Form Approved OMB No: 0920-0445 Expiration Date: 10/31/2002 Faculty and Staff Health Promotion School Questionnaire Faculty and Staff Health Promotion School Questionnaire Questions Wellness Workshops and Employee Assistance Programs 1 - 2 Other Health Promotion Activities and Services 3 - 6 Activities/Services Coordination and Planning 7 - 11 Required Examinations and Screenings 12 - 17 Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for 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 currently 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, Mailstop D-24, Atlanta, GA 30333; Attention PRA (0920-0445). Special Instructions This questionnaire will be administered using Computer Assisted Personal Interviewing. The interviewer will read the questions aloud and type responses to the questions into the laptop computer. The interview program will 1) display the correct tense of verbs, 2) provide alternate answers to questions (e.g., not applicable, “I don’t know”), 3) navigate complex skip patterns, 4) access information that was provided in previous contact with a school, and 5) perform other useful functions. The programming specifications for the interview are not included in this printed version of the questionnaire. If you would like more information about this study or would like clarification of any questions in this questionnaire, please call Tim Smith at 1-800-647-9664, extension 6095. Wellness Workshops and Employee Assistance Programs What is your job title at the school? (In which role do you spend more time?) 1) Principal 11) Guidance Counselor 2) Asst. Principal/Other School 12) Social Worker Administrator 13) Psychologist 3) School Secretary 14) Other Mental Health/Social Services 4) Physical Ed Teacher Provider 5) Athletic Director 15) Nurse 6) Health Ed Teacher 16) Health Aide 7) Other Teacher 17) Physician 8) Food Service Manager 18) Other Health Services Provider 9) Commercial Food Service Provider 19) SBHC Health Services Staff 10) Other School Food Service Staff 20) SBHC Mental Health/Social Services Staff 50) Other Staff During this interview, I will ask about health promotion activities or services that are offered to this school’s faculty and staff because they work for this school. Faculty and staff health promotion activities or services focus on prevention of physical illnesses or injuries, promotion of physical fitness, promotion of mental health, or other activities or services designed to assist school faculty and staff experiencing problems that can impact job performance, physical health, or overall well-being. Please include those activities or services offered by your state, district, school, or anyone outside the school system. However, do not include those activities or services that faculty and staff receive through their personal employee health plans or insurance programs. If I ask you about things that do not apply to this school or that this school does not do, please bear with me. 1. First, I would like to ask about “wellness workshops,” that is, seminars, classes, or other activities focusing on ways to improve or maintain physical health or overall well-being. During the past 12 months, has a wellness workshop been offered to this school’s faculty and staff? Yes 1 No 2 2. Employee Assistance Programs, or EAP’s, provide services designed to assist faculty and staff experiencing personal or social problems that can impact work performance, physical health, or overall well-being. During the past 12 months, has an EAP been offered to this school’s faculty and staff? Yes 1 No 2 Other Health Promotion Activities and Services 3. During the past 12 months have faculty and staff at this school been offered screening for... Yes No a. Hearing problems? 1 2 b. Vision problems? 1 2 c. Oral health problems? 1 2 d. Tuberculosis (TB)? 1 2 e. Height and weight or body mass? 1 2 f. Serum cholesterol level? 1 2 g. Blood pressure level? 1 2 h. Diabetes? 1 2 i. Skin cancer? 1 2 j. Breast cancer? 1 2 k. Colorectal cancer? 1 2 4. Please tell me if each of the following services or programs have been offered to this school’s faculty and staff during the past 12 months. Remember that I am asking about services that this school’s faculty and staff can receive because they work for this school. During the past 12 months, have this school’s faculty and staff been offered... Yes No a. Alcohol or other drug use treatment? 1 2 b. Tobacco use cessation? 1 2 c. Nutrition and dietary behavior counseling? 1 2 d. Weight management? 1 2 e. Physical activity and fitness counseling? 1 2 f. Stress management? 1 2 g. Identification of or counseling for mental or emotional disorders, such as anxiety or depression? 1 2 h. Identification of or referral for physical, sexual, or emotional abuse? 1 2 i. Crisis intervention for personal problems? 1 2 j. Human immunodeficiency virus (HIV) testing and counseling? 1 2 k. Referrals for child care? 1 2 l. Identification of or referral for dental problems? 1 2 m. Prenatal education? 1 2 n. Identification or treatment of STDs? 1 2 5. During the past 12 months, have any physical activity programs, such as aerobics classes, basketball leagues, or walking or jogging clubs been offered to this school’s faculty and staff? Yes 1 No 2 6. I’d like to ask about the use of school facilities or equipment that could be used for physical activity, such as a gym, cafeteria, swimming pool, weight-lifting equipment, and cardiovascular exercise equipment. Are any indoor or outdoor facilities or is any equipment made available for this school’s faculty or staff to use? Yes 1 No 2 Activities/Services Coordination and Planning 7. Currently, does someone at this school oversee or coordinate health promotion activities or services for this school’s faculty and staff? Yes 1 No 2 If this school does not offer any faculty and staff health promotion or services (Q1, Q2, Q3a-k, Q4a-n, Q5, and Q6 are No), skip to Q12. SHOW CARD 1 8. This card lists organizations or agencies that might offer health promotion activities or services to faculty and staff from this school. During the past 12 months, have any activities or services been offered to this school’s faculty and staff by... Yes No a. A local health department? 