Form Approved OMB No: 0920-0445 Expiration Date: 10/31/2002 Health Services District Questionnaire Health Services District Questionnaire Questions Standard Health Services 1 - 53 Student Health Records 1 Required Immunizations and Vaccinations 2 - 5 Procedures for Student Medication 6 - 7 Approach to Students or Staff with HIV/AIDS 8 - 10 Provision of Health Services 11 - 53 Collaboration 11 - 12 Promotion 13 Evaluation 14 Illness and Injury 15 - 20 Screening 21 - 32 Other Services 33 - 39 Staffing Characteristics 40 - 53 School-Based Health Center Services 54 - 55 Services at Other Sites 56 - 58 Providers 56 - 57 Services 58 Health Services Coordinator 59 - 69 Public reporting burden for this collection of information is estimated to average 45 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 1. This questionnaire focuses on your district practices and policies. 2. When we use the word “policy,” we mean any mandate issued by the local school board or other local agency that affects health services in schools throughout your district. Please consider any policies officially adopted at the district level. These include policies developed by your district, or those based on model policies developed by your state or elsewhere. 3. We recognize that there may be some exceptions, but please answer the questions based on what is customary in your district. Please do not consider school practices or policies when answering the questions. (We will ask about school practices and policies when we collect information from schools across the country.) 4. If you would like more information about this study or would like clarification of any questions in this survey, please call Tim Smith at 1-800-647-9664, extension 6095. Standard Health Services 1. Has your district adopted a policy stating that schools will keep the following information in any type of student record? Yes No a. A physical health history 1 2 b. An emotional or mental health history 1 2 c. Tuberculosis skin test results 1 2 d. Screening records 1 2 e. Immunization or vaccination status 1 2 f. Medication needs 1 2 g. Dietary needs or restrictions 1 2 h. Physical activity restrictions 1 2 i. Emergency contact information 1 2 j. An authorization for emergency treatment 1 2 k. Insurance coverage information 1 2 2. Has your district adopted a policy stating that students entering kindergarten or first grade will have each of the following immunizations or vaccinations? If your district does not include any schools with kindergarten or first grade, mark this box ? and skip to Question 4. Yes No a. A measles-containing vaccine, such as MMR 1 2 b. A polio vaccine, such as OPV 1 2 c. Diphtheria 1 2 d. Tetanus 1 2 e. Haemophilus influenzae type b or Hib 1 2 f. Influenza 1 2 g. Hepatitis B 1 2 h. Chicken pox (varicella) 1 2 i. Pneumococcal 1 2 3. Based on policies adopted by your district, are students who have not received the required school-entry immunizations or vaccinations immediately excluded from attending classes or are they allowed to attend classes? If your district has not adopted a policy, please mark this box ? and skip to Question 4. Immediately excluded 1 Allowed to attend indefinitely 2 Allowed to attend for a specified number of days until they receive the immunization or vaccination 3 4. Has your district adopted a policy stating that students entering middle/junior high school will have each of the following immunizations or vaccinations? If your district does not include any middle/junior high schools, mark this box ? and skip to Question 5. Yes No a. A second measles-containing vaccine 1 2 b. Hepatitis A 1 2 c. Hepatitis B 1 2 d. Chicken pox (varicella) 1 2 e. Tetanus 1 2 5. Has your district adopted a policy stating that students entering senior high school will have each of the following immunizations or vaccinations? If your district does not include any senior high schools, mark this box ? and skip to Question 6. Yes No a. A second measles-containing vaccine 1 2 b. Hepatitis A 1 2 c. Hepatitis B 1 2 d. Chicken pox (varicella) 1 2 e. Tetanus 1 2 6. Has your district adopted a policy stating that schools will have the following documentation before school faculty or staff may administer prescription drugs to a student? If school faculty and staff are not allowed to administer prescription drugs to students, please mark this box ? and skip to Question 7. Yes No a. Written instructions from the physician or prescriber 1 2 b. Written request from the parent or guardian 1 2 c. Written information on possible side-effects 1 2 7. Has your district adopted a policy stating that some students may self-medicate at school using the following medications? If students in your district are not permitted to self-medicate, please mark this box ? and skip to Question 8 . Yes No a. A prescription inhaler 1 2 b. Epinephrine 1 2 c. Insulin or other injected medications 1 2 d. Other prescribed medications 1 2 e. Over-the-counter medications 1 2 8. Has your district adopted a policy stating that schools will allow students who have human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) to engage in the following activities as long as they are able? Yes No a. Attend classes like other students 1 2 b. Participate in school sports like other students 1 2 c. Participate in any other school activities 1 2 9. Has your district adopted a policy stating that schools will allow faculty and staff who have HIV or AIDS to continue working as long as they are able? Yes 1 No 2 10. Has your district adopted a policy stating that schools will have a system in place to notify teachers when any of their students have any of the following conditions? Yes No a. HIV or AIDS 1 2 b. Any other chronic health condition, such as diabetes or asthma 1 2 c. Any other communicable health condition, such as measles or chicken pox 1 2 11. The following questions ask about standard health services, meaning those health services offered at the school, usually by a school nurse. By health services, we mean services such as first aid, administration of medications, identification and treatment of acute illnesses, or immunizations or vaccinations. Later in the questionnaire, we will ask about any services offered by school-based health centers or at other sites. During the past 12 months, have district health services staff worked on school health services activities with each of the following groups? Yes No a. District health education staff 1 2 b. District physical education staff 1 2 c. District food service staff 1 2 d. District mental health or social services staff 1 2 12. During the past 12 months, have district health services staff worked on school health services activities with staff or members from each of these organizations? Yes No a. Local health department 1 2 b. Local hospital 1 2 c. Local mental health or social services agency 1 2 d. Health organization, such as the American Heart Association or the American Red Cross 1 2 e. Local colleges or universities 1 2 f. Local businesses 1 2 13. During the past 12 months, has your district done each of the following activities to promote the school health services program? Yes No a. Provided families with information on the school health services program 1 2 b. Met with a parents’ organization, such as the PTA, to discuss the school health services program 1 2 c. Invited family members to tour the school health services facilities 1 2 14. During the past 2 years, have the following aspects of your district health services program been evaluated? Yes No a. Student use of the school health services program 1 2 b. The quality of the school health services program 1 2 c. Student satisfaction with the school health services program 1 2 d. Family satisfaction with the school health services program 1 2 e. School health services policies 1 2 f. Health services staff development or in-service programs 1 2 15. Has your district adopted a policy stating that schools will take each of the following actions after a student is seriously injured on school property? By “seriously injured,” we mean an injury requiring emergency medical services (EMS) response or immediate care by a physician or other health care professional, and the loss of at least a half day of school. Yes No a. Notify the student’s parents or guardians 1 2 b. Notify the student’s teachers 1 2 c. Report the incident to the state or local health department 1 2 d. Write an injury report 1 2 If an injury report is not required, please skip to Question 18. Otherwise, continue with Questions 16 and 17. 16. Has your district adopted a policy stating that the following pieces of information will be recorded on the student injury reports? Yes No a. Location where injury occurred (e.g., playground or field, hallway or stairway) 1 2 b. Activity during which injury occurred (e.g., baseball, sitting, throwing) 1 2 c. Nature of injury (e.g., bruise, burn) 1 2 d. School staff who were present when the injury occurred 1 2 e. Cause of injury (e.g., a fall, equipment, another student) 1 2 f. Response of school staff to the injury (e.g., EMS call, treatment provided by school staff) 1 2 g. Immediate outcome of injury (e.g., hospitalization, school days missed by student) 1 2 17. Has your district adopted a policy stating that schools will submit student injury report data to the local school district or local health department? Yes 1 No 2 18. Has your district adopted a policy stating that schools will make supplies for applying universal precautions available in the following locations? These supplies include disposable latex gloves, antiseptic towelettes, and bandages. Yes No a. In all classrooms 1 2 b. In the gymnasium, on playgrounds, or on playing fields 1 2 c. On school buses or in other vehicles used to transport students 1 2 19. Has your district adopted a policy stating that schools will take each of the following actions when a student experiences a serious illness at school? By “serious illness,” we mean one requiring EMS response, or immediate care by a physician or other health care professional, and the loss of at least a half day of school. Yes No a. Notify the student’s parents or guardians 1 2 b. Notify the student’s teachers 1 2 c. Report notifiable diseases to the state or local health department 1 2 d. Write an illness report 1 2 If an illness report is not required, please skip to Question 21. Otherwise, continue with Question 20. 20. Has your district adopted a policy stating that schools will submit student illness report data to the local school district or local health department? Yes 1 No 2 21. The next questions are about district policies on student health screenings. By “student health screenings,” we mean screenings conducted for most students in the school or in certain grades at the school. Please do not include screenings conducted for special populations of students, for example screenings conducted only for special education students. Has your district adopted a policy stating that schools will screen students for hearing problems? Yes 1 No 2 ==> Skip to Question 23 22. Has your district adopted a policy stating that the following actions will be taken when a student’s hearing screening indicates a potential problem? Yes No a. Notify the student’s parents or guardians 1 2 b. Notify the student’s teachers 1 2 23. Has your district adopted a policy stating that schools will screen students for vision problems? Yes 1 No 2 ==> Skip to Question 25 24. Has your district adopted a policy stating that the following actions will be taken when a student’s vision screening indicates a potential problem? Yes No a. Notify the student’s parents or guardians 1 2 b. Notify the student’s teachers 1 2 25. Has your district adopted a policy stating that schools will screen students for oral health problems? Yes 1 No 2 ==> Skip to Question 27 26. Has your district adopted a policy stating that the following actions will be taken when a student’s oral health screening indicates a potential problem? Yes No a. Notify the student’s parents or guardians 1 2 b. Notify the student’s teachers 1 2 27. Has your district adopted a policy stating that schools will screen students for tuberculosis? Yes 1 No 2 ==> Skip to Question 29 28. Has your district adopted a policy stating that the following actions will be taken when a student’s tuberculosis screening indicates a potential problem? Yes No a. Notify the student’s parents or guardians 1 2 b. Notify the student’s teachers 1 2 c. Notify the state or local health department 1 2 29. Has your district adopted a policy stating that schools will screen students for height and weight or body mass problems? Yes 1 No 2 ==> Skip to Question 31 30. Has your district adopted a policy stating that the following actions will be taken when a student’s height and weight or body mass screening indicates a potential problem? Yes No a. Notify the student’s parents or guardians 1 2 b. Notify the student’s teachers 1 2 31. Has your district adopted a policy stating that schools will screen students for scoliosis? Yes 1 No 2 ==> Skip to Question 33 32. Has your district adopted a policy stating that the following actions will be taken when a student’s scoliosis screening indicates a potential problem? Yes No a. Notify the student’s parents or guardians 1 2 b. Notify the student’s teachers 1 2 33. Has your district adopted a policy stating that schools will provide each of the following services to students when needed? Yes No a. First aid 1 2 b. Cardiopulmonary resuscitation (CPR) 1 2 c. Administration of medications 1 2 d. Prescriptions for medications 1 2 e. Immunizations or vaccinations 1 2 f. Identification or treatment of acute illnesses 1 2 g. Identification or treatment of chronic illnesses 1 2 h. Case management for students with chronic health conditions, such as asthma or diabetes 1 2 i. Administration of sports physicals 1 2 j. Identification of or referrals for dental problems 1 2 k. Lab tests 1 2 l. Prenatal care referrals 1 2 m. Identification or treatment of sexually transmitted diseases (STDs) 1 2 34. Has your district adopted a policy stating that schools will make condoms available to students? Yes 1 No 2 35. Has your district adopted a policy stating that school nurses will participate in the development of Individualized Education Plans (IEPs), when indicated? Yes 1 No 2 36. Has your district adopted a policy stating that school nurses will participate in the development of Individualized Health Plans (IHPs)? Yes 1 No 2 37. Has your district adopted a policy stating that health services staff will follow “Do Not Resuscitate,” or DNR orders? Yes 1 No 2 38. Has your district adopted a policy stating that schools will provide each of the following services to students when needed? These services might be provided in one-on-one or small group discussions by any school staff. Please do not include classroom instruction. Yes No a. Nutrition and dietary behavior counseling, including weight management 1 2 b. Eating disorders prevention 1 2 c. Physical activity and fitness counseling 1 2 d. Pregnancy prevention 1 2 e. HIV prevention 1 2 f. STD prevention 1 2 g. Suicide prevention 1 2 h. Tobacco use prevention 1 2 i. Alcohol or other drug use prevention 1 2 j. Violence prevention, for example bullying, fighting, or homicide 1 2 k. Accident or injury prevention 1 2 39. Has your district adopted a policy stating that schools will provide each of the following services to students when needed? Again, these services might be provided by any school staff. Yes No a. Tobacco use cessation 1 2 b. Alcohol or other drug use treatment 1 2 c. Crisis intervention for personal problems 1 2 d. Identification of or counseling for mental or emotional disorders, such as anxiety or depression 1 2 e. Stress management 1 2 f. Eating disorders treatment 