Form Approved OMB No: 0920-0445 Expiration Date: 11/30/2008 Health Services District Questionnaire Health Services District Questionnaire Questions District Configuration 1 Student Health Records 2 Required Immunizations 3 - 7 Tuberculosis Testing 8 - 11 Procedures for Student Medication 12 - 19 Approach to Students or Staff with HIV or AIDS 20 - 21 Medicaid 22 Collaboration 23 - 25 Evaluation 26 Injury Reports 27 - 29 Standard Precautions 30 Illness Reports 31 - 32 Screening 33 - 42 Other Services 43 - 50 Staffing Characteristics 51 – 64 Model Policies 65 School-Based Health Center Services 66 - 68 Services at Other Sites 69 - 71 Health Services Coordinator 72 - 81 Public reporting burden for this collection of information is estimated to average 40 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-74, Atlanta, GA 30333; Attention PRA (0920-0445). NOTE: THROUGHOUT THIS QUESTIONNAIRE, TEXT THAT APPEARS IN ALL CAPITAL LETTERS WILL NOT BE READ ALOUD TO RESPONDENTS. THIS QUESTIONNAIRE WILL BE ADMINISTERED USING COMPUTER ASSISTED TELEPHONE INTERVIEW TECHNOLOGY. THE INTERVIEWER WILL READ THE QUESTIONS ALOUD AND TYPE RESPONSES TO THE QUESTIONS INTO THE 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, AND 4) PERFORM OTHER USEFUL FUNCTIONS. THE PROGRAMMING SPECIFICATIONS FOR THE INTERVIEW ARE NOT INCLUDED IN THIS PRINTED VERSION OF THE QUESTIONNAIRE. 1. This questionnaire focuses on your district’s policies and practices regarding health services. 2. When I use the word “policy,” I mean any law, rule, regulation, administrative order, or similar kind of mandate issued by the local school board or other local agency with authority over schools in your district. I am most interested in what is required by the district, not what is recommended or contained in non-binding guidance documents, unless the question specifically asks about recommendations. 3. If a district policy is worded in such a way that it requires schools to develop and adopt their own policies on a given topic, for the purpose of this questionnaire please consider it the same as a district-wide requirement. 4. I recognize that the district may sometimes grant policy exceptions or waivers, but please answer each question based on what is considered the general policy and standard practice. 5. 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. To save time, I would like to determine the school levels contained in your district and ask you only about those. 1a. Does your district contain elementary schools? Yes 1 No 2 1b. What about middle or junior high schools? Yes 1 No 2 1c. What about senior high schools? Yes 1 No 2 The first question asks about information that might be found in student records. 2. Has your district adopted a policy stating that schools will obtain and 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 screening results 1 2 d. Other screening records, such as vision or hearing 1 2 e. Immunization status 1 2 f. Medication needs 1 2 g. Dietary needs or restrictions 1 2 h. Severe food or other allergies 1 2 i. Physical activity restrictions 1 2 j. Asthma action plans 1 2 k. Emergency contact information 1 2 l. An authorization for emergency treatment 1 2 m. Insurance coverage information 1 2 Now I’d like to ask you about your district’s policies regarding student immunizations. IF DISTRICT DOES NOT CONTAIN ELEMENTARY SCHOOLS (Q1A IS “NO”), SKIP TO THE INSTRUCTIONS TO Q6. 3. Has your district adopted a policy stating that students entering kindergarten or first grade will have… Yes No a. A measles-containing vaccine, such as MMR? 1 2 b. A polio vaccine, such as IPV? 1 2 c. A diphtheria vaccine? 1 2 d. A tetanus vaccine? 1 2 e. A haemophilus influenzae type b or Hib vaccine? 1 2 f. An influenza vaccine? 1 2 g. A hepatitis B vaccine? 1 2 h. A chicken pox or varicella vaccine? 1 2 4. Has your district adopted a policy related to whether students are excluded from attending classes if they have not received the required immunizations for entry into kindergarten or first grade? Yes 1 No 2 -->SKIP TO Q6 Please choose the one statement that best describes your district’s policies related to whether students are excluded from attending classes if they have not received the required immunizations for entry into kindergarten or first grade. Please do not include students who are exempt from immunization requirements for medical, religious, or philosophical reasons. 5. Based on policies adopted by your district, are students who have not received the required immunizations for entry into kindergarten or first grade… Immediately excluded from attending classes, 1 Allowed to attend classes indefinitely, or 2 Are they allowed to attend for a specified number of days and then excluded? 3 IF DISTRICT DOES NOT CONTAIN MIDDLE OR JUNIOR HIGH SCHOOLS (Q1B IS “NO”), SKIP TO THE INSTRUCTIONS TO Q7. 6. Has your district adopted a policy stating that students entering middle or junior high school will have… Yes No a. A second measles-containing vaccine? 1 2 b. A hepatitis A vaccine? 1 2 c. A hepatitis B vaccine? 1 2 d. A chicken pox or varicella vaccine? 1 2 e. A tetanus booster? 1 2 IF DISTRICT DOES NOT CONTAIN SENIOR HIGH SCHOOLS (Q1C IS “NO”), SKIP TO THE INTRODUCTION TO Q8. 