Indicators for School Health Programs: Coordinated School Health Programs (CSHP) and Reduction of Chronic Disease Risks Fiscal Year: March 1, 2005 - February 28, 2006 Division of Adolescent and School Health Cooperative Agreement 03004: Improving the Health, Education, and Well-Being of Young People Through Coordinated School Health Programs Instructions This set of indicators describes the performance of your Coordinated School Health Program (CSHP) project in ten areas: (1) activities of the State Education Agency and State Health Agency; (2) activities of the CSHP state-wide coalition; (3) physical activity, nutrition, and tobacco-use (PANT) policy; (4) PANT curricula and instruction; (5) PANT assessment of student performance; (6) PANT health promotion programs and environmental approaches; (7) external collaboration; (8) targeting youth populations; (9) project planning; and (10) other information and activities. A glossary of terms is included at the end of the indicators. Activities to be reported are those for which any amount of DASH funds were used, or in which staff time to develop, implement, or evaluate activities was funded in any amount by DASH. These questions address only priority health risk behaviors of Program Announcement 03004. Please answer each question carefully and accurately. Not all items or activities may reflect the emphasis of your CSHP Project for the current fiscal year, and therefore you may report that you have not performed activities in those areas by entering zeros. Additionally, you may not currently collect information about some activities. If so, please leave the answer blank. Please be sure to include materials for those items requesting attachments. Public reporting burden of this collection of information is estimated to average 9 hours per response, including the time reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS-E-11, Atlanta, Georgia 30333; ATTN: PRA (0920-0672). For further questions or assistance with completing this report please contact your CDC project officer. Person completing the Indicators: Name:____________________________________________________________________________ Title:_____________________________________________________________________________ State:_____________________________________ Phone:________________________________ Email:____________________________________________________________________________ I. JOINT ACTIVITIES OF THE STATE EDUCATION AGENCY (SEA) AND STATE HEALTH AGENCY (SHA) 1. During FY 2005, did the SEA and SHA have a current memorandum of understanding (MOU)? YES NO 2. During FY 2005, the SEA and SHA partnership plan includes specific activities to: (Choose one for each.) YES NO A. Seek additional funding ( ( B. Market or communicate about CSHP ( ( (i.e. create awareness or interest in new or on-going CSHP with the general public or partners) C. Develop or implement PANT programs ( ( D. Develop or change policy (e.g. statute, model ( ( policy, etc.) E. Share resources (e.g. databases, information, programs, etc.) ( ( F. Provide professional development ( ( G. Evaluate CSHP or PANT activities ( ( II. ACTIVITIES OF THE CSHP STATE-WIDE COALITION 3. Does your state currently have a CSHP state-wide coalition? (Choose one.) YES NO--> Skip to 6 4. Does your CSHP state-wide coalition have a written plan (e.g. strategic plan, state blueprint, etc.) to improve school health programs statewide? (Choose one.) YES NO 5. During FY 2005, in which of the following activities has the CSHP state-wide coalition been involved? (Choose one for each.) YES NO A. Implement a CSHP written plan ( ( B. Seek additional funding ( ( C. Market or communicate about CSHP programs ( ( (i.e. create awareness or interest in new or on-going CSHP programs with the general public or partners) D. Develop or implement PANT programs ( ( E. Develop, change, or advise on policy ( ( (e.g. statute, model policy, etc.) F. Share resources (e.g. databases, information, programs, etc.) ( ( G. Provide professional development ( ( H. Provide incentives (including financial) to develop or implement CSHP programs ( ( III. POLICY 6. During FY 2005, did your CSHP project participate in any of the following activities on policy for physical activity, nutrition, or tobacco-use prevention? A. DISTRIBUTE to districts or schools established or model policies, policy guidance, or other policy materials to inform policy direction. PHYSICAL ACTIVITY YES NO-we have such policies, but have not distributed them this fiscal year. --> Skip to 6B NO-we do not have such policies. --> Skip to 6B If YES to any category, provide the total: 1. Number of schools reached directly ______ 2. Number of districts reached directly ______ 3. Number of regional support units reached directly (if applicable) ______ 4. Number of hits on policy web pages (if applicable) ______ 5. Number of external partners reached directly ______ NUTRITION YES NO-we have such policies, but have not distributed them this fiscal year. --> Skip to 6B NO-we do not have such policies. --> Skip to 6B If YES to any category, provide the total: 1. Number of schools reached directly ______ 2. Number of districts reached directly ______ 3. Number of regional support units reached directly (if applicable) ______ 4. Number of hits on policy web pages (if applicable) ______ 5. Number of external partners reached directly ______ TOBACCO YES NO-we have such policies, but have not distributed them this fiscal year. --> Skip to 6B NO-we do not have such policies. --> Skip to 6B If YES to any category, provide the total: 1. Number of schools reached directly ______ 2. Number of districts reached directly ______ 3. Number of regional support units reached directly (if applicable) ______ 4. Number of hits on policy web pages (if applicable) ______ 5. Number of external partners reached directly ______ B. Provide PROFESSIONAL DEVELOPMENT to district or school staff that included information about established or model policies, policy standards, or other policy materials to inform policy direction. PHYSICAL ACTIVITY YES NO--> Skip to 6C If YES to any category, provide the total: 1. Number of professional development events including policy issues ______ 2. Number of participants in professional development events including policy issues ______ 3. Number of schools reached directly ______ 4. Number of districts reached directly ______ 5. Number of regional support units reached directly (if applicable) ______ 6. Number of external partners reached directly ______ NUTRITION YES NO--> Skip to 6C If YES to any category, provide the total: 1. Number of professional development events including policy issues ______ 2. Number of participants in professional development events including policy issues ______ 3. Number of schools reached directly ______ 4. Number of districts reached directly ______ 5. Number of regional support units reached