity patterns, that is,
engaging in activities such as biking, swimming, team sports, brisk walking, etc.?
Not at all active
A little active
Fairly active
Very active
Extremely active

For these next questions, please think about your experiences with physical activity.
2. There are lots of things that can prevent people from exercising as much as they’d like to. Please mark
how much you disagree or agree with each of the statements listed below.

I don’t exercise as much as I like to because...

Strongly
disagree

Somewhat
disagree

Neither
disagree
nor agree

Somewhat
agree

Strongly
agree

a. I don’t like to sweat ................................................................
b. I’m too busy ................................................................
c. I don’t like to exercise ................................................................
d. I don’t want to mess up my hair ................................
e. I don’t like how my body looks when I exercise ................................
f.

It costs too much money to exercise ................................

g. My family doesn’t like to exercise ................................
h. I’m not athletic ................................................................
i.

I don’t have the skills to exercise ................................

3. Please think about being physically active on most days of the week. Then please mark how much you
disagree or agree with each of the statements listed below.
If I were to be physically active on most days of
the week it would…

Strongly
disagree

Somewhat
disagree

a. Be fun ................................................................................................
b. Help me cope with stress ................................................................
c. Help me make new friends ................................................................
d. Get or keep me in shape................................................................
e. Make or keep me more attractive ................................
f.

Give me more energy ................................................................

g. Make me better in sports, dance or other
activities ................................................................................................

Neither
disagree
nor agree

Somewhat
agree

Strongly
agree

4. There are lots of reasons why people would exercise most days of the week. Please mark how much
you disagree or agree with each of the statements listed below.
I would exercise most days of the week
because…

Strongly
disagree

Somewhat
disagree

a. I would feel bad about myself if I didn’t ................................
b. I enjoy exercising................................................................
c. I would feel like I failed if I didn’t ................................
d. It helps me feel better ................................................................
e. I have thought about it and decided that I
want to exercise ................................................................
f.

Others would be upset with me if I didn’t ................................

g. It is an important thing for me to do ................................

Neither
disagree
nor agree

Somewhat
agree

Strongly
agree

5. Please mark how much you disagree or agree with this statement: I feel confident in my ability to
exercise most days of the week.
Strongly disagree
Somewhat disagree
Neither disagree nor agree
Somewhat agree
Strongly agree

Section 2. Using Electronic Devices
People watch TV or videos and play games using many different kinds of electronic devices. When
thinking about videos, please count Netflix, YouTube, ONDemand, etc. From the list below, please
mark which ones you use and how often you use each.
6. On weekdays (Monday – Friday), about how many hours per day do you use each electronic device?
Not at
all

Less than Half hour
half hour to 2 hours

a. Desktop, laptop computer or tablet ................................
b. Cell phone or Smartphone (for gaming
and/or watching videos)................................................................
c. Television ................................................................
d. Gaming console like Wii, Xbox, PlayStation,
etc. ................................................................................................
e. Handheld gaming devices like Nintendo DS,
Sony PSP, etc. ................................................................
f.

Electronic reader, like Kindle or Nook ................................

2 to 4
hours

4 to 6
hours

6+
hours

7. On weekends (Saturday & Sunday), about how many hours per day do you use each electronic
device?
Not at
all

Less than Half hour
half hour to 2 hours

a. Desktop, laptop computer or tablet ................................
b. Cell phone or Smartphone (for gaming
and/or watching videos)................................................................
c. Television ................................................................
d. Gaming console like Wii, Xbox, PlayStation,
etc. ................................................................................................
e. Handheld gaming devices like Nintendo
DS, Sony PSP, etc. ................................................................
f.

Electronic reader, like Kindle or Nook ................................

8. How many TVs are in your home?
0
1
2
3
4
5 or more

2 to 4
hours

4 to 6
hours

6+ hours

For these next questions, please think about the electronic devices you marked in Questions 6 and 7.
9. There are lots of reasons why people would try to limit the amount of time they spend using electronic
devices. Please mark how much you disagree or agree with each of the statements listed below.
I would try to limit the amount of time I spend
using electronic devices (most days of the week)
because…

Strongly
disagree

Somewhat
disagree

Neither
disagree
nor agree

Somewhat
agree

Strongly
agree

a. I would feel bad about myself if I didn’t ................................
b. I would feel like I failed if I didn’t................................
c. Limiting the amount of time I spend using
electronic devices helps me feel better ................................
d. I have thought about it and decided that I
want to ................................................................................................
e. Others would be upset with me if I didn’t limit
the amount of time I spend using electronic
devices ................................................................................................
f.