1 2 g. Identification of or referral for physical, sexual, or emotional abuse 1 2 h. HIV testing and counseling 1 2 i. Referrals for after-school programs such as day-care or supervised recreation 1 2 j. Services for gay, lesbian, or bisexual students 1 2 k. Referrals for child care for teen mothers 1 2 l. Assistance with enrolling in the Special Supplemental Food Program for Women, Infants, and Children (WIC) or accessing food stamps or food banks 1 2 m. Assistance with enrolling in Medicaid or the Children’s Health Insurance Program (CHIP) 1 2 n. Job readiness skills programs 1 2 40. Based on policies adopted by your district, what is the minimum level of education required for a newly-hired school nurse? If specific requirements are not described, please mark this box ? and skip to Question 41. Mark ? one box. Associate’s degree in nursing 1 Associate’s degree in some other field 2 Undergraduate degree in nursing 3 Undergraduate degree in some other field 4 Graduate degree in nursing 5 Graduate degree in some other field 6 41. Based on policies adopted by your district, which of the following qualifications will a newly-hired school nurse have? If specific qualifications are not described, please mark this box ? and skip to Question 42. Yes No a. Licensed practical nurse’s (LPN’s) license 1 2 b. Registered nurse’s (RN’s) license 1 2 42. Has your district adopted a policy stating that a newly-hired school nurse will be certified by a state agency or board? If your state does not certify school nurses, please mark this box ? and skip to Question 43. Yes 1 No 2 43. Based on policies adopted by your district, what is the required student-to-school nurse ratio? If your district has not adopted a policy, please mark this box ? and skip to Question 44. _____ Students per school nurse 44. Based on policies adopted by your district, what is the required school-to-school nurse ratio? If your district has not adopted a policy, please mark this box ? and skip to Question 45. _____ Schools per school nurse 45. Currently, how many school nurses provide standard health services at schools in your district? If your district does not have any school nurses, please mark this box ? and skip to Question 50. _____ Nurses 46. During the past 2 years, has your district provided any funding for or offered staff development on each of the following topics to school nurses? This might include workshops, conferences, continuing education, graduate courses, or any other kind of in-service. Yes No a. First aid 1 2 b. CPR 1 2 c. Administration of medications 1 2 d. Prescriptions for medications 1 2 e. Immunizations or vaccinations 1 2 f. Identification or treatment of acute illnesses 1 2 g. Identification or treatment of chronic illnesses 1 2 h. Case management for students with chronic health conditions, such as asthma or diabetes 1 2 i. Sports physicals 1 2 j. Dental problems 1 2 k. Lab tests 1 2 l. Prenatal care 1 2 m. Identification or treatment of STDs 1 2 47. During the past 2 years, has your district provided any funding for or offered staff development on each of the following topics to school nurses? Yes No a. Nutrition and dietary behavior counseling, including weight management 1 2 b. Eating disorders prevention 1 2 c. Physical activity and fitness counseling 1 2 d. Pregnancy prevention 1 2 e. HIV prevention 1 2 f. STD prevention 1 2 g. Suicide prevention 1 2 h. Tobacco use prevention 1 2 i. Alcohol or other drug use prevention 1 2 j. Violence prevention, for example bullying, fighting, or homicide 1 2 k. Accident or injury prevention 1 2 48. During the past 2 years, has your district provided any funding for or offered staff development on each of the following topics to school nurses? Yes No a. Tobacco use cessation 1 2 b. Alcohol or other drug use treatment 1 2 c. Crisis intervention for personal problems 1 2 d. Identification of or counseling for mental or emotional disorders, such as anxiety or depression 1 2 e. Stress management 1 2 f. Eating disorders treatment 1 2 g. Identification of or referral for physical, sexual, or emotional abuse 1 2 h. HIV testing and counseling 1 2 i. After-school programs such as day-care or supervised recreation 1 2 j. Services for gay, lesbian, or bisexual students 1 2 k. Child care options for teen mothers 1 2 l. Enrollment in WIC or accessing food stamps or food banks 1 2 m. Enrollment in Medicaid or CHIP (Children’s Health Insurance Program) 1 2 n. Job readiness skills programs 1 2 49. In your district, who employs school nurses? Yes No a. School district 1 2 b. Schools 1 2 c. Local health departments 1 2 d. Local hospitals 1 2 e. Local mental health or social services agencies 1 2 f. Universities or medical schools 1 2 g. Managed care organizations 1 2 50. Has your district adopted a policy stating that health aides will work under the supervision of a nurse or physician at all times? By “supervision”, we mean training, monitoring, and evaluation. If your district does not have any health aides, please mark this box ? and skip to Question 51. Yes 1 No 2 51. Has your district adopted a policy stating that each school will have someone to oversee or coordinate health services at the school? Yes 1 No 2 52. During the past 2 years, has your district provided any funding for or