directly (if applicable) ______ 6. Number of external partners reached directly ______ TOBACCO YES NO--> Skip to 6C If YES to any category, provide the total: 1. Number of professional development events including policy issues ______ 2. Number of participants in professional development events including policy issues ______ 3. Number of schools reached directly ______ 4. Number of districts reached directly ______ 5. Number of regional support units reached directly (if applicable) ______ 6. Number of external partners reached directly ______ C. Provide INDIVIDUALIZED TECHNICAL ASSISTANCE to district or school staff on established or model policies, policy standards, or other policy materials to inform policy direction. PHYSICAL ACTIVITY YES NO --> Skip to 6D If YES to any category, provide the total: 1. Number of schools reached directly ______ 2. Number of districts reached directly ______ 3. Number of regional support units reached directly (if applicable) ______ 4. Number of external partners reached directly ______ NUTRITION YES NO --> Skip to 6D If YES to any category, provide the total: 1. Number of schools reached directly ______ 2. Number of districts reached directly ______ 3. Number of regional support units reached directly (if applicable) ______ 4. Number of external partners reached directly ______ TOBACCO YES NO --> Skip to 6D If YES to any category, provide the total: 1. Number of schools reached directly ______ 2. Number of districts reached directly ______ 3. Number of regional support units reached directly (if applicable) ______ 4. Number of external partners reached directly ______ D. Assist districts or schools in policy development or policy implementation on the following topics. (Assistance to districts or schools may be through distributing materials on policy, professional development, or providing individualized technical assistance.) Choose YES or NO for each. Health Education 1. Requirements for K-12 health education classes YES NO 2. Certification requirements for teachers of health education classes YES NO 3. Nutrition education for students YES NO 4. Tobacco use prevention education for students YES NO 5. Other health education policies (specify):___________________________ YES NO Physical Activity and Physical Education Policies 1. Requirements for K-12 physical education YES NO 2. Certification requirements for teachers of physical education classes YES NO 3. Recess for elementary students YES NO 4. After-school intramurals and/or sports clubs YES NO 5. Other policies on physical activity or physical education (specify):_______________________ YES NO Healthy Eating Policies 1. Access to school meals for all students YES NO 2. Nutritional quality of all foods and beverages available on school campuses YES NO 3. Limiting student access to foods or beverages outside of the federally regulated school meals program YES NO 4. School fund-raising campaigns that consist of non-food items or healthful foods YES NO 5. Classroom guidelines that discourage the use of food as a reward or punishment YES NO 6. Other policies on healthy eating (specify):____________________ YES NO Tobacco Policies 1. Use of tobacco products by students, staff, parents, and visitors on school property YES NO 2. Tobacco advertising in school buildings, at school functions, or in school publications YES NO 3. Tobacco-use cessation programs for students and staff YES NO 4. Other policies on tobacco (specify):__________________________ Please continue on the next page --> YES NO IV. CURRICULA & INSTRUCTION 7. During FY 2005, did your CSHP project participate in any of the following activities on curriculum and instruction for physical education? A. DISTRIBUTE physical education curricular standards, frameworks, instructional strategies, or other guidance to schools or districts. YES NO-we have physical education curricular standards, frameworks, instructional strategies or other guidance, but have not distributed them this fiscal year. --> Skip to 7B NO-we do not have physical education curricular standards, frameworks, instructional strategies, or other guidance. --> Skip to 7B If YES, provide the total: 1. Number of schools reached directly __________ 2. Number of districts reached directly __________ 3. Number of regional support units reached directly (if applicable) ___________ 4. Number of external partners reached directly ____________ B. Provide PROFESSIONAL DEVELOPMENT on physical education curricular standards, frameworks, or instructional strategies to schools or districts. YES NO--> Skip to 7C If YES, provide the total: 1. Total number of professional development events including exemplary curricula, curricular standards, frameworks, instructional strategies, or other guidance _____ 2. Total number of participants in professional development events including exemplary curricula, curricular standards, frameworks, instructional strategies, or other guidance _____ 3. Number of schools reached directly ______ 4. Number of districts reached directly ______ 5. Number of regional support units reached directly (if applicable) _____ 6. Number of external partners reached directly ______ C. Provide INDIVIDUALIZED TECHNICAL ASSISTANCE on physical education curriculum or instruction (e.g. help in reviewing, revising, developing, or selecting instructional materials) to schools or districts. YES NO--> Skip to 8 If YES, provide the total: 1. Number of schools reached directly ____ 2. Number of districts reached directly ____ 3. Number of regional support units reached directly (if applicable) _____ 4. Number of external partners reached directly ______ 8. During FY 2005, did your CSHP project participate in any of the following activities on curriculum and instruction to address content areas of physical activity, nutrition, or tobacco use prevention in health education? A. DISTRIBUTE exemplary health education curricular standards, frameworks, instructional strategies, or other guidance to schools or districts. PHYSICAL ACTIVITY YES NO-we have curricular standards, frameworks, instructional strategies or guidance, but have not distributed them this fiscal year. --> Skip to 8B NO-we do not have such curricular standards, frameworks, instructional strategies or guidance --> Skip to 8B If YES for any category, provide the total: 1. Number of schools reached directly ______ 2. Number of districts reached directly ______ 3. Number of regional support units reached directly (if applicable) ______ 4. Number of external partners reached directly ______ NUTRITION YES NO-we have curricular standards, frameworks, instructional strategies or guidance, but have not distributed them this fiscal year. --> Skip to 8B NO-we do not have such curricular standards, frameworks, instructional strategies or guidance --> Skip to 8B If YES for any category, provide the total: 1. Number of schools reached directly ______ 2. Number