2012 SCHOOL HEALTH PROFILES

SCHOOL PRINCIPAL QUESTIONNAIRE

 

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 below for the grade span listed below.  Please consult with other people if you are not sure of an answer.

2.       Please use a #2 pencil to fill in the answer circles completely.  Do not fold, bend, or staple this questionnaire or mark outside the answer circles.

3.       Follow the instructions for each question.

4.       Write any additional comments you wish to make at the end of the questionnaire.

5.       Return the questionnaire in the envelope provided.

 

Person completing this questionnaire

 

Name: _____________________________________________________________________

Title: ______________________________________________________________________

School name: _______________________________________________________________

District: ____________________________________________________________________

Telephone number: ___________________________________________________________

 

To be completed by the SEA or LEA conducting the survey

 

School name: ________________________  Grade span: ____________________________

 

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2012 SCHOOL HEALTH PROFILES

PRINCIPAL QUESTIONNAIRE

 

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                                                          Yes    No

a.     Physical activity............................................. 0.... 0

b.     Nutrition..................................................... 0.... 0

c.     Tobacco-use prevention........................................ 0.... 0

d.     Asthma........................................................ 0.... 0

e.     Injury and violence prevention................................ 0.... 0

 

 

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 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                                    Yes      No          No SIP

a.     Health education.......................... 0...... 0............ 0

b.     Physical education and physical activity.. 0...... 0............ 0

c.     Nutrition services and foods and beverages

       available at school ...................... 0...... 0............ 0

d.     Health services........................... 0...... 0............ 0

e.     Mental health and social services......... 0...... 0............ 0

f.     Healthy and safe school environment....... 0...... 0............ 0

g.     Family and community involvement.......... 0...... 0............ 0

h.     Faculty and staff health promotion........ 0...... 0............ 0

 

 

3.     During the past year, did your school review health and safety data such as Youth Risk Behavior Survey data or fitness data as part of your school’s improvement planning process? (Mark one response.)

 

a. Yes

b. No

c. Our school did not engage in an improvement planning process during the past year.

 

 

4.     Currently, does someone at your school oversee or coordinate school health and safety programs and activities? (Mark one response.)

 

a. Yes

b. 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.)

 

a. Yes

b. No        Skip to Question 8

 

 

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

 

              Group                                                         Yes    No

a.     School administrators......................................... 0.... 0

b.     Health education teachers..................................... 0.... 0

c.     Physical education teachers................................... 0.... 0

d.     Other classroom teachers...................................... 0.... 0

e.     Mental health or social services staff (e.g.,

       school counselors)............................................ 0.... 0

f.     Nutrition or food service staff............................... 0.... 0

g.     Health services staff (e.g., school nurses)................... 0.... 0

h.     Maintenance and transportation staff.......................... 0.... 0

i.     Technology staff.............................................. 0.... 0

j.     Library/media center staff.................................... 0.... 0

k.     Student body.................................................. 0.... 0

l.     Parents or families of students............................... 0.... 0

m.     Community members............................................. 0.... 0

n.     Local health departments, agencies, or organizations.......... 0.... 0

o.     Faith-based organizations..................................... 0.... 0

p.     Businesses.................................................... 0.... 0

q.     Local government agencies..................................... 0.... 0

 

 

7.     During the past year, has any school health council, committee, or team at your school done any of the following activities? (Mark yes or no for each activity.)

 

       Activity                                                      Yes    No

a.     Identified student health needs based on a review

       of relevant data.............................................. 0.... 0

b.     Recommended new or revised health and safety policies

       and activities to school administrators or the school

       improvement team.............................................. 0.... 0

c.     Sought funding or leveraged resources to support health

       and safety priorities for students and staff.................. 0.... 0

d.     Communicated the importance of health and safety policies

       and activities to district administrators, school administrators,

       parent-teacher groups, or community members................... 0.... 0

e.     Reviewed health-related curricula or instructional

       materials..................................................... 0.... 0

 

 

HIV PREVENTION AND SEXUAL ORIENTATION

 

8.     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                                                         Yes    No

a.          Attendance of students with HIV infection..................... 0.... 0

b.          Procedures to protect HIV-infected students and staff from

       discrimination................................................ 0.... 0

c.     Maintaining confidentiality of HIV-infected students and staff 0.... 0

d.     Worksite safety (i.e., universal precautions for all

       school staff)................................................. 0.... 0

e.     Confidential counseling for HIV-infected students............. 0.... 0

f.     Communication of the policy to students, school

       staff, and parents............................................ 0.... 0

g.     Adequate training about HIV infection for school staff........ 0.... 0

h.     Procedures for implementing the policy........................ 0.... 0

 

 

9.     Are any school staff required to receive professional development (e.g., workshops,

       conferences, continuing education, or any other kind of in-service) on HIV, STD, or pregnancy prevention issues and resources for the following groups? (Mark yes or no for each group.)

 

              Group                                                         Yes    No

a.     Ethnic/racial minority youth at high risk (e.g., black, Hispanic,

       or American Indian youth)..................................... 0.... 0

b.     Youth who participate in drop-out prevention, alternative

       education, or GED programs.................................... 0.... 0

 

 

10.    Does your school have a student-led club that aims to create a safe, welcoming, and accepting school environment for all youth, regardless of sexual orientation or gender identity?  These clubs sometimes are called gay/straight alliances. (Mark one response.)

 

a. Yes

b. No

 

 

11.    Does your school engage in each of the following practices related to lesbian, gay, bisexual, transgender, or questioning (LGBTQ) youth? (Mark yes or no for each practice.)

 

              Practice                                                      Yes    No

       a.     Identify “safe spaces” (e.g., a counselor’s office, designated

              classroom, or student organization) where LGBTQ youth can

              receive support from administrators, teachers, or other

              school staff ................................................. 0.... 0

b.          Prohibit harassment based on a student’s perceived or actual

       sexual orientation or gender identity......................... 0.... 0

c.     Encourage staff to attend professional development on safe

       and supportive school environments for all students, regardless

       of sexual orientation or gender identity...................... 0.... 0 

d.     Facilitate access to providers not on school property who have

       experience in providing health services, including HIV/STD

       testing and counseling, to LGBTQ youth........................ 0.... 0

e.     Facilitate access to providers not on school property who have

       experience in providing social and psychological services to

       LGBTQ youth................................................... 0.... 0

 

 

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.)

 

12.    Is physical education required for students in any of grades 6 through 12 in your school? (Mark one response.)

 

a. Yes

b. No        Skip to Question 14

 

 

13.    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 not taught

              Grade                                    Yes      No      in your school

a.     6......................................... 0...... 0............ 0

b.     7......................................... 0...... 0............ 0

c.     8......................................... 0...... 0............ 0

d.     9......................................... 0...... 0............ 0

e.     10........................................ 0...... 0............ 0

f.     11........................................ 0...... 0............ 0

g.     12........................................ 0...... 0............ 0

 

 

PHYSICAL EDUCATION AND PHYSICAL ACTIVITY

 

14.  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.)

 

a. Yes

b. No

 

 

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

 

              Material                                                      Yes    No

a.     Goals, objectives, and expected outcomes for physical

       education..................................................... 0.... 0

b.     A chart describing the annual scope and sequence of instruction

       for physical education........................................ 0.... 0

c.     Plans for how to assess student performance in physical

       education..................................................... 0.... 0

d.     A written physical education curriculum....................... 0.... 0

 

 

16.    Outside of physical education, do students participate in physical activity breaks in classrooms during the school day? (Mark one response.)

 

a. Yes

b. No

 

17.    Does your school offer opportunities for all students to participate in intramural sports programs or physical activity clubs?  (Intramural sports programs 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.)

 

a. Yes

b. No

 

 

18.    Does your school offer interscholastic sports to students? (Mark one response.)

 

a. Yes

b. No

 

 

19.    A joint use agreement is a formal agreement between a school or school district and another public or private entity to jointly use either school facilities or community facilities to share costs and responsibilities.  Does your school, either directly or through the school district, have a joint use agreement for shared use of school or community physical activity facilities? (Mark one response.)

