SELECTED MODULE 1 QUESTIONS SCORE CARD Instructions 1. Carefully read and discuss the Module 1 Discussion Questions, which contains questions and scoring descriptions for each item listed on this Score Card. 2. Circle the most appropriate score for each item. 3. After all questions have been scored, calculate the overall Module Score and complete the Module 1 Planning Questions located at the end of this module. CC.3 Communicate school health and safety policies to students, parents, staff, and visitors Does the school communicate its school health and safety policies in all of the following ways? * tobacco-free-school signs * weapon-free-school signs * staff orientation and staff meetings * student orientation * student handbook * staff handbook * parent handbook and/or newsletters * contracts with outside vendors and organizations that rent school facilities * announcements at school events * community meetings * 3 = Yes, in all of these ways. 2 = In most of these ways. 1 = In some of these ways. 0 = In none of these ways. S.3 No tolerance for harassment or bullying harassment or bullying*? * staff and students treating each other with respect and courtesy * fairly and consistently implementing disciplinary policies among all student groups * emphasizing fair play and nonviolence on the playground, on the school bus, and at school events * encouraging students to report harassment or bullying * providing support for victims *Harassment or bullying is the repeated infliction or attempted infliction of injury, discomfort, or humiliation on a weaker student by one or more students with more power. 3 = Yes, in each of these five ways. 2 = In four of these ways. 1 = In three of these ways. 0 = In two or fewer of these ways. PA.1 Access to physical activity facilities outside school hours Can all students use your school’s indoor and outdoor physical activity facilities outside school hours*? *Outside school hours means after school, and during evenings, weekends, and school vacations. NOTE: Use of indoor facilities should be supervised. 3 = Yes, both indoor and outdoor facilities are available to all students. 2 = Indoor or outdoor facilities, but not both, are available to all students. 1 = Indoor or outdoor facilities are available to all students, but the hours of availability are very limited. 0 = No, neither indoor nor outdoor facilities are available to all students. PA.3 Prohibit using physical activity as punishment Does the school prohibit using physical activity* and withholding physical education class** as punishment? Is this prohibition consistently followed? *An example of using physical activity as punishment is making students run laps or do push-ups as a consequence of inappropriate behavior. **Withholding physical education class as punishment means not allowing students to attend all or part of physical education class as a consequence of inappropriate behavior in another class or failure to complete an assignment in another class. It does not refer to the physical education teachers’ disciplining students during physical education class by having them sit out for a period of time. NOTE: Please do not consider issues related to participation in interscholastic sports programs when answering this question. 3 = Yes, using physical activity as punishment and withholding physical education class as punishment are prohibited, and both prohibitions are consistently followed. 2 = One of these practices is prohibited, and this prohibition is consistently followed. 1 = One of these practices is prohibited, but this prohibition is not consistently followed. 0 = Neither practice is prohibited. N.1 Prohibit using food as reward or punishment Does the school prohibit giving students food as a reward* and withholding food as punishment**? Is this prohibition consistently followed? *An example of using food as a reward is providing candy or fast-food coupons to students because they have behaved well or met an academic or fundraising goal. **An example of withholding food as punishment is not giving one student a snack or meal that is offered to all other students, because of his or her inappropriate behavior. 3 = Yes, using food as a reward and withholding food as punishment are prohibited, and both prohibitions are consistently followed. 2 = One of these practices is prohibited, and this prohibition is consistently followed. 1 = One of these practices is prohibited, but this prohibition is not consistently followed. 0 = Neither practice is prohibited. N.2 Fund-raising efforts supportive of healthy eating Do school fundraising efforts support healthy eating by selling non-food items or foods that are low in fat, sodium, and added sugars (e.g., fruits, vegetables, pretzels, air-popped popcorn) instead of by selling foods that are high in fat, sodium, or added sugars (e.g., candy)? 3 = Yes, fundraising efforts never include selling foods high in fat, sodium, or added sugars. 2 = Fundraising efforts rarely include selling foods high in fat, sodium, or added sugars. 1 = Fundraising efforts include selling foods high in fat, sodium, or added sugars about half the time. 0 = Fundraising efforts typically include selling foods high in fat, sodium, or added sugars. T.2 Prohibit tobacco use among staff and visitors Does the school prohibit the use of tobacco* by staff and visitors, 24 hours a day, in the following locations? * in all school buildings** * on all school grounds** * all school-sponsored events off school grounds * all school vehicles *Use of tobacco means all forms: cigarettes, cigars, cigarillos, chewing tobacco and snuff, bidis, clove cigarettes, etc. **Includes extracurricular events. 3 = Yes, in all locations. 2 = Tobacco use by staff and visitors is prohibited in all school buildings and on all school grounds, but is allowed either at school-sponsored events off school grounds or in school vehicles. 1 = Tobacco use by staff and visitors is prohibited only in school buildings, but is allowed on school grounds or tobacco use is allowed at both school-sponsored events off school grounds and in school vehicles. 0 = Tobacco use by staff and visitors is allowed in school buildings or tobacco use is allowed on school grounds, at school-sponsored events off school grounds, and in school vehicles. A.1 Written policies for self-carry and self-administration of medications Does your school or district have written policies* that permit students to self-carry and self-administer prescribed medications for asthma and include all of the following? *Policies can be developed at the school level, or they can be developed at the school district or state level and implemented at the school level. They include legal codes, rules, standards, administrative orders, guidelines, mandates, or resolutions. * Approval from authorized prescriber (e.g., MD, DO, PNP, etc.) * Approval from parent/guardian * Approval from school nurse * Request for back-up medication to be kept in the school health office * Student contract with clear rules and consequences for violations * Immediate notification of parent/guardian if permission is withdrawn * Annual parental notification about policy 3 = Yes, our school has written policies that include all of these components. 2 = Our school has written policies that include most of these components. 1 = Our school has written policies that include only a few of these components. 0 = No, our school does not have written policies, or the policies do not include these components. TOTALS: Add up the numbers that are circled and enter the sum. MODULE SCORE = (Total Points / 24) X 100 (If you decide to skip any of the topic areas, make sure you adjust the denominator for the Module Score (24) by subtracting 3 for each question eliminated). PLANNING QUESTIONS The Module 1 Planning Questions will help your school use its School Health Index results to identify and prioritize changes that will improve policies and programs to improve students’ health and safety. Planning Question 1 Look back at the scores you assigned to each question. According to these scores, what are the strengths and the weaknesses of your school’s policies and environment related to students’ health and safety? Planning Question 2 For each of the weaknesses identified above, list several recommended actions to improve the school’s scores (e.g., create and maintain a school health committee). Planning Question 3 List below each of the actions identified in Planning Question 2. Use the five-point scales defined below to rank each action on five dimensions (importance, cost, time, commitment, feasibility). Add the points for each action to get the total points. Use the total points to help you choose one, two, or three top-priority actions that you will recommend to the School Health Index team for implementation this year. Importance -- How important is the action to my school? 5 = Very important 3 = Moderately important 1 = Not important Cost -- How expensive would it be to plan and implement the action? 5 = Not expensive 3 = Moderately expensive 1 = Very expensive Time-- How much time and effort would it take to implement the action? 5 = Little or no time and effort 3 = Moderate time and effort 1 = Very great time and effort Commitment -- How enthusiastic would the school community be about implementing the action? 5 = Very enthusiastic 3 = Moderately enthusiastic 1 = Not enthusiastic Feasibility -- How difficult would it be to complete the action? 5 = Not difficult 3 = Moderately difficult 1 = Very difficult