Survey

3 Day Physical Activity Recall Survey

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1. Name

Name

*
2. Age

Age

*
3. Grade

Grade 5th

6th

7th

8th

9th

10th

11th

12th

Other or Not Graded

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4. School

School Monroe Center Elementary School

Meridian Junior High School

Stillman Valley High School

The following pictures represent the 3DPAR Activities Scale.

The numbers below represent the activities in which you participated in each 30-minute block of time during the 3 days you are recalling. You may use this as a guide as you complete the next three questions.

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5. Day #1: What did you do? (See Activities Menu above for examples of some of the activities.) If you select # 59 "Other" for any time block, please explain what you did in a word or two in the following section.

	Activity Number	Activity Level
7:00-7:30 a.m.	Day #1: What did you do? (See Activities Menu above for examples of some of the activities.) If you select # 59 "Other" for any time block, please explain what you did in a word or two in the following section. 7:00-7:30 a.m. Activity Number	Activity Level
7:30-8:00 a.m.	7:30-8:00 a.m. Activity Number	Activity Level
8:00-8:30 a.m.	8:00-8:30 a.m. Activity Number	Activity Level
8:30-9:00 a.m.	8:30-9:00 a.m. Activity Number	Activity Level
9:00-9:30 a.m.	9:00-9:30 a.m. Activity Number	Activity Level
9:30-10:00 a.m.	9:30-10:00 a.m. Activity Number	Activity Level
10:00-10:30 a.m.	10:00-10:30 a.m. Activity Number	Activity Level
10:30-11:00 a.m.	10:30-11:00 a.m. Activity Number	Activity Level
11:00-11:30 a.m.	11:00-11:30 a.m. Activity Number	Activity Level
11:30-12:00 noon	11:30-12:00 noon Activity Number	Activity Level
12:00-12:30 p.m.	12:00-12:30 p.m. Activity Number	Activity Level
12:30-1:00 p.m.	12:30-1:00 p.m. Activity Number	Activity Level
1:00-1:30 p.m.	1:00-1:30 p.m. Activity Number	Activity Level
1:30-2:00 p.m.	1:30-2:00 p.m. Activity Number	Activity Level
2:00-2:30 p.m.	2:00-2:30 p.m. Activity Number	Activity Level
2:30-3:00 p.m.	2:30-3:00 p.m. Activity Number	Activity Level
3:00-3:30 p.m.	3:00-3:30 p.m. Activity Number	Activity Level
3:30-4:00 p.m.	3:30-4:00 p.m. Activity Number	Activity Level
4:00-4:30 p.m.	4:00-4:30 p.m. Activity Number	Activity Level
4:30-5:00 p.m.	4:30-5:00 p.m. Activity Number	Activity Level
5:00-5:30 p.m.	5:00-5:30 p.m. Activity Number	Activity Level
5:30-6:00 p.m.	5:30-6:00 p.m. Activity Number	Activity Level
6:00-6:30 p.m.	6:00-6:30 p.m. Activity Number	Activity Level
6:30-7:00 p.m.	6:30-7:00 p.m. Activity Number	Activity Level
7:00-7:30 p.m.	7:00-7:30 p.m. Activity Number	Activity Level
7:30-8:00 p.m.	7:30-8:00 p.m. Activity Number	Activity Level
8:00-8:30 p.m.	8:00-8:30 p.m. Activity Number	Activity Level
8:30-9:00 p.m.	8:30-9:00 p.m. Activity Number	Activity Level
9:00-9:30 p.m.	9:00-9:30 p.m. Activity Number	Activity Level
9:30-10:00 p.m.	9:30-10:00 p.m. Activity Number	Activity Level
10:00-10:30 p.m.	10:00-10:30 p.m. Activity Number	Activity Level
10:30-11:00 p.m.	10:30-11:00 p.m. Activity Number	Activity Level
11:00-11:30 p.m.	11:00-11:30 p.m. Activity Number	Activity Level
11:30-12:00 midnight	11:30-12:00 midnight Activity Number	Activity Level

6. If you used # 59 "Other" as an answer for any of your DAY #1 activities, list those activities here. Please be brief, using just a few words or less.

If you used # 59 "Other" as an answer for any of your DAY #1 activities, list those activities here. Please be brief, using just a few words or less. Other (7:00-7:30 a.m.)
Other (7:30-8:00 a.m.)
Other (8:00-8:30 a.m.)
Other (8:30-9:00 a.m.)
Other (9:00-9:30 a.m.)
Other (9:30-10:00 a.m.)
Other (10:00-10:30 a.m.)
Other (10:30-11:00 a.m.)
Other (11:00-11:30 a.m.)
Other (11:30-12:00 noon)
Other (12:00-12:30 p.m.)
Other (12:30-1:00 p.m.)
Other (1:00-1:30 p.m.)
Other (1:30-2:00 p.m.)
Other (2:00-2:30 p.m.)
Other (2:30-3:00 p.m.)
Other (3:00-3:30 p.m.)
Other (3:30-4:00 p.m.)
Other (4:00-4:30 p.m.)
Other (4:30-5:00 p.m.)
Other (5:00-5:30 p.m.)
Other (5:30-6:00 p.m.)
Other (6:00-6:30 p.m.)
Other (6:30-7:00 p.m.)
Other (7:00-7:30 p.m.)
Other (7:30-8:00 p.m.)
Other (8:00-8:30 p.m.)
Other (8:30-9:00 p.m.)
Other (9:00-9:30 p.m.)
Other (9:30-10:00 p.m.)
Other (10:00-10:30 p.m.)
Other (10:30-11:00 p.m.)
Other (11:00-11:30 p.m.)
Other (11:30-12:00 midnight)

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7. DAY #2: What did you do? (See Activities Menu above for examples of some of the activities.)

	Activity Number	Activity Level
7:00-7:30 a.m.	DAY #2: What did you do? (See Activities Menu above for examples of some of the activities.) 7:00-7:30 a.m. Activity Number	Activity Level
7:30-8:00 a.m.	7:30-8:00 a.m. Activity Number	Activity Level
8:00-8:30 a.m.	8:00-8:30 a.m. Activity Number	Activity Level
8:30-9:00 a.m.	8:30-9:00 a.m. Activity Number	Activity Level
9:00-9:30 a.m.	9:00-9:30 a.m. Activity Number	Activity Level
9:30-10:00 a.m.	9:30-10:00 a.m. Activity Number	Activity Level
10:00-10:30 a.m.	10:00-10:30 a.m. Activity Number	Activity Level
10:30-11:00 a.m.	10:30-11:00 a.m. Activity Number	Activity Level
11:00-11:30 a.m.	11:00-11:30 a.m. Activity Number	Activity Level
11:30-12:00 noon	11:30-12:00 noon Activity Number	Activity Level
12:00-12:30 p.m.	12:00-12:30 p.m. Activity Number	Activity Level
12:30-1:00 p.m.	12:30-1:00 p.m. Activity Number	Activity Level
1:00-1:30 p.m.	1:00-1:30 p.m. Activity Number	Activity Level
1:30-2:00 p.m.	1:30-2:00 p.m. Activity Number	Activity Level
2:00-2:30 p.m.	2:00-2:30 p.m. Activity Number	Activity Level
2:30-3:00 p.m.	2:30-3:00 p.m. Activity Number	Activity Level
3:00-3:30 p.m.	3:00-3:30 p.m. Activity Number	Activity Level
3:30-4:00 p.m.	3:30-4:00 p.m. Activity Number	Activity Level
4:00-4:30 p.m.	4:00-4:30 p.m. Activity Number	Activity Level
4:30-5:00 p.m.	4:30-5:00 p.m. Activity Number	Activity Level
5:00-5:30 p.m.	5:00-5:30 p.m. Activity Number	Activity Level
5:30-6:00 p.m.	5:30-6:00 p.m. Activity Number	Activity Level
6:00-6:30 p.m.	6:00-6:30 p.m. Activity Number	Activity Level
6:30-7:00 p.m.	6:30-7:00 p.m. Activity Number	Activity Level
7:00-7:30 p.m.	7:00-7:30 p.m. Activity Number	Activity Level
7:30-8:00 p.m.	7:30-8:00 p.m. Activity Number	Activity Level
8:00-8:30 p.m.	8:00-8:30 p.m. Activity Number	Activity Level
8:30-9:00 p.m.	8:30-9:00 p.m. Activity Number	Activity Level
9:00-9:30 p.m.	9:00-9:30 p.m. Activity Number	Activity Level
9:30-10:00 p.m.	9:30-10:00 p.m. Activity Number	Activity Level
10:00-10:30 p.m.	10:00-10:30 p.m. Activity Number	Activity Level
10:30-11:00 p.m.	10:30-11:00 p.m. Activity Number	Activity Level
11:00-11:30 p.m.	11:00-11:30 p.m. Activity Number	Activity Level
11:30-12:00 midnight	11:30-12:00 midnight Activity Number	Activity Level

