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)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |