Screening Questions

Thank you for your interest in this survey. In this survey we will ask
you about issues related to your quality of life.  This survey is being
conducted by Research Triangle Institute, a non-profit research
organization. 

Please first answer some questions about your situation to confirm that
you are eligible to participate in the survey. If you have any problems
or concerns about this survey, please contact Panel Relations at
800-782-7699, and someone will direct your questions to the appropriate
researchers at Research Triangle Institute. 

 “During the past month, did you participate in any physical
activities or exercises such as running, calisthenics, golf, gardening,
or walking for exercise for work or for leisure?”   

Yes

No

How many people live in your household, including yourself?

_______ people

How many children (less than 18 years old) currently live in your
household?

_____children

Are you currently living with a spouse or partner? 

Yes

No

If “no” to Q1, then:  “Thank you for your interest, but you are
not eligible for today’s survey.”

OMB Control Number 2060-XXXX

Approval Expires xx/xx/xxxx

The public reporting and recordkeeping burden for this collection of
information is estimated to average 3 minutes per response.  Send
comments on the Agency's need for this information, the accuracy of the
provided burden estimates, and any suggested methods for minimizing
respondent burden, including through the use of automated collection
techniques to the Director, Collection Strategies Division, U.S.
Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW,
Washington, D.C. 20460.  Include the OMB control number in any
correspondence.  Do not send the completed survey to this address.