1 2 b. A local hospital? 1 2 c. A local mental health or social services agency? 1 2 d. A university or medical school? 1 2 e. A managed care organization? 1 2 f. Any health organization, such as the American Heart Association or the American Cancer Society? 1 2 g. Your school district? 1 2 9. During the past 12 months, have... Yes No a. Notices been included with paychecks or sent with pay stubs to publicize the health promotion activities or services offered to faculty and staff from this school? 1 2 b. Fliers or bulletins been posted at the school to publicize the health promotion activities or services offered to faculty and staff ? 1 2 c. Letters been mailed directly to faculty and staff? 1 2 d. Announcements been made at staff meetings? 1 2 e. Special assemblies or presentations been offered? 1 2 10. During the past 12 months, ... Yes No a. Have financial incentives been offered to encourage participation in the health promotion activities or services? 1 2 b. Have prizes been awarded for individual participation to encourage participation in the health promotion activities or services? 1 2 c. Have competitions between groups of faculty and staff been held, for example, a contest between teachers from different grades or departments? 1 2 d. Has release time for participation been given? 1 2 11. I’d like to ask about the objectives of health promotion activities or services for this school’s faculty and staff. When planning activities or services for this school’s faculty and staff, is consideration given to... Yes No a. Reducing the number of sick days used? 1 2 b. Reducing the use or cost of health insurance benefits? 1 2 c. Reducing the number of faculty and staff injuries? 1 2 d. Improving faculty and staff morale? 1 2 e. Creating an environment in which faculty and staff serve as “healthy” role models for students? 1 2 Required Examinations and Screenings Next, I would like to ask about faculty and staff health examinations and screenings required for employment. SHOW CARD 2 12. Please tell me which of these statements best describes the requirement for a physical health examination prior to employment. It is required of all faculty and staff prior to employment. 1 It is required depending on the position the person will have at the school. 2 It is required depending on something other than the person’s position. 3 It is not required of any faculty or staff prior to employment. 4 13. Which of the statements on this card best describes the requirement for tuberculosis or TB screening prior to employment? It is required of all faculty and staff prior to employment. 1 It is required depending on the position the person will have at the school. 2 It is required depending on something other than the person’s position. 3 It is not required of any faculty or staff prior to employment. 4 14. Which of the statements on this card best describes the requirement for illegal drug use screening prior to employment? It is required of all faculty and staff prior to employment. 1 It is required depending on the position the person will have at the school. 2 It is required depending on something other than the person’s position. 3 It is not required of any faculty or staff prior to employment. 4 SHOW CARD 3 15. Finally, I would like to ask about health examinations that this school’s faculty and staff are required to receive periodically while they are employed at this school. Which of the statements on this card best describes the requirement for a physical health examination while employed at this school? It is required periodically of all faculty and staff while employed at the school. 1 It is required periodically depending on the position the person has at the school. 2 It is required periodically depending on something other than the person’s position. 3 It is not required of any faculty or staff while employed at the school. 4 16. Which of the statements on this card best describes the requirement for tuberculosis or TB screening while employed at this school? It is required periodically of all faculty and staff while employed at the school. 1 It is required periodically depending on the position the person has at the school. 2 It is required periodically depending on something other than the person’s position. 3 It is not required of any faculty or staff while employed at the school. 4 17. Which of the statements on this card best describes the requirement for illegal drug use screening while employed at this school? It is required periodically of all faculty and staff while employed at the school. 1 It is required periodically depending on the position the person has at the school. 2 It is required periodically depending on something other than the person’s position. 3 It is not required of any faculty or staff while employed at the school. 4 18. My supervisor may wish to call you to ask about how I conducted this interview. Would you please tell me a telephone number where we might reach you starting with the area code? ( ) - 1) Daytime or 2) Evening/weekend Thank you very much for taking the time to complete this interview. Faculty and Staff Health Promotion School Questionnaire - Final Version — Revised: 10/26/99 10 Faculty and Staff Health Promotion School Questionnaire - Final Version — Revised: 10/26/99 Wellness Workshops and Employee Assistance Programs Other Health Promotion Activities and Services Activities/Services Coordination and Planning Required Examinations and Screenings