 

a. Yes

b. No

 

 

TOBACCO-USE PREVENTION POLICIES

 

20.    Has your school adopted a policy prohibiting tobacco use? (Mark one response.)

 

a. Yes

b. No     Skip to Question 27

 

 

21.    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.)

 

                                                 Students    Faculty/Staff   Visitors

              Type of tobacco                   Yes    No     Yes    No     Yes    No

a.     Cigarettes......................... 0..... 0..... 0..... 0..... 0..... 0

b.     Smokeless tobacco (i.e., chewing

       tobacco, snuff, or dip)............ 0..... 0..... 0..... 0..... 0..... 0

c.     Cigars............................. 0..... 0..... 0..... 0..... 0..... 0

d.     Pipes.............................. 0..... 0..... 0..... 0..... 0..... 0

 

 

22.    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.)

 

                                                 Students    Faculty/Staff   Visitors

              Time                              Yes    No     Yes    No     Yes    No

a.     During school hours................ 0..... 0..... 0..... 0..... 0..... 0

b.     During non-school hours ........... 0..... 0..... 0..... 0..... 0..... 0

 

 

23.    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.)

                                                 Students    Faculty/Staff   Visitors

              Location                          Yes    No     Yes    No     Yes    No

a.     In school buildings................ 0..... 0..... 0..... 0..... 0..... 0

b.     Outside on school grounds, including

       parking lots and playing fields.... 0..... 0..... 0..... 0..... 0..... 0

c.     On school buses or other vehicles

       used to transport students......... 0..... 0..... 0..... 0..... 0..... 0

d.     At off-campus, school-sponsored

       events............................. 0..... 0..... 0..... 0..... 0..... 0

 

24.    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.)

 

                                                                       Not

              Group                                         Yes    No     Applicable

a.     Students....................................... 0.... 0........ 0

b.     Faculty and staff.............................. 0.... 0........ 0

c.     Visitors....................................... 0.... 0........ 0

 

 

25.    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.)

 

a. Yes

b. No

 

 

26.    At your school, who is responsible for enforcing your tobacco-use prevention policy? (Mark one response.)

 

a. No single individual is responsible

b. Principal

c. Assistant principal

d. Other school administrator

e. Other school faculty or staff member

 

 

27.    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 criterion.)

 

              Criterion                                                     Yes    No

a.     Zero tolerance................................................ 0.... 0

b.     Effect or severity of the violation........................... 0.... 0

c.     Grade level of student........................................ 0.... 0

d.     Repeat offender status........................................ 0.... 0

 

 

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

                                                                               Always

                                                                              or almost

              Action                             Never   Rarely   Sometimes    always

a.     Parents or guardians are notified.... 0....... 0........ 0.......... 0

b.     Referred to a school counselor....... 0....... 0........ 0.......... 0

c.     Referred to a school administrator... 0....... 0........ 0.......... 0

d.     Encouraged, but not required, to

       participate in an assistance, education,

       or cessation program................. 0....... 0........ 0.......... 0

e.     Required to participate in an assistance,

       education, or cessation program...... 0....... 0........ 0.......... 0

f.     Referred to legal authorities........ 0....... 0........ 0.......... 0

g.     Placed in detention.................. 0....... 0........ 0.......... 0

h.     Not allowed to participate in extra-curricular

       activities or interscholastic sports. 0....... 0........ 0.......... 0

i.     Given in-school suspension........... 0....... 0........ 0.......... 0

j.     Suspended from school................ 0....... 0........ 0.......... 0

k.     Expelled from school................. 0....... 0........ 0.......... 0

l.     Reassigned to an alternative school.. 0....... 0........ 0.......... 0

 

 

29.    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.)

 

a. Yes

b. No

 

 

30.    Does your school provide tobacco cessation services for each of the following groups? (Mark yes or no for each group.)

