Form Cg-6049 "Personal Fitness Plan"

Form CG-6049 is a United States Coast Guard form also known as the "Personal Fitness Plan". The latest edition of the form was released in March 1, 2016 and is available for digital filing.

Download a PDF version of the Form CG-6049 down below or find it on United States Coast Guard Forms website.

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DEPARTMENT OF HOMELAND SECURITY
U.S. Coast Guard
PERSONAL FITNESS PLAN
All Coast Guard military personnel shall complete sections 1-5, (read instructions on back before starting) and submit to
their Supervisor in the months of April and October. Civilian personnel participating in exercise during the work day must also
complete sections 1-5 and submit this form to their Supervisor. The most current form shall be kept on file or electronically
saved by the individual and Supervisor.
Last Name, First Name, Middle Initial
Date
Unit
1.
My Fitness & Health Improvement goal is:
2.
Optional. Enter your Physical Readiness Test Scores below, compare results with tables in COMDTINST M6200.1 Appendix D and check your fitness
level.
Push-ups
Sit-ups or Curl-ups
1.5 mile run
Superior
Superior
Superior
In 1 minute
In 1 minute
________
________
Excellent
Excellent
Excellent
______
Good
______
Good
min
sec
Good
Fair
Fair
or 1 mile walk
Fair
Poor
Poor
________
Poor
Very Poor
Very Poor
V02 max
Very Poor
I plan to meet Commandant requirements of 180 minutes a week of moderate to vigorous physical activity by doing the following:
3.
3a. My AEROBIC ACTIVITY PLAN
Activities
Time (min.)
Intensity
3b. My STRENGTH TRAINING PLAN
Activities
Time (min.)
Frequency (# of days/wk)
Members Signature
Supervisors Signature
4.
5.
If Member was referred for physical fitness guidance, indicate below to whom or to what site the member was referred.
PRIVACY ACT STATEMENT
Authority:
5. U.S.C. 301, 3301; 44 U.S.C. 3101; 10 U.S.C. 1071-1107; 14 U.S.C. 93(a) (17); 14 U.S.C. 632; and 12107
To assess an individual’s fitness level as part of the Coast Guard Weight and Body Fat Standards and Health and Fitness Programs
Purpose:
Routine Uses: Information will be used by Coast Guard personnel to evaluate an individual’s fitness and develop a personal fitness plan. Any external
disclosures of data within this record will be made in accordance with DHS/USCG-011, Military Personnel Health Records System of
Records, 73 Federal Register 77773, December 19, 2008 and OPM/GOVT-10, Employee Medical File System of Records, 71 Federal
Register 35360, June 19, 2006.
Disclosure:
Furnishing this information is mandatory, failure to furnish this information may impede the health and fitness assessment process.
CG-6049 (03/16)
Page 1 of 2
Reset
DEPARTMENT OF HOMELAND SECURITY
U.S. Coast Guard
PERSONAL FITNESS PLAN
All Coast Guard military personnel shall complete sections 1-5, (read instructions on back before starting) and submit to
their Supervisor in the months of April and October. Civilian personnel participating in exercise during the work day must also
complete sections 1-5 and submit this form to their Supervisor. The most current form shall be kept on file or electronically
saved by the individual and Supervisor.
Last Name, First Name, Middle Initial
Date
Unit
1.
My Fitness & Health Improvement goal is:
2.
Optional. Enter your Physical Readiness Test Scores below, compare results with tables in COMDTINST M6200.1 Appendix D and check your fitness
level.
Push-ups
Sit-ups or Curl-ups
1.5 mile run
Superior
Superior
Superior
In 1 minute
In 1 minute
________
________
Excellent
Excellent
Excellent
______
Good
______
Good
min
sec
Good
Fair
Fair
or 1 mile walk
Fair
Poor
Poor
________
Poor
Very Poor
Very Poor
V02 max
Very Poor
I plan to meet Commandant requirements of 180 minutes a week of moderate to vigorous physical activity by doing the following:
3.
3a. My AEROBIC ACTIVITY PLAN
Activities
Time (min.)
Intensity
3b. My STRENGTH TRAINING PLAN
Activities
Time (min.)
Frequency (# of days/wk)
Members Signature
Supervisors Signature
4.
5.
If Member was referred for physical fitness guidance, indicate below to whom or to what site the member was referred.
PRIVACY ACT STATEMENT
Authority:
5. U.S.C. 301, 3301; 44 U.S.C. 3101; 10 U.S.C. 1071-1107; 14 U.S.C. 93(a) (17); 14 U.S.C. 632; and 12107
To assess an individual’s fitness level as part of the Coast Guard Weight and Body Fat Standards and Health and Fitness Programs
Purpose:
Routine Uses: Information will be used by Coast Guard personnel to evaluate an individual’s fitness and develop a personal fitness plan. Any external
