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pdfATTACHMENT 4A-4: FLASHE TEENAGER 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) that gets you moving and breathing harder.
u
Some parts of the survey are about you. Others are about your parents and family.
u
In this survey, “parent” means the adult who takes care of you. It could be your birth mother or father or
your adopted mother or father. It could also be your guardian, an adult relative or an adult who isn’t related
to you.
u
You’ll need about 15 minutes to do the survey.
u
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.
u
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.
u
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
ü
GO TO QUESTION 2
Yes
1b.
When was the last time you
answered a mail survey
questionnaire?
1
2
3
2.
ü
1-5 months ago
6-12 months ago
More than 12 months ago
Have you ever answered a telephone survey questionnaire before?
0
1
ü
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: Teen
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 school) that
gets you moving and breathing harder.
1. Please mark how much you disagree or agree with each of the statements listed below.
During a typical week…
Strongly
Disagree
Disagree
a. My friends encourage me to exercise most
days of the week ................................................................
b. My friends play sports or are physically
active with me ................................................................
c. My friends exercise most days of the week ................................
d. My friends walk or ride bikes to school or to a
friend’s house ................................................................
2
Neither
Agree
Strongly
Agree
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 me more good looking ................................................................
f.
Give me more energy ................................................................
g. Make me better in sports, dance or other
activities ................................................................................................
3
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 ................................
4
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
6. In the past school year, how often have you had homework assignments that limited the amount of
time you had available for physical activity?
Never
Rarely
Sometimes
Often
Always
I don’t know
5
7. Please indicate if you have the following items in your home, yard or apartment complex and if you
have them, how often you use each item.
Not
available
Available Use once a Use once Use once
but never month or every other a week or
use
less
week
more
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. ................................................................
j.
Weight lifting equipment ................................................................
k. Trampoline ................................................................
l.
Active gaming like Wii or Xbox ................................
m. Exercise videos or DVD’s................................................................
n. Room or space to play inside
o. Toys like jump ropes and Frisbees
6
Section 2. Getting To and From School
8. On how many days during the school week do you get to school by…
Please mark one box for each row
1 day
2 days
3 days
4 days
5 days
I don’t get to
school this way
5 days
I don’t leave
school this way
a. Walking? ................................................................
b. Riding a bike? ................................................................
c. Taking a car or bus? ................................................................
9. On how many days during the school week do you leave from school by…
Please mark one box for each row
1 day
2 days
3 days
4 days
a. Walking? ................................................................
b. Riding a bike? ................................................................
c. Taking a car or bus? ................................................................
10. Please mark how much you disagree or agree with each of the statements about walking and biking to
school listed below.
It is difficult for me 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. I get bullied, teased, harassed ................................
e. There are stray dogs ................................................................
f.
It is too far ................................................................
g. My parents don’t let me................................................................
7
Neither
agree
nor
disagree
Somewhat
agree
Strongly
agree
Section 3. Using Electronic Devices
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 you use and how often you use each:
11. 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
2 to 4
hours
4 to 6
hours
6+
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 ................................
12. 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
2 to 4
hours
4 to 6
hours
6+
hours
13. How many TVs are in your home?
0
1
2
3
4
5 or more
14. Do you have a TV in your bedroom?
Yes
No
For these next questions, please think about the electronic devices you marked in Questions 11 and
12.
15. There are lots of reasons why 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 because…
Strongly
disagree
Somewhat
disagree
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 ................................
9
Neither
disagree
nor agree
Somewhat
agree
Strongly
agree
16. Please mark how much you disagree or agree with the following 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
17. Please mark how much you disagree or agree with each of the statements listed below.
Strongly
Disagree
Disagree
Neither disagree
or agree
Agree
Strongly
Agree
g. My friends watch TV, play on the computer
or play electronic games most days of the
week ................................................................................................
h. My friends watch TV, play on the computer
or play electronic games with me ................................
Section 4. Time Spent in the Sun and Indoor Tanning
These next questions are about spending time outside and in the sun.
18. 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
10
19. 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
20. 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
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? ................................
21. Now think about the past 12 months. In that entire time, how often did you use…
Never
Rarely
a. A tanning bed or booth?................................................................
b. Sunless tanning creams or sprays, also
known as self-tanning or fake tanning? ................................
11
Sometimes
Often
Always
22. 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 5. Tobacco Use
These next few questions ask about your experiences using tobacco products.
23. Have you smoked at least 100 cigarettes in your entire life?
Yes
No
GO TO QUESTION 26
24. How often do you now smoke cigarettes?
Everyday
Some days
Not at all
25. In the past month (30 days), when you smoked, how many cigarettes did you smoke per day?
_________ Number of cigarettes
26. At what age did you start smoking regularly?
_________ Years old
12
27. 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 6. Sleep and Mood
28. How often do you fall asleep or feel tired during class?
Never
Rarely
Sometimes
Often
Always
29. Do you have a regular bedtime?
Yes
No
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.
30. 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.
13
31. 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.
32. Do you generally have trouble staying asleep at night?
Yes
No
33. How often do you think that you need more sleep?
Never
Rarely
Sometimes
Often
Always
Next we ask about the way you’ve been feeling lately. First, think about the past month.
34. In the past month, how often have you felt…
Never
Rarely
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? ................................
14
Sometimes
Often
Always
Now think about the past 12 months.
35. 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? ................................................................
15
Sometimes
Often
Always
Section 7. Goals in Life
36. For each of the statements listed below, please mark how important it is to you when you think about
what you want for yourself in life.
Not at all
important
to me
A little
important
to me
a. When I‘m an adult, many people will admire me. ................................
b. When I‘m an adult, people will love me ................................
c. The things I do as an adult will make people’s
lives better ................................................................
d. When I’m an adult, I’ll get enough exercise to
be healthy ................................................................
e. People will say I’m good looking as an adult ................................
f.
When I’m an adult, I will have a lot of
excitement in my life ................................................................
g. When I’m an adult, I won’t have to worry
about bad things happening ................................................................
h. When I’m an adult, I’ll have a job that pays well ................................
16
Somewhat
important
to me
Very
important
to me
Extremely
important
to me
Section 8: Your Parent(s)
Again, in this survey “parent” means the adult who takes care of you. It could be your birth mother or
father or your adopted mother or father. It could also be your guardian, an adult relative or an adult
who isn’t related to you.
37. Please mark how often each of the statements listed below regarding what your parent(s) say and do
when it comes to being physical active are true for you.
.
Never
Rarely
a. My parent(s) enjoy exercise and/or being
physically active ................................................................
b. Even if my parent(s) don’t monitor my
activities, I get enough physical activity.................................
c. My parent(s) encourage me to be physically
active, especially if I’ve had a bad day. ................................
d. My parent(s) encourage me to do different
types of physical activity ................................................................
e. My parent(s) take me places where I can by
physically active ................................................................
f.
My parent(s) and I decide together how
much physical activity I have to do. ................................
g. My parent(s) make me exercise or go out
and play ................................................................................................
h. If I get in trouble or act up my parent(s) don’t
let me go play or do my favorite physical
activity …. ................................................................
i.
My parent(s) try to be physically active when
I’m around.................................................................
j.
It’s my parent(s)’ responsibility to make rules
about how much time I spend being
physically active/playing.................................................................
17
Sometimes
Often
Always
Finally, this next set of questions asks about “screen time”, that is, the time you, or your parent(s)
spend watching videos, streaming the internet, playing video games and doing other activities that
involve sitting and looking at a screen.
38. Please mark how often each of the statements listed below regarding what your parent(s) say and do
when it comes to screen time are true for you.
Never
Rarely
Sometimes
Often
a. My parent(s) enjoy screen time ................................
b. If I’ve had a bad day, my parent(s) let me
have screen time ................................................................
c. My parent(s) offer me screen time as a
reward for my good behavior ................................................................
d. My parent(s) take me places where I can play
video games, watch movies, etc ................................
e. If I get in trouble or act up, my parent(s) don’t
let me have screen time. ................................................................
f.
If my parent(s) don’t keep track, I have too
much screen time ................................................................
g. If my parent(s) don’t limit my screen time, I
have too much of it. ................................................................
h. My parent(s) and I decide together how much
screen time I can have ................................................................
i.
My parent(s) decide how much screen time I
can have ................................................................................................
j.
My parent(s) limit their screen time in front of me................................
k. It’s my parent(s)’ responsibility to make rules
about how much screen time I can have ................................
Thank you for taking the time to complete this survey. Your answers are important to us!