 

              Group                                                         Yes    No

a.     Faculty and staff............................................. 0.... 0

b.     Students...................................................... 0.... 0

 

 

31.    Does your school have arrangements with any organizations or health care professionals not on school property to provide tobacco cessation services for each of the following groups? (Mark yes or no for each group.)

 

              Group                                                         Yes    No

a.     Faculty and staff............................................. 0.... 0

b.     Students...................................................... 0.... 0

 

 

NUTRITION-RELATED POLICIES AND PRACTICES

 

32.    When foods or beverages are offered at school celebrations, how often are fruits or non-fried vegetables offered? (Mark one response.)

 

a. Foods or beverages are not offered at school celebrations.

b. Never

c. Rarely

d. Sometimes

e. Always or almost always

 

 

33.    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.)

 

a. Yes

b. No        Skip to Question 35

 

 

34.    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                                              Yes    No

a.     Chocolate candy............................................... 0.... 0

b.     Other kinds of candy.......................................... 0.... 0

c.     Salty snacks that are not low in fat (e.g., regular

       potato chips)................................................. 0.... 0

d.     Cookies, crackers, cakes, pastries, or other baked goods that

       are not low in fat............................................ 0.... 0

e.     Ice cream or frozen yogurt that is not low in fat............. 0.... 0

f.     2% or whole milk (plain or flavored).......................... 0.... 0

g.     Water ices or frozen slushes that do not contain juice........ 0.... 0

h.     Soda pop or fruit drinks that are not 100% juice.............. 0.... 0

i.     Sports drinks (e.g., Gatorade)................................ 0.... 0

j.     Foods or beverages containing caffeine........................ 0.... 0

k.     Fruits (not fruit juice)...................................... 0.... 0

l.     Non-fried vegetables (not vegetable juice).................... 0.... 0

 

 

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

 

                                                                            Yes    No

a.     Priced nutritious foods and beverages at a lower cost while

       increasing the price of less nutritious foods and beverages... 0.... 0

b.     Collected suggestions from students, families, and school

       staff on nutritious food preferences and strategies to promote

       healthy eating................................................ 0.... 0

c.     Provided information to students or families on the nutrition

       and caloric content of foods available........................ 0.... 0

d.     Conducted taste tests to determine food preferences for

       nutritious items.............................................. 0.... 0

e.     Provided opportunities for students to visit the cafeteria to

       learn about food safety, food preparation, or other nutrition-

       related topics................................................ 0.... 0

f.     Served locally or regionally grown foods in the cafeteria

       or classrooms................................................. 0.... 0

g.     Planted a school food or vegetable garden..................... 0.... 0

h.     Placed fruits and vegetables near the cafeteria cashier, where they

       are easy to access............................................ 0.... 0

i.     Used attractive displays for fruits and vegetables in the

       cafeteria..................................................... 0.... 0

j.     Offered a self-serve salad bar to students.................... 0.... 0

k.     Labeled healthful foods with appealing names

       (e.g., crunchy carrots)....................................... 0.... 0

 

 

36.    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.)

 

a. Yes

b. No

 

 

37.    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                                                      Yes    No

a.     In the school building........................................ 0.... 0

b.     On school grounds including on the outside of the school

       building, on playing fields, or other areas of the campus..... 0.... 0

c.     On school buses or other vehicles used to transport students.. 0.... 0

d.     In school publications (e.g., newsletters, newspapers, web sites,

       or other school publications)................................. 0.... 0

 

 

38.    Are students permitted to have a drinking water bottle with them during the school day? (Mark one response.)

 

a. Yes, in all locations

b. Yes, in certain locations

c. No

 

 

39.    Does your school offer a free source of drinking water in the cafeteria during meal times? (Mark one response.)

 

a. Yes

b. No

 

 

HEALTH SERVICES

40.    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 per week.) (Mark one response.)

 

a. Yes

b. No

 

 

41.    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.)

