base: all respondents

In this survey, we are asking you to fill out a “diary” of various
activities that you did on INSERT DATE.  It may be hard to remember what
you did and when, but it is important to this research project for you
to give us the most accurate information possible. The information from
your diary and the other people taking these surveys will be used for
studies of activity patterns.  

Please be assured that any information you provide will be kept strictly
confidential.  Your name will not be provided to anyone outside
Knowledge Networks and you answers will never be linked to your name.

Remember that you will earn **** points/dollars for taking this survey
and **** if you fill out all seven days of diary surveys we will send
you.

Let’s begin.

base: respONDENTS WHO ENTERED SURVEY AFTER 48 HOURS OF INVITATION

[if more than 48 hours since INSERT DATE] Unfortunately the deadline for
filling out this diary has passed.  Diaries need to be filled out within
48 hours of when we send you the invitation.  Please keep checking for
additional opportunities to fill out up to 7 diaries in total.  

base: ALL QUALIFIED RESPONDENTS  

Q1:  What time did you wake up on INSERT DATE?

01	12:00 A.M

…

02	6:00 A.M.		

03	6:15 A.M.		

04	6:30 A.M.		

05	6:45 A.M.		

06	7:00 A.M.		

07	7:15 A.M.		

08	7:30 A.M.		

09	7:45 A.M.		

10	8:00 A.M.		

11	8:15 A.M.

…		

59  11:45 P.M.

base: ALL QUALIFIED RESPONDENTS 

Q2:  When you got woke up on INSERT DATE, where were you?

Indoors at

Home 

Work or school

Other's home

Indoors other [go to Q2.1]     

Outdoors at

Home or near home

Work or school 

Other's home 

A parking lot/garage 

A park or natural area

Outdoors other [go to Q2.1]    

In a vehicle 

A private vehicle (for example, car, truck, taxi)

A public vehicle (for example, bus, train, airplane)

Other vehicle 

Q2.1 [if chose “other”] What other place were you? _________________

base: ALL QUALIFIED RESPONDENTS 

Q3: Now think about the first thing you did immediately after waking up
at [programmer note: insert response from q3].  Please pick the type of
activity from the following list or tell us what you did by choosing the
“other” category. 

Shower, bathe, personal hygiene

Eat 

Sleep/Nap 

Work (any paid work)

Childcare

Caregiving for an adult

General household activities

General leisure activities 

Shop, run errands

Attend classes

Exercise, participate in sports

Travel to another destination [skip to Q4.2]

Other

Q3.1 [if chose other 99] What other activity did you do?____________

Q3.2 [if activity is “travel”] Method of travel

Car

Hybrid car

Minivan 

Full-size Passenger Van 

SUV 

Motorcycle 

Pickup truck 

Walking/Running to destination

Riding on a bus, 

Riding on a train, subway or light rail

Commercial vehicle

Bicycle, Skate, etc. to destination

Airplane

Boat

Other method

Q3.3 [if chose other 99] What other method of travel did you
use?____________

base: ALL QUALIFIED RESPONDENTS 

Q4: What was your level of activity?  Please select the level of
activity from the list below.

Activity	Description	Energy Level

	Sleep 	Sleeping	Very Low	□

Sedentary 	For example, sitting	Low	□

Light 	For example, standing	Low active	□

Moderate	Moderate activities cause only light sweating or a slight to
moderate increase in breathing or heart rate. Some examples are brisk
walking, bicycling for pleasure, golf, or dancing.  	Moderate	□

Vigorous	Vigorous activities cause moderate sweating or large increases
in breathing or heart rate. An example is jogging.	Heavy/vigorous		□

Maximal exertion	Maximal exertion activities cause heavy sweating or
large increases in breathing or heart rate. An example is running hard.
Maximal exertion		□



base: ALL QUALIFIED RESPONDENTS 

The table below lists all your activities so far.  If you need to change
one of your responses, please click on the item you need to change and
use the drop down list to select the correct response. 

Time	Activity	Location or Method of travel	Activity Level

Before Q1	Wake up and get out of bed	Q2	Sleep

Q1	Q3	Q2	Q4



base: ALL QUALIFIED RESPONDENTS 

Q5  What time did you finish [insert Q3]?

Time [PROGRAMMER NOTE: SHOW CHOICES FROM Q1, Starting with Q1.]

