Pwc 170 Cycle Ergometer Exercise Test
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To be completed by TAAG staff:
Student ID: _________________ Test Date: ___ / ___ / ___
(mm/dd/yy)
Form Code: MFI
Version: A
Series: 31
Sequence: 001 (FINAL)
002 (QC)
(circle one)
PWC-170 Cycle Ergometer Exercise Test
Eligibility
Assess the current eligibility of each girl prior to the fitness test. If the girl is unavailable, unable to
participate in PE or is sick on the day of the fitness test, record on this form, but do NOT enter the form in
the DMS unless it is the last
opportunity to measure fitness for that girl. Only one form is allowed per ID,
unless the form is for quality control (QC). Circle Sequence 001 for the final fitness form. Circle Sequence
002 for QC. Only two girls per school may be skipped on the last day of fitness testing.
1. Is the girl available for fitness measure today? YES (
)
NO (
)
go to Question 2
skip to Question 4
2. Is the girl able to participate in PE? [or would she be if she had PE this semester]
YES (
)
LATER (
)
NEVER (
)
go to Question 3
skip to Question 4
Ineligible. STOP. ENTER FORM.
3. Is the girl sick today?
YES (
)
NO (
)
go to Question 4
skip to Question 5
4. Last day for fitness testing in the school? YES (
)
Skip girl [Two skips/school allowed]. STOP. ENTER FORM.
NO (
:
)
Available
Initial workload and pre-exercise heart rate
The subject should complete as many stages as needed (up to four) to reach a heart rate of at least 165
beats per minute (bpm). Each stage is two minutes in length. Weigh the subject to determine the initial
workload. Record her pre-exercise heart rate. Record her average heart rate during the last 10
seconds of each minute of every stage. Follow the protocol on the other side of this form to determine
the increase in workload at the end of each 2-minute stage. Record the total workload for each stage.
Signs and symptoms of fatigue that indicate test termination are addressed in Appendix D.
5. The initial workload is based on the girl’s weight.
1.
< 50 kg (or < 110 lbs) = 0.25 Kp
√
≥ 50 kg (or ≥ 110 lbs) = 0.50 Kp
Indicate her weight with a check (
) in the appropriate box.
2.
6. Tester Initials: ___ ___ ___
Heart Rate Conversion Chart (10-sec pulse):
11 beats = 66 bpm
16 beats = 96 bpm
12 beats = 72 bpm
17 beats = 102 bpm
13 beats = 78 bpm
18 beats = 108 bpm
14 beats = 84 bpm
19 beats = 114 bpm
15 beats = 90 bpm
20 beats = 120 bpm
7. Pre-exercise heart rate:
a. Monitor: _______ bpm
b. Radial pulse for 10 seconds x 6 (
): _______ bpm
see chart above
(over, please)
MFI / Version A / November 15, 2004
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