 

a. This school has no students with known asthma.

b. All students with known asthma have an asthma action plan on file.

c. Most students with known asthma have an asthma action plan on file.

d. Some students with known asthma have an asthma action plan on file.

e. No students with known asthma have an asthma action plan on file.

 

 

42.    At your school, which of the following events are used to identify students with poorly controlled asthma? (Mark all that apply.)

 

a. This school does not identify students with poorly controlled asthma.

b. Frequent absences from school

c. Frequent visits to the school health office due to asthma

d. Frequent asthma symptoms at school

e. Frequent non-participation in physical education class due to asthma

f. Students sent home early due to asthma

g. Calls from school to 911, or other local emergency numbers, due to asthma

 

 

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

 

              Service                                                       Yes    No

a.     Providing referrals to primary health care clinicians or child

       health insurance programs..................................... 0.... 0

b.     Ensuring an appropriate written asthma action plan is obtained 0.... 0

c.     Ensuring access to and appropriate use of asthma medications,

       spacers, and peak flow meters at school....................... 0.... 0

d.     Offering asthma education for students with asthma............ 0.... 0

e.     Minimizing asthma triggers in the school environment.......... 0.... 0

f.     Addressing social and emotional issues related to asthma...... 0.... 0

g.     Providing additional psychosocial counseling or support services

       as needed..................................................... 0.... 0

h.     Ensuring access to safe, enjoyable physical education and activity

       opportunities................................................. 0.... 0

i.          Ensuring access to preventive medications before

physical activity............................................. 0.... 0

 

 

44.    How often are school staff members required to receive training on recognizing and responding to severe asthma symptoms? (Mark one response.)

 

a. More than once per year

b. Once per year

c. Less than once per year

d. No such requirement

 

 

45.    Has your school adopted a policy stating that students are permitted to carry and self-administer asthma medications? (Mark one response.)

 

a. Yes

b. No     Skip to Q48

 

 

46.    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.)

 

              Group                                                         Yes    No

a.     Students...................................................... 0.... 0

b.     Parents and families.......................................... 0.... 0

 

 

47.    At your school, who is responsible for implementing your school’s policy permitting students to carry and self-administer asthma medications? (Mark one response.)

 

a. No single individual is responsible

b. Principal

c. Assistant principal

d. School nurse

e. Other school faculty or staff member

 

 

48.    Does your school provide the following services to students? (Mark yes or no for each service.)

 

              Service                                                       Yes    No

a.     HIV counseling and testing.................................... 0.... 0

b.     STD testing and treatment..................................... 0.... 0

c.     Pregnancy testing............................................. 0.... 0

d.     Provision of condoms.......................................... 0.... 0

e.     Provision of contraceptives other than condoms (e.g., birth control

       pill, birth control shot, intrauterine device [IUD]).......... 0.... 0

f.     Prenatal care................................................. 0.... 0

g.     Human papillomavirus (HPV) vaccine administration............. 0.... 0

 

 

49.    Does your school provide students with referrals to any organizations or health care professionals not on school property for the following services? (Mark yes or no for each service.)

 

              Service                                                       Yes    No

a.     HIV counseling and testing.................................... 0.... 0

b.     STD testing and treatment..................................... 0.... 0

c.     Pregnancy testing............................................. 0.... 0

d.     Provision of condoms.......................................... 0.... 0

e.     Provision of contraceptives other than condoms (e.g., birth control

       pill, birth control shot, intrauterine device [IUD]).......... 0.... 0

f.     Prenatal care................................................. 0.... 0

g.     Human papillomavirus (HPV) vaccine administration............. 0.... 0

 

 

FAMILY AND COMMUNITY INVOLVEMENT

 

50.    During the past two years, have students’ families helped develop or implement policies and programs related to HIV, STD, or teen pregnancy prevention? (Mark one response.)

 

a. Yes

b. No

 

51.    During the past two years, have community members helped develop or implement policies and programs related to HIV, STD, or teen pregnancy prevention? (Mark one response.)

 

a. Yes

b. No

 

 

Thank you for your responses.  Please return this questionnaire.