It’s an important thing for me to do ................................

10. Please mark how much you disagree or agree with this statement: I feel confident in my ability to limit
how much time I spend using electronic devices every day.
Strongly disagree
Somewhat disagree
Neither disagree nor agree
Somewhat agree
Strongly agree

Section 3. Time Spent in the Sun and Indoor Tanning
These next questions are about spending time outside and in the sun.
11. In the summer, on average, how many hours are you outside per day between 10AM and 4 PM on
weekdays (Monday-Friday)?
30 minutes or less
31 minutes to 1 hour
2 hours
3 hours
4 hours
5 hours
6 hours
12. In the summer, on average, how many hours are you outside per day between 10AM and 4 PM on
weekend days (Saturday & Sunday)?
30 minutes or less
31 minutes to 1 hour
2 hours
3 hours
4 hours
5 hours
6 hours

13. For the following questions, think about what you do when you’re outside during the summer on a warm
sunny day.
How often do you…

Never

Rarely

Sometimes

Often

Always

Often

Always

a. Wear sunscreen?................................................................
b. Wear a shirt with sleeves that cover your
shoulders? ................................................................
c. Wear a hat? ................................................................
d. Stay in the shade or under an umbrella? ................................
e. Wear sunglasses? ................................................................
f.

Spend time in the sun in order to get a tan? ................................

14. Now think about the past 12 months. In that entire time, how often did you use…
Never

Rarely

Sometimes

a. A tanning bed or booth?................................................................
b. Sunless tanning creams or sprays, also known
as self-tanning or fake tanning? ................................

15. In the past 12 months, how many times did you have a red or painful sunburn that lasted a day or
more?
0 times
1 time
2 times
3 times
4 times
5 or more times

Section 4. Tobacco Use
These next few questions ask about your experiences using tobacco products.
16. Have you smoked at least 100 cigarettes in your entire life?
Yes
No

GO TO QUESTION 22

17. How often do you now smoke cigarettes?
Everyday
Some days
Not at all
18. In the past month (30 days), when you smoked, how many cigarettes did you smoke per day?

_________ Number of cigarettes
19. At what age did you start smoking regularly?
_________ Years old
20. What was the date of your last cigarette?

/
M

/
D

21. During the past month (30 days), did you smoke cigarettes to help you lose weight or keep from
gaining weight?
Yes
No
I don’t smoke

Section 5. Sleep and Mood
For the following questions, please answer separately for weekdays (Monday-Friday) and weekends
(Saturday-Sunday).
Write the time in the boxes and please mark either A.M. or P.M. EXAMPLE:
o A.M.
7 : 0 0 þ P.M.
22. What time do you usually go to bed in the evening (turn out the lights in order to go to sleep)?
Weekday

Weekend

o A.M.
o P.M.
o A.M.
o P.M.

23. What time do you usually get out of bed in the morning?
Weekday

Weekend

o A.M.
o P.M.
o A.M.
o P.M.

24. Do you generally have trouble staying asleep at night?
Yes
No
25. How often do you think that you need more sleep?
Never
Rarely
Sometimes
Often
Always

These next questions ask about the way you’ve been feeling lately. First, think about the past month.
26. In the past month, how often have you felt…
Never

Rarely

Sometimes

Often

Always

Often

Always

a. That you were unable to control the important
things in your life? ................................................................
b. Confident about your ability to handle your
personal problems? ................................................................
c. That things were going your way? ................................
d. That difficulties were piling up so high that
you could not overcome them? ................................

Now think about the past 12 months.
27. In the past 12 months, how often have you been bothered or troubled by…
Never

Rarely

a. Feeling too tired to do things? ................................
b. Having trouble going to sleep or staying
asleep? ................................................................................................
c. Feeling unhappy, sad or depressed? ................................
d. Feeling hopeless about the future? ................................
e. Feeling nervous or tense? ................................................................
f.

Worrying too much about things? ................................

g. Changes in your appetite? ................................................................

Sometimes

Section 7. Your Teenager
This next part of the survey asks you to think about {FILL TEENAGER’S NAME}’s physical activity,
experiences at school and time spent using or watching electronic devices such as laptops,
smartphones, gaming systems or televisions. Remember to answer only for {FILL TEENAGER’S
NAME}.
For these first questions, keep in mind that physical activity means any play, game, sport, exercise
or transportation (like walking or biking to school) that gets {FILL TEENAGER’S NAME} moving and
breathing harder.
28. Please indicate if you have the following items in your home, yard or apartment complex and if you
have them, how often {FILL TEENAGER’S NAME} uses each item. Please mark the answer that best
applies to {FILL TEENAGER’S NAME}.
Not
available

Available Use once a Use once
but never month or every other
use
less
week

a. Bicycle. Don’t count stationary bikes................................
b. Basketball hoop ................................................................
c. Jump rope ................................................................
d. Sports equipment like balls, racquets, bats
and sticks ................................................................
e. Access to a swimming pool ................................................................
f.