INSTRUCTIONS FOR RETURNING COMPLETED SURVEY
18
Always
FLASHE
Family Life, Activity, Sun,
Health, and Eating Study
alternates
alternates
alternates
(flip over)
Activity Recall
Participant ID:
35132.0412.84472509
FLASHE
Activity Recall
Time
Activity
Instructions
1) Mark for which day of the week you are filling out this booklet.
Choose
one activity
number
11:00-11:30
3) Rate how physically hard each activity was.
4) Mark where and with whom you performed the activity.
Examples of How Hard
Choose
one activity
number
11:30-12:00
Keep these examples in mind when rating how hard each physical activity was.
light
moderate
hard
very hard
Activities
With Whom
Evening
10:30-11:00
2) For each time period during that day, write in the activity number
that matches the main activity you performed during that time period.
Please write only one activity per time period.
How Hard Where
Choose
one activity
number
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational Center
Park or Playground
Very Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational Center
Park or Playground
Very Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational Center
Park or Playground
Very Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
1) Day of the week for which you are filling out this booklet:
alternates
alternates
alternates
alternates
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
2 FLASHE Activity Log
FLASHE Activity Log
11
PHYSICAL ACTIVITIES
01 Aerobics, jazzercise, water
aerobics, taebo
02 Basketball
03 Bicycling, mountain biking
04 Bowling
05 Broomball
06 Calisthenics/Exercises (push-ups,
sit-ups, jumping jacks)
07 Canoeing, kayaking
08 Cheerleading, drill team
09 Dance (at home, at a class, in
school, at a party, at a place of
worship)
10 Exercise machine (cycle, treadmill,
stairmaster, rowing machine)
11 Football
12 Frisbee
13 Golf
14 Gymnastics/Tumbling
15 Hiking
16 Hockey (ice, field, street, or floor)
17 Horseback riding
18 Jumping rope
19 Kick boxing
20 Lacrosse
21 Martial arts (karate, judo, boxing, tai
kwan do, tai chi)
22 Playground games (tether ball, four
square, dodge ball, kick ball)
23 Playing catch
24 Playing with younger children
25 Roller blading, ice skating, roller
skating
26 Riding scooters
27 Running/Jogging
28 Softball/Baseball
29 Skiing (downhill, cross country,
or water)
30 Skateboarding
31 Sailing
32 Skimboarding
33 Sledding, tobogganing,
bobsledding
34 Snorkeling
35 Snowboarding
36 Snowmobiling
37 Snowshoeing
38 Soccer
39 Surfing (body or board)
40 Swimming (laps)
41 Swimming (play, pool games –
Marco Polo, water volleyball)
42 Tennis, racquetball, badminton,
paddleball
43 Trampolining
PHYSICAL ACTIVITIES (cont.)
44 Tubing/Rafting
45 Track & field
46 Volleyball
47 Walking for exercise
48 Walking for transportation
49 Weightlifting
50 Wrestling
51 Yoga, stretching
52 Other physical activities
EATING
53 Eating a meal
54 Snacking
WORK
55 Working (e.g., part-time job,
child care)
56 Doing house chores (e.g.,
vacuuming, dusting, washing
dishes, animal care, etc.)
57 Yard Work (e.g., mowing, raking)
AFTER SCHOOL/SPARE TIME/
HOBBIES
58 Church
59 Hanging around
60 Homework
61 Listening to music
62 Marching band/flag line/drill team
63 Music lesson/playing instrument
64 Playing video games/surfing
internet
65 Reading
66 Shopping
67 Talking on phone
68 Watching TV or movie
TRANSPORTATION
69 Riding in a car/bus
70 Travel by walking
71 Travel by bicycling
SLEEP/BATHING
72 Getting dressed
73 Getting ready (hair, make-up, etc.)
74 Showering/bathing
75 Sleeping
SCHOOL
76 Club, student activity
77 Lunch/free time/study hall
78 P.E. Class
79 ROTC
80 Sitting in class
Example Activity
3)
Mark
a box
to rate
HOW HARD
the activity
is
2)
Write
MAIN
Activity
number
in this
column
Time
Activity
4)
Mark only 1 box in
each column
How Hard Where
With Whom
Afternoon
3:00-3:30
02
Choose
one activity
number
Time
Activity
Light
School
By yourself
Moderate
Recreational Center
With a class or team
Hard
x
Very Hard
x
Park or Playground
Home
Work
How Hard Where
x
With
friends or brother/sister
With a parent/caregiver
With
parent and friend/family
With Whom
Morning
7:00-7:30
Choose
one activity
number
7:30-8:00
Choose
one activity
number
8:00-8:30
Choose
one activity
number
FLASHE Activity Log
Light
School
By yourself
Moderate
Recreational
Center
Park
or
P
layground
With a class or team
Hard
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
Recreational
Center
Park
or
P
layground
With a class or team
Hard
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
3
Instructions
1) Mark for which day of the week you are filling out this booklet.
