1. Jiann-Ping Hsu College of Public Health
Post Office Box 8015
Statesboro, GA 30460-8015
Phone (912) 478-2674 Fax (912) 478-5811
E-Mail jphcoph@georgiasouthern.edu
Web jphcoph.georgiasouthern.edu
The purpose of this survey is to see how much physical activity that a child participates
in with relation to the amount of time that the parent is at work. Participation in this study
is completely voluntary and you may withdraw at any time. Completion of this self-report
survey should take 5-10 minutes. Reply to these study questions will be considered
permission to use your responses in the study. Responses from the collected data are
anonymous and will be reported in aggregated totals only. If there are any questions
concerning this study please contact Dr. Helen Bland at
hwbland@georgiasouthern.edu.
Directions:
Please answer the following questions about your child by writing each response. Only fill out
one survey per child.
In one day, does your child Yes/No For how long?
Indoor
(lie around/sit)
Indoor
(walk/running)
Indoor
(play/tumble)
Outdoor
(lie around/sit)
Outdoor
(walk/running)
Outdoor
(play/tumble)
During the past 7 days, how many days was your child physically active for a total of at least 60
minutes per day? Please check by the appropriate number of days.
___ 1 ___2 ___3 ___4 ___5 ___6 ___7
Please Turn Over!

2. Describe your child:
Sports that your child likes to participate in (football, baseball, soccer etc):
___________________________________
Please list any teams that your child is involved in (baseball, football, soccer, swimming etc):
___________________________________
Describe the child’s parents:
Are the child’s parents employed?
__ Yes
__ No
How many hours a week does each child’s parent work?
Mother Father
________ hours/week ________ hours/week
Please answer the following for yourself/your child:
Your relation to
the child:
Gender: Ethnicity: Age: Income (parent annual
income):
__ Biological
__ Step
__ Adoptive
__ Foster
__ Grandparent
__ Other
__ Male
__ Female
__ African
__ Hispanic
__ Other
(White/Native
American)
__ 3-4
__ 4-5
__ 5+
__ $0-$25,000
__ $26,000-$50,000
__ $51,000-$75,000
__$ 76,000-$100,000
__ Above $100,000
Thank You!