Roller skates/roller blades ................................................................

g. Skateboard ................................................................
h. Scooter................................................................................................
i.

Cardio equipment like treadmills, stationary
bicycles, step climbers, elliptical machines,
rowing machines, etc.................................................................

Weight lifting equipment ................................................................

k. Trampoline ................................................................
l.

Active gaming like Wii or Xbox ................................

m. Exercise videos or DVD’s ................................................................

Use once
a week
or more

29. Now think about {FILL TEENAGER’S NAME}’s time being physically active. How often is each of the
statements listed below true for {FILL TEENAGER’S NAME}?
Never

Rarely

Sometimes

Often

Always

a. My teenager enjoys being physically active ................................
b. Even if I don’t keep track, my teenager will get
enough physical activity ................................................................
c. I encourage my teenager to get more
physical activity. ................................................................
d. I encourage my teenager to do different
types of physical activity ................................................................
e. I take my teenager places where he/she can
by physically active ................................................................
f.

My teenager and I decide together how much
physical activity he/she has to do. ................................

g. I make my teenager exercise or go out and
play ................................................................................................
h. If my teenager gets in trouble or acts up I
don’t let him/her play or do his/her favorite
physical activity …. ................................................................
i.

I try to be physically active in front of my
teenager. ................................................................

It’s my responsibility to make rules about how
physically active my teenager is. ................................

30. In the past school year, how often has your {FILL TEENAGER’S NAME} had homework assignments
that limited the amount of time they had available for physical activity?
Never
Rarely
Sometimes
Often
Always
I don’t know

These next questions ask about “screen time,” that is, the time {FILL TEENAGER’S NAME} spends
using electronic devices to watch videos, stream the internet, play video games and do other
activities that involve sitting and looking at a screen.
31. People watch TV or videos and play games using many different kinds of electronic devices. When
thinking about videos, count Netflix, YouTube, ONDemand, etc. From the list below, please mark
which ones {FILL TEENAGER’S NAME} uses:
Desktop, laptop computer or tablet
Cell phone or Smartphone
Television
Gaming console like Wii, Xbox, PlayStation, etc.
Handheld gaming devices like Nintendo DS, Sony PSP, etc.
Electronic reader, such as Kindle or Nook
32. Now think about {FILL TEENAGER’S NAME}’s time with the electronic devices you marked in
Question 31. How often are each of the statements listed below true for {FILL TEENAGER’S NAME}?
Never

Rarely

a. My teenager enjoys screen time ................................
b. If my teenager has a bad day, I let him/her
have screen time. ................................................................
c. I offer screen time as a reward for my
teenager’s good behavior ................................................................
d. If my teenager gets in trouble or acts up, I
don’t let him/her have screen time ................................
e. If I don’t keep track, my teenager has too
much screen time. ................................................................
f.

If I don’t limit his/her screen time, my teenager
has too much. ................................................................

g. My teenager and I decide together how much
screen time he/she can have. ................................
h. I decide how much screen time my teenager
can have ................................................................
i.

I limit my own screen time in front of my teenager

It’s my responsibility to make rules about how
much screen time my teenager can have................................
15

Sometimes

Often

Always

This section asks about how {FILL TEENAGER’S NAME} usually gets to and from school.
33. On how many days during the school week does {FILL TEENAGER’S NAME} get to school by…

Please mark only one box for each item.

1 day

2 days

3 days

4 days

5 days

My teenager
doesn’t get to
school this way

a. Walking? ................................................................
b. Riding a bike? ................................................................
c. Taking a car or bus? ................................................................

34. On how many days during the school week does {FILL TEENAGER’S NAME} leave from school by…

Please mark only one box for each item.

1 day

2 days

3 days

4 days

5 days

My teenager
doesn’t leave
school this way

35. Please mark how much you disagree or agree with each of the statements about {FILL TEENAGER’S
NAME} walking and biking to school listed below.
It is difficult for {FILL TEENAGER’S NAME} to
walk or bike to school (alone or with someone)
because…

Strongly
disagree

Somewhat
disagree

a. There are no sidewalks ................................................................
b. It’s not considered cool to walk or bike................................
c. It is not safe because of crime (strangers,
gangs, drugs)................................................................
d. My teenager gets bullied, teased, harassed ................................
e. There are stray dogs ................................................................
f.