disclosures of data within this record will be made in accordance with DHS/USCG-011, Military Personnel Health Records System of
Records, 73 Federal Register 77773, December 19, 2008 and OPM/GOVT-10, Employee Medical File System of Records, 71 Federal
Register 35360, June 19, 2006.
Disclosure:
Furnishing this information is mandatory, failure to furnish this information may impede the health and fitness assessment process.
CG-6049 (03/16)
Page 1 of 2
Reset
INSTRUCTIONS FOR COMPLETING PERSONAL FITNESS PLAN FORM
1. Self-explanatory.
2.
Program goals. Members should use this section to enter their goals related to fitness and health, such as fitness achievement,
weight/body fat loss, nutrition improvement, stress reduction, weight management, or health risk reduction.
3.
A well-balanced exercise program should include activities that address the health-related components of fitness (cardiorespiratory
endurance, muscular strength and endurance, flexibility, and body composition). Aerobic activities develop cardiorespiratory
endurance and burn calories to aid in achieving a healthy body composition. Muscle- strengthening activities develop muscular
strength and endurance and assist with the development of a healthy body composition. Activities such as stretching and yoga help
improve flexibility. Members should select activities that address the health-related components of fitness based on the Physical
Activity Guidelines for Adults as established by the U.S. Centers for Disease Control and Prevention (CDC).
4. Self-explanatory.
5.
Supervisor shall indicate to whom or what site the member was referred.
Physical Activity Guidelines for Adults (CDC, 2008)
Aerobic Activities
 2 hours and 30 minutes (150 minutes)/week of moderate intensity* aerobic activity OR 1 hour and 15 minutes (75 minutes)/week
of vigorous-intensity* aerobic activity OR an equivalent mix of both.
 Aerobic activity should be performed for at least 10 minutes at a time and spread throughout the week.
 For greater health benefits, 5 hours (300 minutes)/week at a moderate intensity level OR 2 hours and 30 minutes (150
minutes)/week at a vigorous intensity level OR an equivalent mix of both is recommended.
 Level of Intensity Defined: Intensity can be estimated using a scale of 0 to 10, where 0 is sitting and the highest possible level of
effort is 10.
 Moderate intensity – a person doing moderate-intensity aerobic activity can talk, but not sing, during the activity. This is activity
equivalent to a 5 or 6 on a 10-point scale. Examples: Brisk walking (3 mph or faster but not race walking), water aerobics, bicycle
riding slower than 10 mph, tennis (doubles), ballroom dancing, general gardening.
 Vigorous intensity – a person doing vigorous-intensity aerobic activity can’t say more than a few words without pausing for a
breath. This is activity equivalent to a 7 or 8 on a 10-point scale. Examples: Race walking, jogging, running, swimming laps,
tennis (singles), aerobic dancing, bicycling 10 mph or faster, jumping rope, heavy gardening (continuous digging or hoeing with
heart rate increases), hiking uphill or with a heavy backpack.
Muscle-Strengthening Activities:
 Muscle Strengthening: should be done 2 or more days per week. Muscle-strengthening activities do not count toward the aerobic
activity total. All major muscle groups should be worked. These are the legs, hips, back, abdomen, chest, shoulders, and arms.
Exercises for each muscle group should be repeated 8 to 12 times per set. As exercises become easier, increase the weight or
do another set. Examples: Lifting weights, working with resistance bands, and doing exercises that use body weight for
resistance (push-ups, sit-ups).
 Flexibility: Each time you perform aerobic or strength-training activities, take an extra 10 minutes to stretch the major muscles
groups; hold stretches for 10-30 seconds and repeat each stretch 3-4 times.
Appropriate Physical Activity Intervention Strategies for Weight Loss and Prevention of Weight
Regain for Adults (ACSM, 2009)
 The American College of Sports Medicine (ACSM) states that moderate-intensity physical activity between 150-250 minutes/week
is effective in preventing weight gain, but will provide only modest weight loss. Physical activity greater than 250 minutes/ week is
recommended for weight loss and the prevention of weight regain.
CG-6049 (03/16)
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