2) For each time period during that day, write in the activity number
that matches the main activity you performed during that time period.
Please write only one activity per time period.
3) Rate how physically hard each activity was.
4) Mark where and with whom you performed the activity.
Examples of How Hard
Keep these examples in mind when rating how hard each physical activity was.
light
moderate
hard
very hard
alternates
alternates
alternates
alternates
4 FLASHE Activity Log
Time
Activity
How Hard Where
With Whom
Morning
8:30-9:00
Choose
one activity
number
9:00-9:30
Choose
one activity
number
9:30-10:00
Choose
one activity
number
10:00-10:30
Choose
one activity
number
10:30-11:00
Choose
one activity
number
11:30-12:00
Choose
one activity
number
FLASHE Activity Log
Light
School
By yourself
Moderate
Recreational
Center
Park
or
P
layground
With a class or team
Hard
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
5
Instructions
1) Mark for which day of the week you are filling out this booklet.
2) For each time period during that day, write in the activity number
that matches the main activity you performed during that time period.
Please write only one activity per time period.
3) Rate how physically hard each activity was.
4) Mark where and with whom you performed the activity.
Examples of How Hard
Keep these examples in mind when rating how hard each physical activity was.
light
moderate
hard
very hard
alternates
alternates
alternates
alternates
6 FLASHE Activity Log
Time
Activity
How Hard Where
With Whom
Afternoon
12:00-12:30
Choose
one activity
number
12:30-1:00
Choose
one activity
number
1:00-1:30
Choose
one activity
number
1:30-2:00
Choose
one activity
number
2:00-2:30
Choose
one activity
number
2:30-3:00
Choose
one activity
number
3:00-3:30
Choose
one activity
number
FLASHE Activity Log
Light
School
By yourself
Moderate
Recreational
Center
Park
or
P
layground
With a class or team
Hard
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
7
Instructions
1) Mark for which day of the week you are filling out this booklet.
2) For each time period during that day, write in the activity number
that matches the main activity you performed during that time period.
Please write only one activity per time period.
3) Rate how physically hard each activity was.
4) Mark where and with whom you performed the activity.
Examples of How Hard
Keep these examples in mind when rating how hard each physical activity was.
light
moderate
hard
very hard
alternates
alternates
alternates
alternates
8 FLASHE Activity Log
Time
Activity
How Hard Where
With Whom
Afternoon
3:30-4:00
Choose
one activity
number
4:00-4:30
Choose
one activity
number
4:30-5:00
Choose
one activity
number
Light
School
By yourself
Moderate
Recreational
Center
Park
or
P
layground
With a class or team
Hard
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Evening
5:00-5:30
Choose
one activity
number
5:30-6:00
Choose
one activity
number
6:00-6:30
Choose
one activity
number
6:30-7:00
Choose
one activity
number
FLASHE Activity Log
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
9
Time
Activity
How Hard Where
With Whom
Evening
7:00-7:30
Choose
one activity
number
7:30-8:00
Choose
one activity
number
8:00-8:30
Choose
one activity
number
8:30-9:00
Choose
one activity
number
9:00-9:30
Choose
one activity
number
9:30-10:00
Choose
one activity
number
10:00-10:30
Choose
one activity
number
Light
School
By yourself
Moderate
Recreational
Center
Park
or
P
layground
With a class or team
Hard
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
Light
School
By yourself
Moderate
With a class or team
Hard
Recreational
Center
Park
or Playground
Very
Hard
Home
With friends or brother/sister
With a parent/caregiver
Work
With parent and friend/family
10 FLASHE Activity Log
| File Type | application/pdf |
| Author | Hicks_w |
| File Modified | 2012-05-21 |
| File Created | 2012-05-21 |