offered staff development on HIV and AIDS to school faculty and staff? The staff development program would cover factual information about HIV infection and AIDS, infection control procedures (universal precautions), or policies about HIV infected school staff and students. Yes 1 No 2 53. Does your district provide model policies on HIV infected students and staff to schools? This might include policies developed by your district, or those based on model policies developed by your state or elsewhere. Yes 1 No 2 School-Based Health Center Services 54. The following questions ask about health services offered at school-based health centers — that is, health centers on school property where enrolled students can receive primary care, including diagnostic and treatment services. These services are usually provided by a nurse practitioner or physician’s assistant. Please do not include a traveling or mobile health center. Currently, how many school-based health centers offer health services to students in your district? _____ School-based health centers If none, please skip to Question 56. 55. Currently, does your district provide any funding for any of your school-based health centers? Yes 1 No 2 Services Provided at Other Sites 56. This next set of questions asks about health services delivered to students at other sites not on school property regardless of whether the services are paid for by the school system. These services may be provided by health care professionals who work at school-linked health centers or who have a contract, memorandum of agreement, or other similar arrangement with the district or school to provide health services to students. Currently, does your district have such arrangements to provide health services when needed to students in your district? Yes 1 No 2 ==> Skip to Question 59 57. Which of the following organizations or health care professionals have such arrangements with your district to provide health services to students when needed? Yes No a. School-linked health center 1 2 b. Local health department 1 2 c. Local hospital 1 2 d. Local mental health or social services agency 1 2 e. University or medical school 1 2 f. Managed care organization 1 2 g. Private physician 1 2 h. Private dentist 1 2 58. Does your district have such arrangements to provide each of the following health services to students as needed? Yes No a. Primary care 1 2 b. Administration of medications 1 2 c. Prescriptions for medications 1 2 d. Immunizations or vaccinations 1 2 e. Identification or treatment of acute illnesses 1 2 f. Identification or treatment of chronic illnesses 1 2 g. Case management for students with chronic health conditions, such as asthma or diabetes 1 2 h. Administration of sports physicals 1 2 i. Dental care or dental care referrals 1 2 j. Lab tests 1 2 k. Prenatal care or prenatal care referrals 1 2 l. Identification or treatment of STDs 1 2 Health Services Coordinator 59. Currently, does someone in your district oversee or coordinate school health services? HEB003 Yes 1 No 2 ==> That is the last question. Thank you very much for taking the time to complete this questionnaire. 60. Are you this person? Yes 1 No 2 ==> That is the last question. Thank you very much for taking the time to complete this questionnaire. 61. Who do you work for? Mark ? all that apply. School district 1 Local health department 2 Local hospital 3 Local mental health or social services agency 4 University or medical school 5 Managed care organization 6 Other 7 62. Do you have an undergraduate degree? Yes 1 No 2 ==> Skip to Question 68 63. What did you major in? Mark ? all that apply. Nursing 1 Public health 2 Biology or other science 3 Health care administration 4 Business 5 Counseling 6 Psychology 7 Social work 8 Education 9 Other 10 64. Do you have an undergraduate minor?HEC059 Yes 1 No 2 ==> Skip to Question 66 65. What did you minor in? Mark ? all that apply. Nursing 1 Public health 2 Biology or other science 3 Health care administration 4 Business 5 Counseling 6 Psychology 7 Social work 8 Education 9 Other 10 66. Do you have a graduate degree? Yes 1 No 2 ==> Skip to Question 68 67. In what area or areas? Mark ? all that apply. Nursing 1 Medicine 2 Public health 3 Biology or other science 4 Health care administration 5 Business 6 Counseling 7 Psychology 8 Social work 9 Education 10 Other 11 68. Do you have any of the following licenses? Yes No a. LPN’s license 1 2 b. RN’s license 1 2 c. Medical doctor’s (MD’s) license 1 2 69. Are you certified by a state agency or board to provide health services? If your state does not certify health services professionals or staff, please mark this box ?. Yes 1 No 2 If you would like to provide any additional comments, please use the space below. Thank you very much for taking the time to participate in this study. Additional Comments Please return this questionnaire to: Don Evers Research Triangle Institute P.O. Box 12194 Research Triangle Park, NC 27709 Health Services District Questionnaire - Final Version — Revised: 10/26/99 Health Services District Questionnaire - Final Version — Revised: 10/26/99 25 Health Services District Questionnaire - Final Version — Revised: 10/26/99 Standard Health Services Services Provided at Other Sites Health Services Coordinator