Chalk Number
Bib Color / Number
FITNESS ASSESSMENT SCORE SHEET
Type or print all applicable information in corresponding blocks
(FAC Use)
(FAC Use)
Last Name:
SSN:
First Name:
Gender:
M/F
AF Form 422 Issue Date:
Rank:
Profile:
Y/N
AF Form 422 Expire Date:
Squadron:
Duty Ph:
Test Date:
AGE:
DOB:
Fitness Assessment Checklist
Y
N
N/A
Are you properly hydrated?
Have you just come off a 12 hour shift? If so, contact your UFPM to be rescheduled.
Bring current AF Form 422 if exempt from FA component(s)
Is this a retest after a failure? If yes, continue to next question.
Have you waited the required 42 day period before retesting? If no, continue to next question.
Do you have your Commanders Approval Letter approving your early retest prior to 42 days? If no, please contact your UFPM.
Member completes information above dotted line
FAC Staff document results below dotted line
*BMI Data
Results
AFI 36-2905 Guidance
Abdominal Circumference
Measured w/o shoes; round to nearest ½”
*Round < to nearest ½” fraction is < ¼”
*Round > to nearest ½” fraction is > ¼”
PT jacket & shoes will NOT be worn
*Member must be in the following PT Gear:
PT t-shirt & shorts - or - PT t-shirt & pants
2 Lbs deducted for PT gear
If BMI < 19 mandates member seek appointment
with Medical Provider; UFPM schedule appointment
Height (Inches)
Weight (Lbs)
BMI = (Weight)
x 703÷(Height)2
FAC Initials:
Date:
#1
#4 (*if required)
#2
Total / 3 = Avg
#3
FAC Initials:
Date:
~~~~FITNESS ASSESSEMENT RESULTS ~~~~
Members
Initials
FA Component Totals and Time
1-Mile Walk
bpm:
[
:
]
Gender: {Male=1, Female=0}
VO2 Score:________
1
Push-ups
1
Sit-Ups
TOTAL SCORE
Date
/100
Component Minimums Met? (Circle Yes or No)
1.5-Mile Run or
1-Mile Walk
Abdominal
Circumference
Push
Ups
Sit
Ups
YES / NO
YES / NO
YES / NO
YES / NO
[ Excellent ]
90 – 100
[ Satisfactory ]
75 – 89.9
[Unsatisfactory]
< 75
Next Fitness Assessment Due:
Member’s Acknowledgement Statement
FIP Class Info
Class
/60
/20
/10
/10
Abdominal
Circumference
Estimated VO2 max (ml/kg/min) =
132.853 – 0.0769 (Weight) – 0.3877
(Age) + 6.315 (Gender) – 3.2649
(Time) – 0.1565 (HR)
Fitness
Category
Score
[ 1.5-mile Run ]
[ 1-mile Walk ]
AFI 36-2905 Guidance
- Measurement will be taken on bare
skin above right iliac crest
- Member will look straight w/ arms down
- Measurement will be taken at end of
member’s normal respiration
- 3 measurements avg’ed/rounded down to
nearest ½”, *4th measurement taken
when any of the measures differ by
more than 1” from other measurements
Time
BE-WELL
CLASS
I understand my signature constitutes agreement with my test results. I acknowledge
all scores announced by the fitness test administrator are recorded on this score
sheet.
_______________________________________
*Poor category mandated class
**Poor category mandated class with anyone having abdominal
circumference measurement of > 40” males and > 35” females
MEMBER SIGNATURE
FAC STAFF SIGNATURE:
Osan FA Score Sheet version 2, 26 Jan 2012
PERSONAL DATA – PRIVACY ACT OF 1974 (USC 552a)
______________________________
DATE (DD / MMM / YY)
FITNESS SCREENING QUESTIONNAIRE
(FSQ)
Per AFI AFI36-2905, para 1.24.2., FSQ needs to be completed & signed no earlier than 30 days & no later than 7 days prior to FA test date
(1 copy goes to UFPM and bring 1 copy to FAC on FA testing date)
You are being asked these questions for your safety and health. The AF Fitness Assessment is a maximum-effort
test. Airmen who have not been exercising regularly and/or have other risk factors for a heart attack (increasing
age, smoking, diabetes, high blood pressure, etc.) are at increased risk of injury or death during the test.
Answering these questions honestly is in your best interest.
1. Have you experienced any of the symptoms/problems listed below and not been medically evaluated and cleared for
unrestricted participation in a physical training program?
- Unexplained chest discomfort with or without exertion
- Unusual or unexplained shortness of breath
- Dizziness, fainting, or blackouts associated with exertion
- Other medical problems that may prevent you from safely participating in this test
- Yes: Stop. Notify your UFPM and contact your PCP/MLO for evaluation
- No: Proceed to next question.
2. Are you 35 years of age or older?
- Yes: Proceed to next question.
- No: Stop. Sign form and return to your UFPM. Member may take the fitness assessment.
3. Have you engaged in vigorous physical activity (i.e., activity causing sweating and moderate to marked increases in
breathing and heart rate) averaging at least 30 minutes per session, 3 days per week, over the last 2 months?
- Yes: Stop. Sign form and return to your UFPM. Member may take the fitness assessment.
- No: Proceed to the next question.
4. Do one (1) or more of the following risk factors apply to you?
- Smoked tobacco products in the last 30 days
- Diabetes
- High blood pressure that is not controlled
- High cholesterol that is not controlled
- Family history of heart disease (developed in father/brother before age 55 or mother/sister before age 65)
- Age > 45 years for males; > 55 years for females
- Yes: Stop. Notify UFPM.
- If member was cleared for entry into a fitness program at their last PHA and their PHA is current, the member will
take the fitness assessment. If not cleared, member will be referred to PCM for evaluation, and, if medically cleared for
unrestricted fitness program, the member will take the fitness assessment.
- No: Stop. Sign form and return to your UFPM. Member may take the fitness assessment.
If member experiences any of the symptoms listed in Question #1 during the fitness assessment, they should
stop the test immediately and seek medical attention immediately.
Signature: _______________________________________ Date: __________
Printed Name: ___________________________________ Rank: __________
Duty Phone: _____________________________________ Office Symbol: __________
Authority: 10 USC 8013. Routine Use: This information is not disclosed outside DoD. Disclosure is Mandatory.
Failure to provide this information may result in either administrative discharge or punishment under the UCMJ
Osan FSQ ver2, 26 JAN 2012
PERSONAL DATA – PRIVACY ACT OF 1974 (USC 552a)