2014-15 Physical Fitness Test(Pft) Request For Student Scores Correction Form
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22014-15 Physical Fitness Test (PFT)
Request for Student Scores Correction
This form is to request a correction of the student’s 2014-15 PFT scores and/or calculated results. Please attach a
copy of the student’s official PFT score report and a copy of the WelNet report ().
Submit the request and documents to the school’s PFT Coordinator for review and determination. You will be
notified of the review status as soon as possible.
Today’s Date: _______________________________School (where test taken) ________________Grade:_____
Student Last Name: ___________________________First Name: _______________________ MI: __________
AUHSD ID Number: ___________________________Date of Birth: ___________________________________
Teacher’s Name who administered PFT: _________________________________________________________
Requestor’s Name: __________________________ Relationship to Student: ___________________________
Phone: ____________________________________ Email: _________________________________________
Address: ___________________________________ City: _______________State: _______ Zip Code:_______
Enter the student date to be reiewed for correction (Attach copy of original score report and any supporting
documents.)
A.
Height and Weight - This data is required for One-Mile Run and Body Mass Index (BMII) calculations. Corrections to
this data will change the results of the One-Mile-Run and the BMI.
____Approve ____Deny
Height: __________ feet ________inches
Weight: __________lbs.
1)
Aerobic Capacity
____Approve ____Deny
One-mile Run: ________minutes __________seconds
____Approve ____Deny
2) Pacer (20 meter): _______Number of laps
B.
Abdominal Strength: Curl-Ups:
____________
number of curl-ups
____Approve ____Deny
C.
Trunk Extensor Strength: Trunk Lift:
____________ number of inches
____Approve ____Deny
D.
Upper Body Strength: Push-Ups
_____________ number of push-ups
____Approve ____Deny
E.
Flexibility
____Approve ____Deny
1) Back-Saver Sit and reach (Left and right sides required.)
Left:_________ Number of inches
Right: _________number of inches
2) Shoulder Stretch (Left and right sides required. Y, if the students is able to touch fingertips. N, if student is not
able to touch fingertips.
____Approve ____Deny
Left: _________ (Y or N)
Right: _________ (Y or N)
AUHSD – Assessment and Evaluation
Rev 052915
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