Form 7 Att 10 FitnessTest protocol

Attachment 10

Fitness Test Protocol and Form	OMB#: ####-#### EXP.DATE: ##/##/####
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN
Public reporting burden for this collection of information is estimated to average 15 minutes for this questionnaire, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review 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 current, 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN:PRA (####-####).

Modified Canadian Aerobic Fitness (mCAFT) Step Test

Age: ___ ___ ___ years Gender : M F (circle one) Weight: ___ ___ ___ . ___ kg

Height: ___ ___ ___ . ___ cm 85% predicted HR_max: ___ ___ ___ bpm

Starting point (65 – 70 % Mean Aerobic Power for individual 10 years +): ___ ___ ___ mL • kg^-1 • min^-1

Resting Measures		Test Measures			Post Test Measures
Heart Rate (bpm)	Blood Pressure (mm Hg)	Starting Stage #	Heart Rate (bpm)	RPE	Time (min)	Heart Rate (bpm)	Blood Pressure (mm Hg)
________	_______/_______	1st	________	_____	2	________	______/______
		2nd	________	_____	3.5	________	______/______
		3rd	________	_____	_____	________	______/______
		4th	________	_____	_____	________	______/______
		5th	________	_____	_____	________	______/______
		6th	________	_____	_____	________	______/______
		7th	________	_____	_____	________	______/______
		8th	________	____	_____	________	______/______

Test Status: Complete *Incomplete (circle one)

*If Test Status = Incomplete, select a reason code based on Table 1 below.

Table 1: Incomplete Test Reason Codes

Code	Reason	When to choose this code
1	Refusal	Respondent refuses to participate
2	Unable to maintain proper cadence	Respondent cannot perform the test at the proper cadence
3	Dizziness	Respondent feels dizzy
4	Extreme leg pain	Respondent cannot go on or start the test due to leg pain (lactic acid buildup, injury, arthritis …)
5	Nausea	Respondent feels nauseated or has extreme headache
6	Chest pain	Respondent feels chest pain
7	Facial pallor	Respondent appears ill
8	Other - Specify	Any other reason not listed above. The health technician will be prompted to explain this reason in the text box.

Reason Code for Incomplete Test: _____ N/A (Enter a code or circle “N/A”)

Aerobic Fitness Score: ___ ___ ___ mL • kg^-1 • min^-1

Equation to Determine Aerobic Fitness Score:

Aerobic Fitness Score (VO₂ max) = 10 x [17.2 + (1.29 x O₂ cost of the last completed stage*) – (0.09 x

Weight) – (0.18 x Age)]

= 10 x [17.2 + (1.29 x _____) – (0.09 x ____) – (0.18 x ____)]

= 10 x [17.2 + (_____) – (_____) – (_____)]

= 10 x [______]

= ______ mL • kg^-1 • min^-1

*Use Table 2 below to determine O₂ cost

Table 2: Determination of Oxygen Cost based on mCAFT Results

mCAFT	Females		Males
Stage Completed	Stepping Cadence	O2 Cost	Stepping Cadence	O2 Cost
1	66	15.9	66	15.9
2	84	18.0	84	18.0
3	102	22.0	102	22.0
4	114	24.5	114	24.5
5	120	26.3	132	29.5
6	132	29.5	144	33.6
7	144	33.6	118*	36.2
8	118*	36.2	132*	40.1

*Single step test. O₂ cost is measured in mL • kg^-1 • min^-1

Source: Canadian Society for Exercise Physiology

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