8. If you used # 59 "Other" as an answer for any of your DAY #2 activities, list those activities here. Please be brief, using just a few words or less.

If you used # 59 "Other" as an answer for any of your DAY #2 activities, list those activities here. Please be brief, using just a few words or less. Other (7:00-7:30 a.m.)
Other (7:30-8:00 a.m.)
Other (8:00-8:30 a.m.)
Other (8:30-9:00 a.m.)
Other (9:00-9:30 a.m.)
Other (9:30-10:00 a.m.)
Other (10:00-10:30 a.m.)
Other (10:30-11:00 a.m.)
Other (11:00-11:30 a.m.)
Other (11:30-12:00 noon)
Other (12:00-12:30 p.m.)
Other (12:30-1:00 p.m.)
Other (1:00-1:30 p.m.)
Other (1:30-2:00 p.m.)
Other (2:00-2:30 p.m.)
Other (2:30-3:00 p.m.)
Other (3:00-3:30 p.m.)
Other (3:30-4:00 p.m.)
Other (4:00-4:30 p.m.)
Other (4:30-5:00 p.m.)
Other (5:00-5:30 p.m.)
Other (5:30-6:00 p.m.)
Other (6:00-6:30 p.m.)
Other (6:30-7:00 p.m.)
Other (7:00-7:30 p.m.)
Other (7:30-8:00 p.m.)
Other (8:00-8:30 p.m.)
Other (8:30-9:00 p.m.)
Other (9:00-9:30 p.m.)
Other (9:30-10:00 p.m.)
Other (10:00-10:30 p.m.)
Other (10:30-11:00 p.m.)
Other (11:00-11:30 p.m.)
Other (11:30-12:00 midnight)

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9. DAY #3: What did you do? (See Activities Menu above for examples of some of the activities.)