7. Has your district adopted a policy stating that students entering senior high school will have… Yes No a. A second measles-containing vaccine? 1 2 b. A hepatitis A vaccine? 1 2 c. A hepatitis B vaccine? 1 2 d. A chicken pox or varicella vaccine? 1 2 e. A tetanus booster? 1 2 The next questions ask about your district’s policies regarding tuberculosis or TB testing. IF DISTRICT DOES NOT CONTAIN ELEMENTARY SCHOOLS (Q1A IS “NO”), SKIP TO Q9. 8. Which of the following three statements best describes your district’s requirements for tuberculosis or TB testing for students prior to entry into kindergarten or first grade? The district requires TB testing prior to school entry for all students, 1 The district requires TB testing prior to school entry only for students meeting certain criteria, for example those born or recently living in other countries, or 2 The district does not require TB testing prior to school entry for any students? 3 9. Which of the following three statements best describes your district’s requirements for routine TB testing after school entry? Please do not include TB testing that might be done during a school outbreak. The district requires periodic TB testing for all students, 1 The district requires periodic TB testing only for students meeting certain criteria, for example those born or recently living in other countries, or 2 The district does not require periodic TB testing for any students? 3 IF Q8 IS 3 OR Q8 IS SKIPPED APPROPRIATELY AND Q9 IS 3, SKIP TO THE INTRODUCTION TO Q12. IF Q8 IS 1 OR 2 OR IF Q8 IS SKIPPED AND Q9 IS 3, SKIP TO Q11. 10. Which of the following three statements best describes your district’s requirements for how often (these) students are tested? Again, please do not include TB testing that might be done during a school outbreak. (These) students are tested in one particular grade, 1 (These) students are tested in more than one grade, but not every year, or 2 (These) students are tested every year? 3 11. Which method are schools required to use when initially screening students for TB? PPD skin test done by Mantoux method, 1 Skin test, not otherwise specified, 2 Chest x-ray, or 3 Is no specific testing method required? 4 Now I’d like to ask you a few questions about your district’s policies regarding medication administration to students at school. 12. Has your district adopted a policy related to who may administer medications to a student at school? Yes 1 No 2 -->SKIP TO Q15 13a. Has your district adopted a policy stating that a school nurse may administer medications to students? Yes 1 No 2 13b. What about a school physician? Yes 1 No 2 13c. What about a school health aide? Yes 1 No 2 13d. What about teachers? Yes 1 No 2 13e. What about other school staff, such as principals or secretaries? Yes 1 No 2 IF Q13C, Q13D, OR Q13E ARE “YES,” CONTINUE TO Q14. OTHERWISE, SKIP TO Q15. 14. Has your district adopted a policy stating that when someone other than a school nurse or school physician administers medications to students, the administration will be delegated by the school nurse or school physician? Yes 1 No 2 15. Has your district adopted a policy stating that schools will have written instructions from the physician or prescriber before school nurses, teachers, or any other school staff may administer medications to a student? Yes 1 No 2 No school staff may administer medication 3 16. Has your district adopted a policy stating that schools will have a written request from the parent or guardian before school nurses, teachers, or any other school staff may administer medications to a student? Yes 1 No 2 No school staff may administer medication 3 17. Has your district adopted a policy stating that schools will have written information on possible side-effects before school nurses, teachers, or any other school staff may administer medications to a student? Yes 1 No 2 No school staff may administer medication 3 18. Does your district permit students to carry and self-administer medications? Yes 1 No 2 -->SKIP TO THE INTRODUCTION TO Q20A 19. Has your district adopted a policy stating that some students may carry and self-administer… Yes No a. A prescription quick-relief inhaler? 1 2 b. An epinephrine auto-injector, such as an EpiPen®? 1 2 c. Insulin or other injected medications? 1 2 d. Other prescribed medications? 1 2 e. Over-the-counter medications? 1 2 The next questions ask about state policy related to students who have human immunodeficiency virus - also known as HIV infection, or acquired immunodeficiency syndrome - also known as AIDS. 20. Has your district adopted a policy stating that schools will allow students who have HIV infection or AIDS to… Yes No a. Attend classes as long as they are able? 1 2 b. Participate in school sports as long as they are able? 1 2 c. Participate in any other school activities as long as they are able? 1 2 21. Has your district adopted a policy stating that schools will allow teachers and staff who have HIV infection or AIDS to continue working as long as they are able? Yes 1 No 2 The next question asks about schools in your district that serve as Medicaid providers by providing health services to students. By health services, I mean services such as nursing procedures, or occupational, physical, or speech therapy. 