Student Name:
SSID:
Physical Fitness Test (PFT)
Sample Student Data Collection Form
This form is for your convenience in collecting data for electronic submission.
Do not send this form to the state PFT contractor.
School Name:
STUDENT DEMOGRAPHICS
Grade Level:
Grade 5 Grade 7 Grade 9
Student Last Name:
Student First Name: Student Middle Initial:
PFT Test Date:
INDIVIDUAL STUDENT SCORES
Use the sections below to track student scores as well as test area participation.
Aerobic Capacity
Scores for One-Mile Run or One-Mile Walk should be recorded in minutes and seconds.
For example, eight minutes and fty-ve seconds should be recorded as 8:55. If the student begins
but cannot nish, ll in 59:59 for the time.
One-Mile Run or One-Mile Walk
Raw Score: Counted as participating?
Yes
No
Scores for Progressive Aerobic Cardiovascular Endurance Run (PACER) should be recorded
as the number completed.
PACER Test
Raw Score: Counted as participating?
Yes
No
Abdominal Strength
Scores for Curl-Up should be recorded as the number completed.
This score has a minimum of 1 and a maximum of 75.
Curl-Up
Raw Score: Counted as participating?
Yes
No
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Student Name:
SSID:
Trunk Extensor Strength
Scores for Trunk lift should be recorded as the number completed.
This score has a minimum of 0 and a maximum of 12.
Trunk Lift
Raw Score: Counted as participating?
Yes
No
Upper Body Strength
Scores for Push-Up and Modied Pull-Up should be recorded as the number completed.
These scores have a minimum of 1 and a maximum of 75.
Push-Up
Raw Score: Counted as participating?
Yes No
Modied Pull-Up
Raw Score: Counted as participating? Yes No
Scores for Flexed Arm Hang should be recorded as the number completed.
This score has a minimum of 0 seconds and a maximum of 90 seconds.
Flexed Arm Hang
Raw Score: Counted as participating?
Yes No
Flexibility
Scores for Back-Saver Sit and Reach should be recorded as the number of inches on each side.
These scores have a minimum of 0 and a maximum of 12.
Back-Saver Sit and Reach
Raw Score (Left) : Raw Score (Right) :
Counted as participating? Yes No
Scores for Shoulder Stretch should be recorded as a Yes or No on each side.
Shoulder Stretch
Raw Score (Left): Yes No Raw Score (Right):
Yes
No
Counted as participating?
Yes
No
California Department of Education • January 2022 Page 2 of 2