of districts reached directly ______ 3. Number of regional support units reached directly (if applicable) ______ 4. Number of external partners reached directly ______ TOBACCO YES NO-we have curricular standards, frameworks, instructional strategies or guidance, but have not distributed them this fiscal year. --> Skip to 8B NO-we do not have such curricular standards, frameworks, instructional strategies or guidance --> Skip to 8B If YES for any category, provide the total: 1. Number of schools reached directly ______ 2. Number of districts reached directly ______ 3. Number of regional support units reached directly (if applicable) ______ 4. Number of external partners reached directly ______ B. Provide PROFESSIONAL DEVELOPMENT on exemplary health education curricular standards, frameworks, instructional strategies, or other guidance to schools or districts. PHYSICAL ACTIVITY YES NO--> Skip to 8C If YES in any category, provide the total: 1. Number of professional development events including exemplary curricular standards, frameworks, instructional strategies, or other guidance ______ 2. Number of participants in professional development events including exemplary curricular standards, frameworks, instructional strategies, or other guidance ______ 3. Number of schools reached directly ______ 4. Number of districts reached directly ______ 5. Number of regional support units reached directly (if applicable) ______ 6. Number of external partners reached directly ______ NUTRITION YES NO--> Skip to 8C If YES in any category, provide the total: 1. Number of professional development events including exemplary curricular standards, frameworks, instructional strategies, or other guidance ______ 2. Number of participants in professional development events including exemplary curricular standards, frameworks, instructional strategies, or other guidance ______ 3. Number of schools reached directly ______ 4. Number of districts reached directly ______ 5. Number of regional support units reached directly (if applicable) ______ 6. Number of external partners reached directly ______ TOBACCO YES NO--> Skip to 8C If YES in any category, provide the total: 1. Number of professional development events including exemplary curricular standards, frameworks, instructional strategies, or other guidance ______ 2. Number of participants in professional development events including exemplary curricular standards, frameworks, instructional strategies, or other guidance ______ 3. Number of schools reached directly ______ 4. Number of districts reached directly ______ 5. Number of regional support units reached directly (if applicable) ______ 6. Number of external partners reached directly ______ C. Provide INDIVIDUALIZED TECHNICAL ASSISTANCE on health education curriculum or instruction (e.g. help in reviewing, revising, developing, or selecting instructional materials) to schools or districts. PHYSICAL ACTIVITY YES NO--> Skip to 9 If YES in any category, provide the total: 1. Number of schools reached directly ______ 2. Number of districts reached directly ______ 3. Number of regional support units reached directly (if applicable) ______ 4. Number of external partners reached directly ______ NUTRITION YES NO--> Skip to 9 If YES in any category, provide the total: 1. Number of schools reached directly ______ 2. Number of districts reached directly ______ 3. Number of regional support units reached directly (if applicable) ______ 4. Number of external partners reached directly ______ TOBACCO YES NO--> Skip to 9 If YES in any category, provide the total: 1. Number of schools reached directly ______ 2. Number of districts reached directly ______ 3. Number of regional support units reached directly (if applicable) ______ 4. Number of external partners reached directly ______ V. ASSESSMENT OF STUDENT PERFORMANCE 9. During FY 2005, did your CSHP project participate in any of the following activities on the assessment of student performance for physical education? A. DISTRIBUTE physical education frameworks or guidelines about how to assess or measure students' knowledge and skills to schools or districts? (Do not include materials on how to conduct the Youth Risk Behavior Survey or the School Health Profiles or materials on height or weight measurements.) YES NO-we have physical education frameworks or guidelines about how to assess or measure students' knowledge and skills, but have not distributed them. --> Skip to 9B NO-we do not have physical education frameworks or guidelines about how to assess or measure students' knowledge and skills. --> Skip to 9B If YES, provide the total: 1. Number of schools reached directly ______ 2. Number of districts reached directly ______ 3. Number of regional support units reached directly (if applicable) ______ 4. Number of external partners reached directly ______ B. Provide PROFESSIONAL DEVELOPMENT for schools or districts on how to assess or measure students' knowledge and skills in physical education. YES NO--> Skip to 9C If YES, provide the total: 1. Number of professional development events including exemplary curricula, instructional strategies, content standards, or programmatic strategies ______ 2. Number of participants in professional development events including exemplary curricula, instructional strategies, content standards, or programmatic strategies ______ 3. Number of schools reached directly ______ 4. Number of districts reached directly ______ 5. Number of regional support units reached directly (if applicable) ______ 6. Number of external partners reached directly ______ C. Provide INDIVIDUALIZED TECHNICAL ASSISTANCE to schools or districts regarding frameworks or guidelines about how to assess or measure students' knowledge and skills in physical education. YES NO--> Skip to 10 If YES, provide the total: 1. Number of schools reached directly ______ 2. Number of districts reached directly ______ 3. Number of regional support units reached directly (if applicable) ______ 4. Number of external partners reached directly ______ 10. During FY 2005, did your CSHP project participate in any of the following activities on the assessment of student performance for physical activity, nutrition, or tobacco use prevention in health education? A. DISTRIBUTE health education frameworks or guidelines about how to assess or measure students' knowledge and skills to schools or districts for physical activity, nutrition, or tobacco use prevention? (Do not include materials on how to conduct the Youth Risk Behavior Survey or the School Health Profiles.) YES NO-we have health education frameworks, guidelines, or strategies about how to assess or measure students' knowledge and skills but have not distributed them this fiscal year. --> Skip to 10B NO-we do not have health education frameworks, guidelines, or strategies about how to assess or measure students' knowledge and skills. --> Skip to 10B If YES in any category, provide the total: 1. Number of schools reached directly ______ 2. Number of districts reached directly ______ 3. Number of regional support units reached directly (if applicable) ______ 4. Number of external partners reached directly ______ B. Provide PROFESSIONAL DEVELOPMENT to schools or districts about how to assess or measure students' knowledge and skills relevant to physical activity, nutrition, or tobacco use prevention in health education. YES NO--> Skip to 10C If YES in any category, provide the total: 1. Number of professional development events including exemplary curricula, instructional strategies, content standards, or programmatic strategies ______ 2. Number of participants in professional development events including exemplary curricula, instructional strategies, content standards, or programmatic strategies ______ 3. Number of schools reached directly ______ 4. Number of districts reached directly ______ 5. Number of regional support units reached directly (if applicable) ______ 6. Number of external partners reached directly ______ C. Provide INDIVIDUALIZED TECHNICAL ASSISTANCE to schools or districts regarding assessment or measurement of students' knowledge and skills for physical activity, nutrition, or tobacco use prevention in health education. YES NO--> Skip to 11 If YES in any category, provide the total: 1. Number of schools reached directly ______ 2. Number of districts reached directly ______ 3. Number of regional support units reached directly (if applicable) ______ 4. Number of external partners reached directly ______ VI. HEALTH PROMOTION PROGRAMS AND ENVIRONMENTAL APPROACHES 11. During FY 2005, did your CSHP project engage in any of the following activities to help schools promote physical activity? A. DISTRIBUTE model programs, guidance, implementation strategies, or other resource materials (not to include policy materials) to school district or school staff to promote physical activity through any of the following: A. Improving physical activity opportunities during school breaks or recess YES NO-we have model programs, guidance, implementation strategies, or other resource materials, but have not distributed them this fiscal year NO-we do not have model programs, guidance, implementation strategies, or other resource materials B. Planning and implementing walk-to-school initiatives YES NO-we have model programs, guidance, implementation strategies, or other resource materials, but have not distributed them this fiscal year NO-we do not have model programs, guidance, implementation strategies, or other resource materials C. Improving opportunities for physical activity in after-school programs YES NO-we have model programs, guidance, implementation strategies, or other resource materials, but have not distributed them this fiscal year NO-we do not have model programs, guidance, implementation strategies, or other resource materials D. Planning or implementing organized physical activity programs beyond physical education or competitive athletics (e.g. intramural sports and physical activity clubs) YES NO-we have model programs, guidance, implementation strategies, or other resource materials, but have not distributed them this fiscal year NO-we do not have model programs, guidance, implementation strategies, or other resource materials (If NO to all of the above, skip to 11B) If YES to any of the above, provide the total: 1. Number of schools reached directly ___________ 2. Number of districts reached directly ___________ 3. Number of regional support units reached directly (if applicable) ________ 4. Number of external partners reached directly ______ B. Provide PROFESSIONAL DEVELOPMENT on model programs, guidance, implementation strategies, or other resource materials (not to include policy materials) to school district or school staff to promote physical activity through any of the following: YES NO A. Improving physical activity opportunities during school breaks or recess ( ( B. Planning or implementing organized physical activity programs beyond physical education or competitive athletics (e.g. intramural sports and physical activity clubs) ( ( C. Improving opportunities for physical activity in after-school programs ( ( D. Planning and implementing walk-to-school initiatives ( ( (If NO to all of the above, skip to 11C) If YES to any of the above, provide the total: 1. Number of professional development events including model programs, guidance, implementation strategies, or other resource materials ______ 2. Number of participants in professional development events including model programs, guidance, implementation strategies, or other resource materials _____ 3. Number of schools reached directly ______ 4. Number of districts reached directly ______ 5. Number of regional support units reached directly (if applicable) _____ 6. Number of external partners reached directly ______ C. Provide INDIVIDUALIZED TECHNICAL ASSISTANCE to promote physical activity (i.e. developing model programs or selecting resource materials) to school district or school staff through any of the following: YES NO A. Improving physical activity opportunities during school breaks or recess ( ( B. Planning or implementing organized physical activity programs beyond physical education or competitive athletics (e.g. intramural sports and physical activity clubs) ( ( C. Improving opportunities for physical activity in after-school programs ( ( D. Planning and implementing walk-to-school initiatives ( ( (If NO to all of the above, skip to 12) If YES to any of the above, provide the total: 1. Number of schools reached directly ___________ 2. Number of districts reached directly ___________ 3. Number of regional support units reached directly (if applicable) ________ 4. Number of external partners reached directly ______ 12. During FY 2005,did your CSHP project engage in any of the following activities to help schools promote healthy eating? A. DISTRIBUTE model programs, guidance, implementation strategies, or other resource materials (not including policy materials) to school district or school staff to promote healthy eating through any of the following A. Improving nutritional quality of school meals YES NO-we have model programs, guidance, implementation strategies, or other resource materials, but have not distributed them this fiscal year NO-we do not have model programs, guidance, implementation strategies, or other resource material B. Marketing healthy school meals YES NO-we have model programs, guidance, implementation strategies, or other resource materials, but have not distributed them this fiscal year NO-we do not have model programs, guidance, implementation strategies, or other resource material C. Improving the nutritional quality of school food and beverages outside of school meals (e.g. vending machines and a la carte) YES NO-we have model programs, guidance, implementation strategies, or other resource materials, but have not distributed them this fiscal year NO-we do not have model programs, guidance, implementation strategies, or other resource material D. Marketing healthy school food and beverage choices outside of school meals (e.g. vending machines, classroom snacks, a la carte) YES NO-we have model programs, guidance, implementation strategies, or other resource materials, but have not distributed them this fiscal year NO-we do not have model programs, guidance, implementation strategies, or other resource material (If NO to all of the above, skip to 12B) If YES to any of the above, provide the total: 1. Number of schools reached directly ___________ 2. Number of districts reached directly ___________ 3. Number of regional support units reached directly (if applicable) ________ 4. Number of external partners reached directly ______ B. Provide PROFESSIONAL DEVELOPMENT on model programs, guidance, implementation strategies, or other resource materials (not to include policy materials) to school district or school staff to promote healthy eating through any of the following YES NO YES NO A. Improving nutritional quality of school meals ( ( B. Marketing healthy school meals ( ( C. Improving the nutritional quality of school food and beverages outside of school meals (e.g. vending machines and a la carte) ( ( D. Marketing healthy school food and beverage choices outside of school meals (e.g. vending machines, classroom snacks, a la carte) ( ( (If NO to all of the above, skip to 12C) If YES to any of the above, provide the total: 1. Number of professional development events including model programs, guidance, implementation strategies, or other resource materials ______ 2. Number of participants in professional development events including model programs, guidance, implementation strategies, or other resource materials _____ 3. Number of schools reached directly ______ 4. Number of districts reached directly ______ 5. Number of regional support units reached directly (if applicable) _____ 6. Number of external partners reached directly ______ C. Provide INDIVIDUALIZED TECHNICAL ASSISTANCE to promote healthy eating (e.g. developing model programs or selecting resource materials) to school district or school staff through any of the following YES NO YES NO A. Improving nutritional quality of school meals ( ( B. Marketing healthy school meals ( ( C. Improving the nutritional quality of school food and beverages outside of school meals (e.g. vending machines and al a carte) ( ( D. Marketing healthy school food and beverage choices outside of school meals (e.g. vending machines, classroom snacks, a la carte) ( ( (If NO to all of above, skip to 13) If YES to any of the above, provide the total: 1. Number of schools reached directly ___________ 2. Number of districts reached directly ___________ 3. Number of regional support units reached directly (if applicable) ________ 4. Number of external partners reached directly ______ 13. During FY 2005, did your CSHP project engage in the following activities to help schools promote a tobacco-free lifestyle? A. DISTRIBUTE model programs, guidance, implementation strategies, or other resource materials (not to include policy materials) to help school district or school staff plan and implement tobacco-use cessation programs for students. YES NO-we have model program, guidance, implementation strategies or other resource materials but we have not distributed them--> Skip to 13B NO-we do not have model programs, guidance, implementation strategies or other resource materials--> Skip to 13B If YES to any of the above, provide the total: 1. Number of schools reached directly ___________ 2. Number of districts reached directly ___________ 3. Number of regional support units reached directly (if applicable) ________ 4. Number of external partners reached directly ______ B. Provide PROFESSIONAL DEVELOPMENT on model programs, guidance, implementation strategies, or other resource materials (not to include policy materials) to help school district or school staff plan and implement tobacco-use cessation programs for students. YES NO--> Skip to 13C If YES to any of the above, provide the total: 1. Number of professional development events including model programs, guidance, implementation strategies, or other resource materials ______ 2. Number of participants in professional development events including model programs, guidance, implementation strategies, or other resource materials _____ 3. Number of schools reached directly ______ 4. Number of districts reached directly ______ 5. Number of regional support units reached directly (if applicable) _____ 6. Number of external partners reached directly ______ C. Provide INDIVIDUALIZED TECHNICAL ASSISTANCE (for example in developing model programs or selecting resource materials) to help school district or school staff plan and implement tobacco-use cessation programs for students. YES NO--> Skip to 14 If YES, provide the total: 1. Number of schools reached directly ___________ 2. Number of districts reached directly ___________ 3. Number of regional support units reached directly (if applicable) ________ 4. Number of external partners reached directly ______ VII. EXTERNAL COLLABORATION 14. During FY 2005, did your CSHP project jointly plan and implement program activities with definable roles and responsibilities with any of the following external partners? (Choose YES or NO for each.) PHYSICAL ACTIVITY A. Agencies serving primarily African American youth YES NO B. Agencies serving primarily Hispanic youth YES NO C. Agencies serving primarily American Indian/Alaskan Native youth YES NO D. Agencies serving primarily Asian/Pacific Islander youth YES NO E. Businesses YES NO F. Community-based organizations (CBOs) YES NO G. Faith-based organizations YES NO H. Foundations (private or non-profit) YES NO I. Governor's appointed council to improve the health of youth (this can include overall health of youth or individual health) YES NO J. Health care organizations (e.g. advocacy, service, professional, or membership associations) YES NO K. Local education agencies YES NO L. Local health agencies YES NO M. State health coalitions or networks YES NO N. Universities and other institutions of higher education YES NO O. National non-governmental organizations, including state and local affiliates YES NO P. Parents/parent groups YES NO Q. School-aged youth YES NO R. Others (Specify)__________________________ YES NO NUTRITION A. Agencies serving primarily African American youth YES NO B. Agencies serving primarily Hispanic youth YES NO C. Agencies serving primarily American Indian/Alaskan Native youth YES NO D. Agencies serving primarily Asian/Pacific Islander youth YES NO E. Businesses YES NO F. Community-based organizations (CBOs) YES NO G. Faith-based organizations YES NO H. Foundations (private or non-profit) YES NO I. Governor's appointed council to improve the health of youth (this can include overall health of youth or individual health) YES NO J. Health care organizations (e.g. advocacy, service, professional, or membership associations) YES NO K. Local education agencies YES NO L. Local health agencies YES NO M. State health coalitions or networks YES NO N. Universities and other institutions of higher education YES NO O. National non-governmental organizations, including state and local affiliates YES NO P. Parents/parent groups YES NO Q. School-aged youth YES NO R. Others (Specify)__________________________ YES NO TOBACCO A. Agencies serving primarily African American youth YES NO B. Agencies serving primarily Hispanic youth YES NO C. Agencies serving primarily American Indian/Alaskan Native youth YES NO D. Agencies serving primarily Asian/Pacific Islander youth YES NO E. Businesses YES NO F. Community-based organizations (CBOs) YES NO G. Faith-based organizations YES NO H. Foundations (private or non-profit) YES NO I. Governor's appointed council to improve the health of youth (this can include overall health of youth or individual health) YES NO J. Health care organizations (e.g. advocacy, service, professional, or membership associations) YES NO K. Local education agencies YES NO L. Local health agencies YES NO M. State health coalitions or networks YES NO N. Universities and other institutions of higher education YES NO O. National non-governmental organizations, including state and local affiliates YES NO P. Parents/parent groups YES NO Q. School-aged youth YES NO R. Others (Specify)__________________________ YES NO VIII. TARGETING YOUTH DISPROPORTIONATELY AFFECTED BY CHRONIC DISEASE 15. In FY 2005, did your CSHP project implement PANT programmatic activities (e.g. distributing materials, providing professional development or technical assistance) specifically focused on any of the following youth disproportionately affected by chronic disease? (Choose YES or NO for each.) DISTRIBUTING MATERIALS A. African American youth YES NO B. Hispanic youth YES NO C. American Indian/Alaskan Native youth YES NO D. Asian/Pacific Islander youth YES NO E. Other youth disproportionately affected by chronic disease (Specify)________________ YES NO PROFESSIONAL DEVELOPMENT A. African American youth YES NO B. Hispanic youth YES NO C. American Indian/Alaskan Native youth YES NO D. Asian/Pacific Islander youth YES NO E. Other youth disproportionately affected by chronic disease (Specify)________________ YES NO INDIVIDUALIZED TECHNICAL ASSISTANCE A. African American youth YES NO B. Hispanic youth YES NO C. American Indian/Alaskan Native youth YES NO D. Asian/Pacific Islander youth YES NO E. Other youth disproportionately affected by chronic disease (Specify)________________ YES NO IX. PROJECT PLANNING 16. During FY 2005, did your CSHP project participate in any of the following activities to help districts or schools to assess, plan, or coordinate school health programs? A. DISTRIBUTE the School Health Index or similar tool to district or school staff to help assess and plan school health programs. (Choose one.) YES NO--> Skip to 16B If YES, what tool(s) were distributed? (Choose all that apply.) The School Health Index A modified version of the School Health Index Other (specify)__________________ B. Provide PROFESSIONAL DEVELOPMENT on the School Health Index or similar tool to district or school staff to help assess and plan school health programs. (Choose one.) YES NO--> Skip to 16C If YES, provide the total: 1. Number of professional development events ______ 2. Number of participants in professional development events _____ 3. Number of schools reached directly ___________ 4. Number of districts reached directly _____________ 5. Number of regional support units reached directly (if applicable) _______ 6. Number of external partners reached directly ______ C. Provide INDIVIDUALIZED TECHNICAL ASSISTANCE on the School Health Index or similar tool to district or school staff to help assess and plan school health programs. (Choose one.) YES NO--> Skip to 16D If YES, provide the total: 1. Number of schools reached directly __________ 2. Number of districts reached directly__________ 3. Number of regional support units reached directly (if applicable) ________ 4. Number of external partners reached directly ______ D. Provide assistance (e.g., financial assistance, guidance, resources, technical assistance) to help districts or schools establish, maintain, or improve a school health council or a similar group responsible for developing school policies and programs or coordinating school health activities. (Choose one.) YES NO--> Skip to 16E If YES, provide the total: 1. Number of schools reached directly _______ 2. Number of districts reached directly _______ 3. Number of regional support units reached directly (if applicable) ________ 4. Number of external partners reached directly ______ E. Provide assistance (e.g. financial assistance, guidance, resources, technical assistance) to help districts or schools establish or maintain a school health leadership position (e.g. School Health Coordinator) to lead and coordinate school health activities. (Choose one.) YES NO--> Skip to 17 If YES, provide the total: 1. Number of schools reached directly _______ 2. Number of districts reached directly _______ 3. Number of regional support units reached directly (if applicable) ________ 4. Number of external partners reached directly ______ 17. During FY 2005, did your CSHP project have any sources other than DASH funding that supported state-wide activities consistent with those planned by the CSHP state-wide coalition? (May include federal, state, or private funding.) (Choose one.) YES NO--> Skip to 18 If YES: a. What is the total dollar amount of the funding you received other than DASH funding that supported state-wide activities consistent with those planned by the CSHP state-wide coalition? (Please include federal, state, and private funding): $__________ 18. Does your CSHP project have a written PROFESSIONAL DEVELOPMENT plan? (Choose one.) YES NO (If YES, please attach a copy of the plan) 19. How many school districts do you have in your state? ______ TOTAL 20. How many regional support units do you use to support CSHP project activities? ______ TOTAL (if applicable) X. OTHER INFORMATION & ACTIVITIES 21. Is there information that we asked for in this year's Indicators that you estimated or guessed at? YES NO--> Skip to 22 A. What kind of information did you estimate or guess at? (Mark all that apply.) _____ Distribution of print materials _____ Distribution of electronic materials _____ Professional development events _____ Individualized technical assistance _____ Funding dollar amounts B. On what topics did you estimate or guess at information? (Mark all that apply.) _____ Policies _____ Curricula and instruction _____ Assessment of student performance _____ Health promotion programs and environmental approaches _____ Project planning 22. Is there information that we asked for in this year's Indicators that you did not collect at all? YES NO--> Skip to 23 A. What kind of information did you not collect at all? (Mark all that apply.) _____ Distribution of print materials _____ Distribution of electronic materials _____ Professional development events _____ Individualized technical assistance _____ Funding dollar amounts B. On what topics did you not collect information at all? (Mark all that apply.) _____ Policies _____ Curricula and instruction _____ Assessment of student performance _____ Health promotion programs and environmental approaches _____ Project planning 23. During FY 2005, did your CSHP project conduct any additional, noteworthy, major activities to improve physical activity, nutrition, or tobacco-use prevention policies, curriculum, instruction, or assessment? Did these activities focus on improving the quality of PANT programs for African American, Hispanic, American Indian/Alaskan Native, or Asian/Pacific Islander youth, or other youth disproportionately affected by chronic disease? If so, please describe in an attached narrative. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 24. Please describe in an attached narrative, one specific improvement to your CSHP project during FY 2005 that occurred as a result of your evaluation activities. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 25. Please provide any additional general comments or information in the space below. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ THANK YOU FOR YOUR RESPONSES. PLEASE RETURN THE INDICATORS. GLOSSARY Please refer to the following definitions when answering the questions. COLLABORATION - Two or more partners jointly plan and implement program activities with definable roles and responsibilities for each partner. COORDINATED SCHOOL HEALTH PROGRAM (CSHP) - A planned and coordinated school-based program designed to enhance child and adolescent health, which consists of eight components: health education; physical education; health services; counseling, psychological, and social services; nutrition services; healthful school environment; family and community involvement; and health promotion for staff. CSHP STATE-WIDE COALITION - A confederation of organizations with similar goals that agree to work together toward a common goal. People who serve on coalitions, whether professional or volunteer, have obligations to the organization they represent as well as to the coalition. CURRICULUM - An educational plan incorporating a structured, developmentally appropriate series of intended learning outcomes and associated learning experiences for students; generally organized as a related combination or series of school-based materials, content, and events. DEVELOPMENT - The process of bringing into being, making active, available, or effective, CSHP-related materials, plans, policies, or activities. DISTRIBUTE - Putting exemplary materials in the hands of appropriate personnel. Distribution may occur in response to requests for materials or through proactive sharing of information. ENVIRONMENTAL APPROACHES - Those policies and programs that are intended to affect physical surroundings and the psychosocial climate and culture of the school. Environmental approaches include policies, programs, and services that reinforce school health education and physical education curricula as well as contribute to health outcomes for students and staff. EVALUATION PLAN - A written evaluation plan may include process evaluation, to determine if activities were as planned and how well they were conducted, as well as outcome evaluation, to determine the impact of an activity or program on program objectives. EXEMPLARY - An evaluated curriculum or program with evidence of effectiveness, or a curriculum or program that has used research-based or science-based strategies. An exemplary curriculum or program is: (1) developmentally and culturally appropriate; (2) medically and scientifically accurate; (3) consistent with scientifically researched evidence of effectiveness; and (4) built on a theoretic approach based on proven principles for prevention. EXTERNAL PARTNERS - Agencies, organizations, and groups outside your own agency with which you collaborate or associate to further the goals of your CSHP project. FISCAL YEAR (FY) - March 1, 2004 to February 28, 2005, the budget period for the cooperative agreement. FRAMEWORK - An outline or plan that presents both the content (e.g. important concepts, skills, and generalizations) and the process for developing curricula, instruction, and assessment. GUIDANCE - A set of strategies that apply frameworks to develop policies, curricula, instruction, and assessment. HEALTH EDUCATION - Includes the planned materials, instructions, and educational experiences delivered in the classroom setting and that provide students with opportunities to acquire the knowledge and skills necessary for making health promoting decisions and achieving health literacy. HEALTHY EATING - Eating behaviors that promote health, growth, and intellectual development; prevent immediate nutrition-related health problems; and reduce risks for long-term chronic diseases (e.g. coronary heart disease, cancer, and stroke). Healthy eating behaviors include a diet consistent with recommendations from the Dietary Guidelines for Americans (http://www.healthierus.gov/dietaryguidelines/). IMPLEMENTATION - To put into effect or to accomplish plans, policies, or activities related to CSHP projects. INDIVIDUALIZED TECHNICAL ASSISTANCE - Tailored assistance to meet site-specific needs with collaborative communication between a specialist and the site. Assistance takes into account site-specific circumstances and culture, and can be provided through phone, mail, e-mail, Internet, or in-person meetings. MATERIALS - Resources including written materials (e.g. curricula, training materials, pamphlets); audio visual materials (e.g. motion pictures and video tapes); pictorials (e.g. posters and similar educational materials using photographs, slides, drawings, or paintings); and electronic resources (e.g. Web sites, PDF files, PowerPoint files). MEMORANDUM OF UNDERSTANDING (MOU) - An agreement between agencies specifying the process or procedures for collaborative development of CSHP infrastructure. May also be called a Memorandum of Agreement. NUMBER OF DISTRICTS REACHED DIRECTLY - A district is reached directly when one or more district level staff receive materials, training, or assistance from personnel funded by your CSHP project. NUMBER OF REGIONAL SUPPORT UNITS REACHED DIRECTLY - A regional support unit is reached directly when one or more regional support unit staff receive materials, training, or assistance from personnel funded by your CSHP project. NUMBER OF SCHOOLS REACHED DIRECTLY - A school is reached directly when one or more school staff receive materials, training, or assistance from personnel funded by your CSHP project. NUTRITION - Relates to the foods and beverages people consume. PARTNERSHIP PLAN - Jointly prepared plans between the state education agency and the state health agency for coordinating administrative responsibilities, establishing reciprocal roles, and complementing school and youth-related health programs across the two agencies. PHYSICAL ACTIVITY - Any bodily movement produced by skeletal muscles which results in caloric expenditure. PHYSICAL ACTIVITY, NUTRITION, AND TOBACCO-USE PREVENTION (PANT) PROJECT - Any activities or personnel that are funded in part or in whole, through DASH cooperative agreement 03004 funds for chronic disease prevention through CSHP with a focus on PANT. May include the work of contract staff. PHYSICAL EDUCATION - A planned and structured program of instruction and learning experiences that enables students to develop the knowledge, attitudes, skills, behaviors and confidence needed to be physically active for life. POLICY - Any mandate issued or policies adopted by school district boards of education, the state school board, state legislature, or other district or state agencies that affects the environment in schools throughout the state. These include policies developed by your state, or those based on model policies developed elsewhere. Sample model policies for PANT are available in Fit, Healthy and Ready to Learn: A School Health Policy Guide (March 2000), developed by the National Association of State Boards of Education (NASBE). Sample policies can be viewed at NASBE's website: http://www.nasbe.org/healthyschools/fithealthy.mgi. PROFESSIONAL DEVELOPMENT - Those processes and activities designed to enhance the professional knowledge, skills and attitudes of educators and others who work with youth, so that they might, in turn, improve the learning and health outcomes of children and adolescents. Professional development is consciously designed to actively engage learners and includes the planning, design, implementation, evaluation and follow-up of professional development events (e.g. training, workshops, conferences, web-based learning, coaching/mentoring). PROFESSIONAL DEVELOPMENT EVENT- A set of skill-building processes and activities designed to assist targeted groups of participants in mastering specific learning objectives. Such events are delivered in an adequate time span (at least 3 hours) and may include, but are not limited to, curriculum and other training, workshops, conferences, and on-line or distance learning courses. PROGRAM - A multi-faceted approach to decrease health risk behaviors that may include a combination of strategies such as one-on-one interventions, policy and climate changes, advocacy, peer interventions, mentoring programs, youth asset development, and outreach. REGIONAL SUPPORT UNITS - A state-recognized agency or organization (e.g. universities, regional education support agencies, regional offices of education, regional training centers, teacher centers, county superintendent's offices, etc.) that provides professional development, technical assistance and educational materials to school districts and schools within the state. SCHOOL - A division of the public school system consisting of students in one or more grades or other identifiable groups organized to give instruction of a defined type. One school may share a building with another school or one school may be housed in several buildings. Each school usually has an identification number assigned by the state department of education for tracking purposes. Synonyms for public schools include charter schools, magnet schools, vocational schools and alternative schools. SCHOOL DISTRICT - An education agency at the local level that exists primarily to operate public schools or to contract for public school services. Synonyms are local basic administrative unit, local education agency, SAU, parish, independent school districts, etc. SCHOOL HEALTH COORDINATOR - The professional at the district or school level who is responsible for the management and the coordination of all school health policies, activities, and resources. SCHOOL HEALTH COUNCIL - An advisory group of individuals who represent segments of the community. The group acts collectively to provide advice to the school system on aspects of the school health program. SCHOOL HEALTH INDEX - The School Health Index is a self-assessment and planning tool that enables those who use it to identify the strengths and weaknesses of school health promotion policies and programs; develop an action plan for improving student health; and involve teachers, parents, students, and the community in improving school policies and programs. SERVING PRIMARILY - Agencies whose main focus is on providing services tailored to a specific, identifiable population (e.g. by race, sexual orientation, etc.), or increasing the ability of others to provide services to that population. SPECIFICALLY FOCUSED ON - Programs or activities that are tailored to a particular, identifiable population (e.g. by race, gender, etc.), or activities to increase the ability of others to provide such services or activities. STANDARDS - An established set of indicators that describe the knowledge and skills essential to the development of student health literacy and provide the foundation for curriculum development, instruction, and assessment of student performance. Many states use the National Health Education Standards as the foundation for their own health education standards. An abbreviated version of the National Health Education Standards developed by the Joint Committee on National Health Education Standards can be found at http://www.aahperd.org/aahe/pdf_files/standards.pdf. STATE EDUCATION AGENCY (SEA) - The department of state or territorial government responsible for public education policy, funding, monitoring and training within that state or territory. STATE HEALTH AGENCY (SHA) - The department of state or territorial government responsible for public health policy, funding, monitoring and training within that state or territory. TOBACCO-USE PREVENTION - Interventions that prevent or delay the initiation of tobacco use or reduce the prevalence of tobacco use, including tobacco-use cessation. Interventions may target individuals or groups of youth, in terms of policy and/or environmental changes, and may occur in schools or in partnership with community organizations. YOUTH DISPORPORTIONATLEY AFFECTED - In addition to certain ethnic groups that appear to be disproportionately affected with chronic disease, youth who are at risk for chronic disease later in life include those who are obese (overweight), who use tobacco, and/or have high blood pressure.