01	12:00 A.M

…

02	6:00 A.M.		

03	6:15 A.M.		

04	6:30 A.M.		

05	6:45 A.M.		

06	7:00 A.M.		

07	7:15 A.M.		

08	7:30 A.M.		

09	7:45 A.M.		

10	8:00 A.M.		

11	8:15 A.M.

…		

59  11:45 P.M.

Q6  Now think about the next thing you did.  Please pick the type of
activity from the following list or tell us what you did by choosing the
“other” category. 

	

Shower, bathe, personal hygiene

Eat 

Sleep/Nap 

Work (any paid work)

Childcare

Caregiving for an adult

General household activities

General leisure activities 

Shop, run errands

Attend classes

Exercise, participate in sports

Travel to another destination [skip to Q9]

Other

Q6.1 [if chose other 99]	What other activity did you do? _______________

Q7: Where were you? 

Indoors at

Home [skip to 8 or 10 as appropriate]

Work or school

Other's home

Indoors other         

Outdoors at

Home or near home[skip to 8 or 10 as appropriate]

Work or school 

Other's home 

A parking lot/garage 

A park or natural area

Outdoors other

Q7.1 [if chose other]	What other place were you? _____________________

Q8: (if change from own home to other place or back with no travel): (if
change from own home to other place with no travel):  During your last
activity, you were [insert location from last activity] and now you are
[insert location from current activity].  Is this correct?

01 Yes

02 No [return to Q7]

Q8.1 How did you get from Q2 to Q7?

Car

Hybrid car

Minivan 

Full-size Passenger Van 

SUV 

Motorcycle 

Pickup truck 

Walking/Running to destination

Riding on a bus, 

Riding on a train, subway or light rail

Commercial vehicle

Bicycle, Skate, etc. to destination

Airplane

Boat

Other method

Q8.2 [if chose other 99] What other method of travel did you
use?____________

Q9 [if activity is “travel”] Method of travel

Car

Hybrid car

Minivan 

Full-size Passenger Van 

SUV 

Motorcycle 

Pickup truck 

Walking/Running to destination

Riding on a bus, 

Riding on a train, subway or light rail

Commercial vehicle

Bicycle, Skate, etc. to destination

Airplane

Boat

Other method

Q9.1 [if chose other 99] What other method of travel did you
use?____________

Q10: What was you level of activity?

□

Sedentary 	For example, sitting	Low	□

Light 	For example, standing	Low active	□

Moderate	Moderate activities cause only light sweating or a slight to
moderate increase in breathing or heart rate. Some examples are brisk
walking, bicycling for pleasure, golf, or dancing.  	Moderate	□

Vigorous	Vigorous activities cause moderate sweating or large increases
in breathing or heart rate. An example is jogging.	Heavy/vigorous		□

Maximal exertion	Maximal exertion activities cause heavy sweating or
large increases in breathing or heart rate. An example is running hard.
Maximal exertion		□



base: ALL QUALIFIED RESPONDENTS 

The table below lists all your activities so far.  If you need to change
one of your responses, please click on the item you need to change and
use the drop down list to select the correct response. 

Time	Activity	Location or Method of travel	Activity Level















	

CONTINUE UNTIL CYCLE THROUGH 24 HOURS

Q11 On [insert date], did you leave [insert name of city]? 

Yes

No [skip to 13]

Q12 [if yes] Below is a table of your activities on [insert date] that
took place away from your home.  Please type in the name of the city
where the activity took place if it took place in another city.

Q13 You indicated that some of the activities took place at “work or
school” Do you know the address of the building where the work took
place or where you go to school?

Yes, the address is _________________ [skip to Q15]

No

Q13.1 [if no] Do you know the name of the nearest major intersection?

Yes

No

Q13.2	If you were to drive from your house to this location, how long
would it take?

01	Less than 5 minutes		

02	5 to 10 minutes		

03	10 to 20 minutes		

04	20 to 40 minutes		

05	More than 40 minutes 			

Post-diary

	

base: ALL QUALIFIED RESPONDENTS 

Q15  Think about the amount of time you spent indoors and outdoors
compared to the amount time you usually spend indoors and outdoors on
weekdays.  Using the scale below, please indicate the amount of time you
spent indoors or outdoors on [PROGRAMMER NOTE: INSERT DATE] compared to
a typical day.

A lot more 	A little more	Usual amount of		A little more	A lot more

Time indoors	time indoors	time indoors and 		time outdoors	time outdoors

				outdoors

 	 1		2		3			4		5		

BASE: SPENT A LOT OR A LITTLE MORE TIME INDOORS 

Q16 Which of the following contributed to you spending more time
indoors? Please check all that apply.

01	Your health on this day 		

02	The health of your child on this day	

03	The health of another person you care for on this day		

04	Conditions were not good outside.		

05	I had previously scheduled plans to do an indoor activity.		

06	No particular reason 

96	Other, What other reason contributed to you spending more time
indoors?

BASE: conditions outside WERE Not NICE

Q16.1  Which outdoor conditions contributed to you spending more time
indoors? Please check all that apply.

01	Too hot		

02	Too cool		

03	Too humid		

04	Poor air quality		

05	Too much dust or pollen		

06	Too much rain		

07	Too windy			

96	Other, What other reason contributed to you spending more time
indoors?

BASE: SPENT A LOT OR A LITTLE MORE TIME OUTDOORS 

Q17  Which of the following contributed to you spending more time
outdoors? Please check all that apply.

01	Conditions outside were nice

02	I had previously scheduled plans to do an outdoor activity

03  No particular reason	

96	Other, What other reason contributed to you spending more time
outdoors?

BASE: conditions outside WERE NICE

Q17.1  (md6351-md6356)  Which outdoor conditions  contributed to your
spending more time outdoors? Please check all that apply.

01	Good weather		

02	Good air quality		

03	Low dust or pollen		

96	Other, What other reason contributed to you spending more time
outdoors?

base: ALL QUALIFIED RESPONDENTS 

Q18  (md6401-md64012)  Did you experience any of the following symptoms
on [PROGRAMMER NOTE: INSERT DATE]? <I>Please check all that apply.</I>

	

01	Coughing		

02	Wheezing		

03	Shortness of breath		

04	Asthma attack		

05	Runny nose or other cold symptoms		

06	Nausea, stomachache		

07	Fever		

08	Earache		

09	Sore throat		

10	Chest pain		

96    Other, What other symptoms did you experience?

97	I did not experience any symptoms on [PROGRAMMER NOTE: INSERT DATE].	
	

BASE: HAVE EXPERIENCED SYMPTOMS 

Q18.1	 How long your [PROGRAMMER NOTE: INSERT RESPONSE FROM Q17] last?

1	All day		

2	Most of the day		

3	Some of the day

4	A short time		

BASE: HAVE EXPERIENCED SYMPTOMS 

Q18.2	 How would you characterize your [PROGRAMMER NOTE: INSERT RESPONSE
FROM Q17]?

1	Mild		

2	Moderate		

3	Severe		

BASE: ALL QUALIFIED RESPONDENTS 

Q19  Did you take any medication on [PROGRAMMER NOTE: INSERT DATE]? 
Please include prescription and over the counter medicines.

1	Yes		

2	No		

BASE: TOOK MEDICATION 

Q20 Did you take any medication that you do not usually take every day
or did you take a higher dose of a medication you usually take? 

Yes

No

Q21 What medications did you take? <I>Please enter one medication per
box.</I>

[TEXT BOX]

[TEXT BOX]

[TEXT BOX]

[TEXT BOX]

[TEXT BOX]

BASE: ALL QUALIFIED RESPONDENTS 

Q22  Did you have your windows open between 7 a.m. and 8 p.m. on
[PROGRAMMER NOTE: INSERT DATE]?

1	Yes		

2	No		

8	Not sure			

BASE: HAD WINDOWS OPEN 

Q22.1  For how long between 7 a.m. and 8 p.m. did you have your windows
open?

Q19.11			Q19.12

Hours			Minutes

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|__|__|                                  |__|__|			 	

Thank you for completing this survey.  We appreciate your time and
effort.

[if appropriate] You will be asked to fill out more diary surveys for
the next (1/2/3) days.  It is very important for this research study
that we get more than 1 diary from each person and ideally that we get
all 7 diaries from each person.  Don’t forget that you can earn ****
for completing all 7 diaries.

The public reporting and recordkeeping burden for this collection of
information is estimated to average 15 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.

OMB Control Number 2060-xxxx

Approval Expires xx/xx/xxxx

