Fitness Gram Data Collection Form - 6th Grade Students i

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

FitnessGram® Data Collection Form

Student Name:________________________________ Survey ID:______________________________

Birth Date: (MM/DD/YYYY)______________________ Gender:________________________________

BMI

HEIGHT:* _____ (feet) _________ (inches) ___ Refusal ___Absent ___Present but ill/injured

Weight:* _____ ___ Refusal ___Absent ___Present but ill/ injured

*Measure to the last whole number.

PACER

Number of Laps Completed: ___________ ___ Refusal ___Absent ___Present but ill/ injured

Number of Laps After Conversion: **_______________

**Enter this number into FitnessGram

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx)