Data Collection Worksheet
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1 Data Collection Worksheet 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 on Monday with Maria and two s on Wednesday with Olga. Therefore, the total s a week that she visits with friends is 3 s a week. In a typical week, during the past 4 weeks, did you Visit with friends or family (other than those you live with)? than 1 s s s s s If you DID NOT do the activity: Check the NO box and move to the next question.
2 In a typical week, during the past 4 weeks, did you Visit with friends or family (other than those you live with)? s s s s s 2. Go to the senior center? 3. Do volunteer work? 4. Attend church or take part in church activities? s s s s s s s s s s s s s s s 5. Attend other club or group meetings? 6. Use a computer? 7. Dance (such as square, folk, line, ballroom) (do not count aerobic dance here)? s s s s s s s s s s
3 8. Do woodworking, needlework, drawing, or other arts or crafts? s s s s s s s s s s 9. Play golf, carrying or pulling your equipment (count walking time only)? 10. Play golf, riding a cart (count walking time only)? 11. Attend a concert, movie, lecture, or sport event? 12. Play cards, bingo, or board games with other people? 13. Shoot pool or billiards? 14. Play singles tennis (do not count doubles)? s s s s s s s s s s s s s s s s s s s s s s s s s
4 s s s s s 15. Play doubles tennis (do not count singles)? 16. Skate (ice, roller, in-line)? 17. Play a musical instrument? 18. Read? 19. Do heavy work around the house (such as washing windows, cleaning gutters)? 20. Do light work around the house (such as sweeping or vacuuming)? s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s
5 21. Do heavy gardening (such as spading, raking)? 22. Do light gardening (such as watering plants)? 23. Work on your car, truck, lawn mower, or other machinery? s s s s s s s s s s s s s s s **Please note: For the following questions about running and walking, include use of a treadmill. 24. Jog or run? 25. Walk uphill or hike uphill (count only uphill part)? s s s s s s s s s s 26. Walk fast or briskly for exercise (do not count walking leisurely or uphill? 27. Walk to do errands (such as to/from a store or to take children to school (count s s s s s
6 walk time only)? s s s s s 28. Walk leisurely for exercise or pleasure? 29. Ride a bicycle or stationary cycle? 30. Do other aerobic machines such as rowing, or step machines (do not count treadmill or stationary cycle)? 31. Do water exercises (do not count other swimming 32. Swim moderately or fast? 33. Swim gently? s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s
7 34. Do stretching or flexibility exercises (do not count yoga or Tai-chi)? 35. Do yoga or Tai-chi? 36. Do aerobics or aerobic dancing? 37. Do moderate to heavy strength training (such as hand-held weights of than 5 lbs., weight machines, or push-ups)? 38. Do light strength training (such as handheld weights of 5 lbs. or less or elastic bands)? 39. Do general conditioning exercises, such as light calisthenics or chair exercises (do not count strength training)? 40. Play basketball, soccer, or racquetball (do not count time on sidelines)? s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s
8 s s s s s 41. Do other types of physical activity not previously mentioned (please specify)? s s s s s Protocol source:
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