22. In your district, do any schools serve as Medicaid providers by providing health services to students? Yes 1 No 2 Now I’d like to ask you a few questions about collaboration on health services activities with other district-level staff and outside organizations. 23a. During the past 12 months, have district health services staff worked on school health services activities with district-level health education staff? Yes 1 No 2 District does not have district-level health education staff 3 23b. What about with district-level physical education staff? Yes 1 No 2 District does not have district-level physical education staff 3 23c. What about with district-level nutrition or food service staff? Yes 1 No 2 District does not have district-level nutrition or food service staff 3 23d. What about with district-level mental health or social services staff? Yes 1 No 2 District does not have district-level mental health or social services staff 3 24. During the past 12 months, have district health services staff worked on school health services activities with staff or members from… 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 local child welfare agency? 1 2 e. A health organization, such as the American Heart Association or the American Red Cross? 1 2 f. A local college or university? 1 2 g. A local service club, such as the Rotary Club? 1 2 h. A local business? 1 2 25. During the past 12 months, has your district provided families with information on school health services? Yes 1 No 2 The next questions ask about different aspects of your district’s school health services program that might have been evaluated during the past two years. 26a. During the past two years, has the quality of the school health services program been evaluated? Yes 1 No 2 26b. What about school health services policies? Yes 1 No 2 District does not have school health services policies 3 26c. What about school health services staff development or in-service programs? Yes 1 No 2 District did not have school health services staff development or in-service programs in the past two years 3 The next question asks about your district’s policy regarding students who are seriously injured on school property. By “seriously injured,” I mean an injury requiring emergency medical services or EMS response or immediate care by a physician or other health care professional. 27. Has your district adopted a policy stating that schools will complete a report after a student is seriously injured on school property? Yes 1 No 2 -->SKIP TO THE INTRODUCTION TO Q30A 28. Has your district adopted a policy stating that the following information will be recorded on student injury reports? Yes No a. Location where injury occurred, such as playground or field, hallway or stairway 1 2 b. Activity during which injury occurred, such as baseball, sitting, or throwing 1 2 c. Nature of injury, such as bruise or burn 1 2 d. School staff who were present when the injury occurred 1 2 e. Cause of injury, such as a fall, equipment, or another student 1 2 f. Response of school staff to the injury, such as an EMS call or treatment provided by school staff 1 2 g. Immediate outcome of injury, such as hospitalization or school days missed by student 1 2 29. Has your district adopted a policy stating that schools will submit student injury report data to the school district or local health department? Yes 1 No 2 Next I’m going to ask about your district’s policy regarding the application of standard precautions and the availability of these supplies. 30a. Has your district adopted a policy stating that supplies for applying standard or universal precautions, including disposable gloves and bandages, will be available in all classrooms? Yes 1 No 2 30b. What about in the gymnasium, on playgrounds, or on playing fields? Yes 1 No 2 30c. What about on school buses or in other vehicles used to transport students? Yes 1 No 2 31. Has your district adopted a policy stating that schools will report notifiable diseases among students to the state or local health department? Yes 1 No 2 The next question asks about your district’s policy regarding students who experience a serious illness at school. By “serious illness,” I mean one requiring EMS response, or immediate care by a physician or other health care professional. 32. Has your district adopted a policy stating that schools will write a report when a student experiences a serious illness at school? Yes 1 No 2 The next questions are about district policies on student health screenings. By “student health screenings,” I 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. 33. Has your district adopted a policy stating that schools will screen students for hearing problems? Yes 1 No 2 -->SKIP TO Q35 34a. Has your district adopted a policy stating that a student’s parents or guardians will be notified when the student’s hearing screening indicates a potential problem? Yes 1 No 2 34b. Has your district adopted a policy stating that a student’s teacher will be notified when the student’s hearing screening indicates a potential problem? Yes 1 No 2 35. Has your district adopted a policy stating that schools will screen students for vision problems? Yes 1 No 2 -->SKIP TO Q37 36a. Has your district adopted a policy stating that a student’s parents or guardians will be notified when the student’s vision screening indicates a potential problem? Yes 1 No 2 36b. Has your district adopted a policy stating that a student’s teacher will be notified when the student’s vision screening indicates a potential problem? Yes 1 No 2 37. Has your district adopted a policy stating that schools will screen students for oral health problems? Yes 1 No 2 -->SKIP TO Q39 38a. Has your district adopted a policy stating that a student’s parents or guardians will be notified when the student’s oral health screening indicates a potential problem? Yes 1 No 2 38b. Has your district adopted a policy stating that a student’s teacher will be notified when the student’s oral health screening indicates a potential problem? Yes 1 No 2 39. 