It is too far ................................................................

Neither
agree
nor
disagree

Somewhat
agree

Strongly
agree

Finally, we have a few general questions about {FILL TEENAGER’S NAME}.
36. Most parents think about what they’d like in life for their teenager. For each of the statements listed
below, please mark how important it is to you when you think about what you’d like for {FILL
TEENAGER’S NAME}.
Not at all
important

A little
important

Somewhat
important

Very
important

Extremely
important

a. When my teenager is an adult, he/she will be
admired by many people................................................................
b. When my teenager is an adult, he/she will
feel that there are people who really love
him/her ................................................................................................
c. The things my teenager does as an adult will
make other people’s lives better ................................
d. When my teenager is an adult, he/she will get
enough exercise to be healthy ................................
e. My teenager will get good grades in school ................................
f.

People will often comment about how
attractive my teenager looks as an adult ................................

g. When my teenager is an adult, he/she will
have a lot of excitement in life ................................
h. When my teenager is an adult, he/she won’t
have to worry about bad things happening to
him/her ................................................................................................
i.

When my teenager is an adult, he/she will
have a job that pays well ................................................................

37. Has a doctor or other healthcare professional ever told you that {FILL TEENAGER’S NAME} has any
condition that could limit his/her ability to exercise, such as obesity, diabetes, high blood pressure, etc.?
Yes
No
I don’t know

38. Do medical, behavioral or other health conditions interfere with {FILL TEENAGER’S NAME}’s ability to
do any of the following things?
Yes

a. Participate in sports, clubs or other
organized physical activities ................................................................
b. Go on outings such as the park, library, zoo,
shopping, church, restaurants or family
gatherings ................................................................

Thank you for taking the time to complete this survey. Your answers are important to us!
INSTRUCTIONS FOR RETURNING COMPLETED SURVEY

Yesterday
Activity

7 Days Ago

Tai Chi

Toning Exercises/

Calisthenics

5 Days Ago

4 Days Ago

3 Days Ago

2 Days Ago

Day of the Week

HOURS MINUTES

Tennis

HOURS MINUTES

Volleyball

HOURS MINUTES

Walking for Exercise
(outdoor, indoor, treadmill)

HOURS MINUTES

Walking for
Transportation/Leisure

HOURS MINUTES

Water Aerobics

HOURS MINUTES

Yoga

Other (write in)

______________________

6 Days Ago

HOURS MINUTES

I did none of these activities over the past
7 days.

2. Was this week reflective of your usual
activity level?

Yes

4. Over this past week, were you confined to
a bed or chair as a result of injury, illness or
surgery?

Yes

5. Do you have difficulty doing any of the
following activities?

If YES, how many days over the past week were
you confined to a bed or chair? ________days

b. Walking for 10 minutes without resting?

Yes

3. In general how many HOURS per DAY
do you usually spend:

a. Getting in or out of a bed or chair?

Yes

Watching television: _____hours
Working on a computer: _____hours

FLASHE
Family Life, Activity, Sun,
Health, and Eating Study

Physical Activity Checklist
alternates

Participant ID:

FLASHE

Physical Activity Checklist

Today’s Date _____ /_____

Instructions
Please check the box only for activities you have done during the past 7 days. For each activity checked, write down the time spent doing the activity per day.
Yesterday
Activity
Aerobic Dance/

Step Aerobics
Badminton

Basketball

Bicycling

(indoor, outdoor)
Bowling

Dancing (square, line,

ballroom)
Elliptical Trainer

Fishing

Football/Soccer

Gardening or

Yardwork
Golf

Hiking

Horseback Riding

Martial Arts

(karate, judo)
Pilates

Raquetball/

Handball/Squash
Rock Climbing

7 Days Ago

6 Days Ago

5 Days Ago

4 Days Ago

3 Days Ago

2 Days Ago

Day of the Week

HOURS MINUTES

Rowing/Kayaking/

Canoeing

HOURS MINUTES

Running/Jogging
(outdoor, indoor)

HOURS MINUTES

Skating (roller,
ice, blading)
Snow Shoeing

Snow Skiing (downhill)

Snow Skiing
(x-country, Nordic Track)
Softball/Baseball

Stairmaster

Strength/Weight
Training
Swimming
(laps, snorkeling,
scuba diving)

HOURS MINUTES

(flip over)

File Type	application/pdf
Author	Hicks_w
File Modified	2012-05-21
File Created	2012-05-21