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2010 SCHOOL HEALTH PROFILES

ELEMENTARY SCHOOL PRINCIPAL QUESTIONNAIRE

District Name

School Name

Signoff

This questionnaire will be used to assess school health programs and policies across your state or school district. Your cooperation is essential for making the results of this survey comprehensive, accurate, and timely. Your answers will be kept confidential.

INSTRUCTIONS

1. This questionnaire should be completed by the principal (or the person acting in that capacity) and concerns only activities that occur in the school listed above for the grade span listed below. Please consult with other people if you are not sure of an answer.

2. Follow the instructions for each question.

3. Enter any additional comments you wish to make at the end of the questionnaire.

4. Since this questionnaire is lengthy you may wish to complete part and finish the rest later. In this case, click on the Save but not Submit Button at the bottom of the screen. It will save what you have entered. When you wish to resume, access the Elementary Survey, and what has been entered will be displayed. You may resume the questionnaire, and when finished click on the Submit Button.

5. If you complete the questionnaire in one session, click on the Submit Button at the very bottom of the screen.

Person completing this questionnaire

Name:
Title:
Telephone:

1. Has your school ever used the School Health Index or other self-assessment tool to assess your school's policies, activities, and programs in the following areas? (Mark yes or no for each area.)

Area Answer
a. Physical activity Yes No
b. Nutrition Yes No
c. Tobacco-use prevention Yes No
d. Asthma Yes No
e. Injury and violence prevention Yes No

2. The Elementary and Secondary Education Act requires certain schools to have a written School Improvement Plan (SIP). Many states and school districts also require schools to have a written SIP. Does your school's written SIP include health-related goals and objectives on any of the following topics? (Mark yes or no for each topic, or if your school does not have a SIP, mark "No SIP".)

Topic Answer
a. Health education Yes No No SIP
b. Physical education and physical activity Yes No No SIP
c. Nutrition services and foods and beverages available at school Yes No No SIP
d. Health services Yes No No SIP
e. Mental health and social services Yes No No SIP
f. Healthy and safe school environment Yes No No SIP
g. Family and community involvement Yes No No SIP
h. Faculty and staff health promotion Yes No No SIP

3. The Child Nutrition and WIC Reauthorization Act of 2004 requires school districts participating in federally subsidized child nutrition programs (e.g National School Lunch Program or School Breakfast Program) to establish a local school wellness policy. Is your school required to report to your district each of the following types of information regarding implementation of the local wellness policy? (Mark yes or no for each.)

Types of Information Answer
a. Number of minutes of physical education required in each grade Yes No
b. Rates of student participation in school meal programs Yes No
c. Revenue from sale of foods and beverages from school-sponsored fundraisers, vending machines, school stores, or a la carte lines in the school cafeteria Yes No
d. Number of minutes of physical activity outside of physical education (e.g., classroom physical activity breaks, free time physical activity, or recess) Yes No

4. Currently, does someone at your school oversee or coordinate school health and safety programs and activities? (Mark one response.)
Yes
No

5. Is there one or more than one group (e.g., a school health council, committee, or team) at your school that offers guidance on the development of policies or coordinates activities on health topics? (Mark one response.)
Yes
No (Skip to Question 7)

6. Are each of the following groups represented on any school health council, committee, or team? (Mark yes or no for each group.)

Group Answer
a. School administrators Yes No
b. Health education teachers Yes No
c. Physical education teachers Yes No
d. Mental health or social services staff Yes No
e. Nutrition or food service staff Yes No
f. Health services staff (e.g., school nurses) Yes No
g. Maintenance and transportation staff Yes No
h. Technology staff Yes No
i. Library/media center staff Yes No
j. Student body Yes No
k. Parents or families of students Yes No
l. Community members Yes No
m. Local health departments, agencies, or organizations Yes No
n. Faith-based organizations Yes No
o. Businesses Yes No
p. Local government agencies Yes No

7. Has your school adopted a policy that addresses each of the following issues on human immunodeficiency virus (HIV) infection or AIDS? (Mark yes or no for each issue.)

Issue Answer
a. Attendance of students with HIV infection Yes No
b. Procedures to protect HIV-infected students and staff from discrimination Yes No
c. Maintaining confidentiality of HIV-infected students and staff Yes No
d. Worksite safety (i.e., universal precautions for all school staff) Yes No
e. Confidential counseling for HIV-infected students Yes No
f. Communication of the policy to students, school staff, and parents Yes No
g. Adequate training about HIV infection for school staff Yes No
h. Procedures for implementing the policy Yes No

8. Does your school have or participate in each of the following programs? (Mark yes or no for each program.)

Program Answer
a. A student mentoring program Yes No
b. A safe-passages to school program Yes No
c. A program to prevent bullying Yes No
e. A youth development program Yes No

REQUIRED PHYSICAL EDUCATION

(Definition: Required physical education is defined as instruction that helps students develop the knowledge, attitudes, skills, and confidence needed to adopt and maintain a physically active lifestyle that students must receive for graduation or promotion from your school.)

9. Is physical education required for students in any of grades K through 5 in your school? (Mark one response.)
Yes
No (Skip to Question 12)

10. Is a required physical education course taught in each of the following grades in your school? (For each grade, mark yes or no, or if your school does not have that grade, mark "grade not taught in your school.")

Grade Answer
a. K Yes No Grade not taught in your school
b. 1 Yes No Grade not taught in your school
c. 2 Yes No Grade not taught in your school
d. 3 Yes No Grade not taught in your school
e. 4 Yes No Grade not taught in your school
f. 5 Yes No Grade not taught in your school
g. 6 Yes No Grade not taught in your school

11. Can students be exempted from taking required physical education for one grading period or longer for each of the following reasons? (Mark yes or no for each reason.)

Reason Answer
a. Participation in other school activities (e.g., band, or chorus) Yes No
b. Participation in community sports activities Yes No
c. Religious reasons Yes No
d. Long-term physical or medical disability Yes No
e. Cognitive disability Yes No
f. High physical fitness competency test score Yes No
g. Participation in community service activities Yes No

PHYSICAL EDUCATION AND PHYSICAL ACTIVITY

12. During the past two years, did any physical education teachers or specialists at your school receive professional development (e.g., workshops, conferences, continuing education, or any other kind of in-service) on physical education? (Mark one response.)
Yes
No

13. Are those who teach physical education at your school provided with the following materials? (Mark yes or no for each material.)

Material Answer
a. Goals, objectives, and expected outcomes for physical education Yes No
b. A chart describing the annual scope and sequence of instruction for physical education Yes No
c. Plans for how to assess student performance in physical education Yes No
d. A written physical education curriculum Yes No

14. Do students in each of the following grades participate in recess during every school day? (Do not include physical education.) (For each grade, mark yes or no, or if your school does not have that grade, mark "grade not taught in your school.")

Grade Answer
a. K Yes No Grade not taught in your school
b. 1 Yes No Grade not taught in your school
c. 2 Yes No Grade not taught in your school
d. 3 Yes No Grade not taught in your school
e. 4 Yes No Grade not taught in your school
f. 5 Yes No Grade not taught in your school
g. 6 Yes No Grade not taught in your school

15. Does your school offer opportunities for all students to participate in intramural activities or physical activity clubs? (Intramural activities or physical activity clubs are any physical activity programs that are voluntary for students, in which students are given an equal opportunity to participate regardless of physical ability.) (Mark one response.)
Yes
No

16. Outside of school hours or when school is not in session, do children or adolescents use any of your school's indoor physical activity or athletic facilities for community-sponsored physical activity classes or lessons? (Mark one response.)
Yes
No

TOBACCO-USE PREVENTION POLICIES

17. Has your school adopted a policy prohibiting tobacco use? (Mark one response.)
Yes
No (Skip to Question 24)

18. Does the tobacco-use prevention policy specifically prohibit use of each type of tobacco for each of the following groups during any school-related activity? (Mark yes or no for each type of tobacco for each group.)

Type of tobacco Students Faculty/Staff Visitors
a. Cigarettes Yes No Yes No Yes No
b. Smokeless tobacco (i.e., chewing tobacco, snuff, or dip) Yes No Yes No Yes No
c. Cigars Yes No Yes No Yes No
d. Pipes Yes No Yes No Yes No

19. Does the tobacco-use prevention policy specifically prohibit tobacco use during each of the following times for each of the following groups? (Mark yes or no for each time for each group.)

Time Students Faculty/Staff Visitors
a. During school hours Yes No Yes No Yes No
b. During non-school hours Yes No Yes No Yes No

20. Does the tobacco-use prevention policy specifically prohibit tobacco use in each of the following locations for each of the following groups? (Mark yes or no for each location for each group.)

Location Students Faculty/Staff Visitors
a. In school buildings Yes No Yes No Yes No
b. Outside on school grounds, including parking lots and playing fields Yes No Yes No Yes No
c. On school buses or other vehicles used to transport students Yes No Yes No Yes No
d. At off-campus, school-sponsored events Yes No Yes No Yes No

21. Does your school have procedures to inform each of the following groups about the tobacco-use prevention policy that prohibits their use of tobacco? (Mark yes, no, or not applicable for each group.)

Group Answer
a. Students Yes No Not Applicable
b. Faculty and staff Yes No Not Applicable
c. Visitors Yes No Not Applicable

22. Does your school's tobacco-use prevention policy include guidelines on what actions the school should take when students are caught smoking cigarettes? (Mark one response.)
Yes
No

23. At your school, who is responsible for enforcing your tobacco-use prevention policy? (Mark one response.)
No single individual is responsible
Principal
Assistant principal
Other school administrator
Other school faculty or staff member

24. Do each of the following criteria help determine what actions your school takes when students are caught smoking cigarettes? (Mark yes or no for each criteria.)

Criterion Answer
a. Zero tolerance Yes No
b. Effect or severity of the violation Yes No
c. Grade level of student Yes No
d. Repeat offender status Yes No

25. When students are caught smoking cigarettes, how often are each of the following actions taken? (Mark one response for each action.)

Action Answer
a. Parents or guardians are notified Never Rarely Sometimes Always or
almost always
b. Referred to a school counselor Never Rarely Sometimes Always or
almost always
c. Referred to a school administrator Never Rarely Sometimes Always or
almost always
d. Encouraged, but not required, to participate in an assistance, education, or cessation program Never Rarely Sometimes Always or
almost always
e. Required to participate in an assistance, education, or cessation program Never Rarely Sometimes Always or
almost always
f. Referred to legal authorities Never Rarely Sometimes Always or
almost always
g. Placed in detention Never Rarely Sometimes Always or
almost always
h. Not allowed to participate in extra-curricular activities or interscholastic sports Never Rarely Sometimes Always or
almost always
i. Given in-school suspension Never Rarely Sometimes Always or
almost always
j. Suspended from school Never Rarely Sometimes Always or
almost always
k. Expelled from school Never Rarely Sometimes Always or
almost always
l. Reassigned to an alternative school Never Rarely Sometimes Always or
almost always

26. Does your school post signs marking a tobacco-free school zone, that is, a specified distance from school grounds where tobacco use is not allowed? (Mark one response.)
Yes
No

27. During the past two years, has your school done each of the following activities? (Mark yes or no for each activity.)

Activity Answer
a. Gathered and shared information with students and families about mass-media messages or community-based tobacco-use prevention efforts Yes No
b. Worked with local agencies or organizations to plan and implement events or programs intended to reduce tobacco use Yes No

28. Does your school provide tobacco cessation services for faculty and staff? (Mark one response.)
Yes
No

29. Does your school have arrangements with any organization or health care professionals not on school property to provide tobacco cessation services for faculty and staff? (Mark one response.)
Yes
No

NUTRITION-RELATED POLICIES AND PRACTICES

30. When foods or beverages are offered at school celebrations, how often are fruits or non-fried vegetables offered? (Mark one response.)
Foods or beverages are not offered at school celebrations
Never
Rarely
Sometimes
Always or almost always

31. Can students purchase snack foods or beverages from one or more vending machines at the school or at a school store, canteen, or snack bar? (Mark one response.)
Yes
No (Skip to Question 34)

32. Can students purchase each of the following snack foods or beverages from vending machines or at the school store, canteen, or snack bar? (Mark yes or no for each food or beverage.)

Food or beverage Answer
a. Chocolate candy Yes No
b. Other kinds of candy Yes No
c. Salty snacks that are not low in fat (e.g., regular potato chips) Yes No
d. Cookies, crackers, cakes, pastries, or other baked goods that are not low in fat Yes No
e. Ice cream or frozen yogurt that is not low in fat Yes No
f. 2% or whole milk (plain or flavored) Yes No
g. Water ices or frozen slushes that do not contain juice Yes No
h. Soda pops or fruit drinks that are not 100% juice Yes No
i. Sports drinks (e.g., Gatorade) Yes No
j. Foods or beverages containing caffeine Yes No
k. Fruits (not fruit juice) Yes No
l. Non-fried vegetables (not vegetable juice) Yes No

33. Does your school limit the package or serving size of any individual food and beverage items sold in vending machines or at the school store, canteen, or snack bar? (Mark one response.)
Yes
No

34. During this school year, has your school done any of the following? (Mark yes or no for each.)

Answer
a. Priced nutritious foods and beverages at a lower cost while increasing the price of less nutritious foods and beverages Yes No
b. Collected suggestions from students, families, and school staff on nutritious food preferences and strategies to promote healthy eating Yes No
c. Provided information to students or families on the nutrition and caloric content of foods available Yes No
d. Conducted taste tests to determine food preferences for nutritious items Yes No
e. Provided opportunities for students to visit the cafeteria to learn about food safety, food preparation, or other nutrition-related topics Yes No

35. At your school, are candy, meals from fast food restaurants, or soft drinks promoted through the distribution of products, such as t-shirts, hats, and book covers to students? (Mark one response.)
Yes
No

36. Does your school prohibit advertisements for candy, fast food restaurants, or soft drinks in each of the following locations? (Mark yes or no for each location.)

Location Answer
a. In the school building Yes No
b. On school grounds including on the outside of the school building, on playing fields, or other areas of the campus Yes No
c. On school buses or other vehicles used to transport students Yes No
d. In school publications (e.g., newsletters, newspapers, web sites, or other school publications) Yes No

HEALTH SERVICES

37. Is there a full-time registered nurse who provides health services to students at your school? (A full-time nurse means that a nurse is at the school during all school hours, 5 days a week). (Mark one response.)
Yes
No

38. At your school, how many students with known asthma have an asthma action plan on file? (Students with known asthma are those who are identified by the school to have a current diagnosis of asthma as reported on student emergency cards, medication records, health room visit information, emergency care plans, physical exam forms, parent notes, and other forms of health care clinician notification.) (Mark one response.)
This school has no students with known asthma
All students with known asthma have an asthma action plan on file
Most students with known asthma have an asthma action plan on file
Some students with known asthma have an asthma action plan on file
No students with known asthma have an asthma action plan on file

39. At your school, which of the following events is used to identify students with poorly controlled asthma? (Mark all that apply.)
This school does not identify students with poorly controlled asthma
Frequent absences from school
Frequent visits to the school health office due to asthma
Frequent asthma symptoms at school
Frequent non-participation in physical education class due to asthma
Students sent home early due to asthma
Call from school to 911, or other local emergency numbers, due to asthma

40. Does your school provide each of the following services for students with poorly controlled asthma? (Mark yes or no for each service.)

Service Answer
a. Providing referrals to primary healthcare clinicians or child health insurance programs Yes No
b. Ensuring an appropriate written asthma action plan is obtained Yes No
c. Ensuring access to and appropriate use of asthma medications, spacers, and peak flow meters at school Yes No
d. Offering asthma education for students with asthma Yes No
e. Minimizing asthma triggers in the school environment Yes No
f. Addressing social and emotional issues related to asthma Yes No
g. Providing additional psychosocial counseling or support services as needed Yes No
h. Ensuring access to safe, enjoyable physical education and activity opportunities Yes No
i. Ensuring access to preventive medications before physical activity Yes No

41. How often are school staff members required to receive training on recognizing and responding to severe asthma symptoms? (Mark one response.)
More than once per year
Once per year
Less than once per year
No such requirement

42. Has your school adopted a policy stating that students are permitted to carry and self-administer asthma medications? (Mark one response.)
Yes
No (Skip to Question 45)

43. Does your school have procedures to inform each of the following groups about your school's policy permitting students to carry and self-administer asthma medications? (Mark yes or no for each group.)

Groups Answer
a. Students Yes No
b. Parents and families Yes No

44. At your school, who is responsible for implementing your school's policy permitting students to carry and self-administer asthma medication? (Mark one response.)
No single individual is responsible
Principal
Assistant principal
School nurse
Other school faculty or staff member

FAMILY AND COMMUNITY INVOLVEMENT

45. During the past two years, have students' families helped develop or implement policies and programs related to each of the following topics? (Mark yes or no for each topic.)

Topic Answer
a. Tobacco-use prevention Yes No
b. Physical activity Yes No
c. Nutrition and healthy eating Yes No
d. Asthma Yes No

46. During the past two years, have community members helped develop or implement policies and programs related to each of the following topics? (Mark yes or no for each topic.)

Topic Answer
a. Tobacco-use prevention Yes No
b. Physical activity Yes No
c. Nutrition and healthy eating Yes No
d. Asthma Yes No