FitnessGram Data Collection Form - 6th Grade Students in

EVALUATION OF THE PRESIDENTIAL YOUTH FITNESS PROGRAM

Att 28 FitnessGram Data Collection Form

FitnessGram Data Collection Form - 6th Grade Students in Non-PYFP School

OMB: 0920-1167

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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)



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