Don’t Just Sit There
Baseline Questionnaire
| Module A. Below is a set of eight statements, each beginning with the phrase, “If I were to be physically active during my free time on most days….” For each statement, please check one box to indicate your level of agreement or disagreement. |
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| If I were to be physically active during my free time on most days… | Disagree Strongly | Disagree | Neutral | Agree | Strongly Agree | |
| A1. | It would help me cope with stress. | □ | □ | □ | □ | □ |
| A2. | It would be fun. | □ | □ | □ | □ | □ |
| A3. | It would help me make new friends. | □ | □ | □ | □ | □ |
| A4. | It would get or keep me in shape. | □ | □ | □ | □ | □ |
| A5. | It would make me more attractive. | □ | □ | □ | □ | □ |
| A6. | It would give me more energy. | □ | □ | □ | □ | □ |
| A7. | It would make me hot and sweaty. | □ | □ | □ | □ | □ |
| A8. | It would make me better in sports or other activities. | □ | □ | □ | □ | □ |
| Module B. Below are eight more statements. For each, please check one box to indicate your level of agreement or disagreement with that statement. |
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| Strongly Disagree |
Disagree | Neutral | Agree | Strongly Agree |
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| B1. | I can be physically active during my free time on most days. | □ | □ | □ | □ | □ |
| B2. | I can ask my parent or other adult to do physically active things with me. | □ | □ | □ | □ | □ |
| B3. | I can be physically active during my free time on most days even if I could watch TV or play video games instead. |
□ | □ | □ | □ | □ |
| B4. | I can be physically active during my free time on most days even if it is very hot or cold outside. |
□ | □ | □ | □ | □ |
| B5. | I can ask my best friend to be physically active with me during my free time on most days. |
□ | □ | □ | □ | □ |
| B6. | I can be physically active during my free time on most days even if I have to stay at home. |
□ | □ | □ | □ | □ |
| B7. | I have the coordination I need to be physically active during my free time. | □ | □ | □ | □ | □ |
| B8. | I can be physically active during my free time on most days no matter how busy my day is. |
□ | □ | □ | □ | □ |
| Module C. Below are eight outcomes that my result from physical activity. For each, please check one box to indicate how positive (good) or negative (bad) you would feel about experiencing that outcome. |
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| Very Negative |
Negative | Neutral | Positive | Very Positive |
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| C1. | Coping well with stress. | □ | □ | □ | □ | □ |
| C2. | Having fun. | □ | □ | □ | □ | □ |
| C3. | Making new friends. | □ | □ | □ | □ | □ |
| C4. | Being in shape. | □ | □ | □ | □ | □ |
| C5. | Being attractive. | □ | □ | □ | □ | □ |
| C6. | Having plenty of energy. | □ | □ | □ | □ | □ |
| C7. | Getting hot and sweaty. | □ | □ | □ | □ | □ |
| C8. | Being good at sports or other activities. | □ | □ | □ | □ | □ |
| Module D. These last few questions deal with your demographic background and grade in school. | ||||||
| D1. | What is your sex? □ Female □ Male |
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| D2. | Which of the following best describes your race and ethnicity? □ Non-Hispanic White □ Non-Hispanic Black □ Hispanic or Latino □ Other |
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| D3. | What grade are you in? □ Ninth □ Tenth □ Eleventh □ Twelfth |