	Activity Number	Activity Level
7:00-7:30 a.m.	DAY #3: What did you do? (See Activities Menu above for examples of some of the activities.) 7:00-7:30 a.m. Activity Number	Activity Level
7:30-8:00 a.m.	7:30-8:00 a.m. Activity Number	Activity Level
8:00-8:30 a.m.	8:00-8:30 a.m. Activity Number	Activity Level
8:30-9:00 a.m.	8:30-9:00 a.m. Activity Number	Activity Level
9:00-9:30 a.m.	9:00-9:30 a.m. Activity Number	Activity Level
9:30-10:00 a.m.	9:30-10:00 a.m. Activity Number	Activity Level
10:00-10:30 a.m.	10:00-10:30 a.m. Activity Number	Activity Level
10:30-11:00 a.m.	10:30-11:00 a.m. Activity Number	Activity Level
11:00-11:30 a.m.	11:00-11:30 a.m. Activity Number	Activity Level
11:30-12:00 noon	11:30-12:00 noon Activity Number	Activity Level
12:00-12:30 p.m.	12:00-12:30 p.m. Activity Number	Activity Level
12:30-1:00 p.m.	12:30-1:00 p.m. Activity Number	Activity Level
1:00-1:30 p.m.	1:00-1:30 p.m. Activity Number	Activity Level
1:30-2:00 p.m.	1:30-2:00 p.m. Activity Number	Activity Level
2:00-2:30 p.m.	2:00-2:30 p.m. Activity Number	Activity Level
2:30-3:00 p.m.	2:30-3:00 p.m. Activity Number	Activity Level
3:00-3:30 p.m.	3:00-3:30 p.m. Activity Number	Activity Level
3:30-4:00 p.m.	3:30-4:00 p.m. Activity Number	Activity Level
4:00-4:30 p.m.	4:00-4:30 p.m. Activity Number	Activity Level
4:30-5:00 p.m.	4:30-5:00 p.m. Activity Number	Activity Level
5:00-5:30 p.m.	5:00-5:30 p.m. Activity Number	Activity Level
5:30-6:00 p.m.	5:30-6:00 p.m. Activity Number	Activity Level
6:00-6:30 p.m.	6:00-6:30 p.m. Activity Number	Activity Level
6:30-7:00 p.m.	6:30-7:00 p.m. Activity Number	Activity Level
7:00-7:30 p.m.	7:00-7:30 p.m. Activity Number	Activity Level
7:30-8:00 p.m.	7:30-8:00 p.m. Activity Number	Activity Level
8:00-8:30 p.m.	8:00-8:30 p.m. Activity Number	Activity Level
8:30-9:00 p.m.	8:30-9:00 p.m. Activity Number	Activity Level
9:00-9:30 p.m.	9:00-9:30 p.m. Activity Number	Activity Level
9:30-10:00 p.m.	9:30-10:00 p.m. Activity Number	Activity Level
10:00-10:30 p.m.	10:00-10:30 p.m. Activity Number	Activity Level
10:30-11:00 p.m.	10:30-11:00 p.m. Activity Number	Activity Level
11:00-11:30 p.m.	11:00-11:30 p.m. Activity Number	Activity Level
11:30-12:00 midnight	11:30-12:00 midnight Activity Number	Activity Level

10. If you used # 59 "Other" as an answer for any of your DAY #3 activities, list those activities here. Please be brief, using just a few words or less.

If you used # 59 "Other" as an answer for any of your DAY #3 activities, list those activities here. Please be brief, using just a few words or less. Other (7:00-7:30 a.m.)
Other (7:30-8:00 a.m.)
Other (8:00-8:30 a.m.)
Other (8:30-9:00 a.m.)
Other (9:00-9:30 a.m.)
Other (9:30-10:00 a.m.)
Other (10:00-10:30 a.m.)
Other (10:30-11:00 a.m.)
Other (11:00-11:30 a.m.)
Other (11:30-12:00 noon)
Other (12:00-12:30 p.m.)
Other (12:30-1:00 p.m.)
Other (1:00-1:30 p.m.)
Other (1:30-2:00 p.m.)
Other (2:00-2:30 p.m.)
Other (2:30-3:00 p.m.)
Other (3:00-3:30 p.m.)
Other (3:30-4:00 p.m.)
Other (4:00-4:30 p.m.)
Other (4:30-5:00 p.m.)
Other (5:00-5:30 p.m.)
Other (5:30-6:00 p.m.)
Other (6:00-6:30 p.m.)
Other (6:30-7:00 p.m.)
Other (7:00-7:30 p.m.)
Other (7:30-8:00 p.m.)
Other (8:00-8:30 p.m.)
Other (8:30-9:00 p.m.)
Other (9:00-9:30 p.m.)
Other (9:30-10:00 p.m.)
Other (10:00-10:30 p.m.)
Other (10:30-11:00 p.m.)
Other (11:00-11:30 p.m.)
Other (11:30-12:00 midnight)

*1. Name

*2. Age

*3. Grade

*4. School

*5. Day #1: What did you do? (See Activities Menu above for examples of some of the activities.) If you select # 59 "Other" for any time block, please explain what you did in a word or two in the following section.