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 Q41 40. Has your district adopted a policy stating that a student’s parents or guardians will be notified when the student’s height and weight or body mass screening indicates a potential problem? Yes 1 No 2 41. Has your district adopted a policy stating that schools will screen students for scoliosis? Yes 1 No 2 -->SKIP TO THE INTRODUCTION TO Q43 42a. Has your district adopted a policy stating that a student’s parents or guardians will be notified when the student’s scoliosis screening indicates a potential problem? Yes 1 No 2 42b. Has your district adopted a policy stating that a student’s teacher will be notified when the student’s scoliosis screening indicates a potential problem? Yes 1 No 2 The next questions ask about services that may be provided to students when needed. 43. 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 or CPR 1 2 c. Administration of medications 1 2 d. Immunizations 1 2 e. Identification or school-based management of acute illnesses 1 2 f. Identification or school-based management of chronic health conditions, such as asthma or diabetes 1 2 g. Tracking of students with chronic health conditions 1 2 h. Case management for students with chronic health conditions, such as asthma or diabetes 1 2 i. Case management for students with disabilities 1 2 j. Administration of sports physicals 1 2 k. Identification of or referrals for oral health problems 1 2 l. Administration of fluoride rinses 1 2 m. Application of dental sealants 1 2 n. Prenatal care referrals 1 2 o. Identification or treatment of sexually transmitted diseases or STDs 1 2 ANSWER Q44 IF DISTRICT CONTAINS MIDDLE/JUNIOR HIGH OR SENIOR HIGH SCHOOLS. OTHERWISE, SKIP TO Q45. 44. Has your district adopted a policy stating that middle, junior high, or senior high schools will make condoms available to students? Yes 1 No 2 45. Has your district adopted a policy stating that school nurses will participate in the development of Individualized Education Programs, or IEPs, when indicated? Yes 1 No 2 46. Has your district adopted a policy stating that school nurses will participate in the development of Individualized Health Plans, or IHPs? Yes 1 No 2 47. Has your district adopted a policy stating that school nurses will participate in the development of 504 plans, when indicated? Yes 1 No 2 48. Has your district adopted a policy stating that health services staff will follow “Do Not Resuscitate,” or DNR orders? Yes 1 No 2 The next questions ask about health services that might be provided in one-on-one or small group sessions by any school staff, but not as part of classroom instruction. 49. Has your district adopted a policy stating that schools will provide… Yes No a. Nutrition and dietary behavior counseling? 1 2 b. Physical activity and fitness counseling? 1 2 c. Pregnancy prevention? 1 2 d. HIV prevention? 1 2 e. STD prevention? 1 2 f. Suicide prevention? 1 2 g. Tobacco use prevention? 1 2 h. Alcohol or other drug use prevention? 1 2 i. Violence prevention, for example bullying, fighting, or homicide? 1 2 j. Injury prevention and safety counseling? 1 2 50. Has your district adopted a policy stating that schools will provide… Yes No a. Instruction on self-management of chronic health conditions, such as asthma or diabetes? 1 2 b. Tobacco use cessation? 1 2 c. Alcohol or other drug use treatment? 1 2 d. Crisis intervention for personal problems? 1 2 e. Identification of emotional or behavioral disorders, such as anxiety, depression, or ADHD? 1 2 f. Counseling for emotional or behavioral disorders, such as anxiety, depression, or ADHD? 1 2 g. Stress management? 1 2 h. Weight management? 1 2 i. Eating disorders treatment? 1 2 j. HIV counseling, testing, and referral? 1 2 k. Identification of or referral for physical, sexual, or emotional abuse? 1 2 l. Referrals for after-school programs such as day-care or supervised recreation? 1 2 m. Services for gay, lesbian, or bisexual students? 1 2 n. Referrals for child care for teen mothers? 1 2 o. Assistance with enrolling in WIC, or accessing food stamps or food banks? 1 2 p. Assistance with enrolling in Medicaid or SCHIP? 1 2 q. Assistance with accessing benefits for students with disabilities? 1 2 The next questions ask about your district’s education requirements for newly hired health services staff. 51. Based on policies adopted by your district, what is the minimum level of education required for a newly hired school nurse? Associate’s degree in nursing 1 Associate’s degree in any field 2 Undergraduate degree in nursing 3 Undergraduate degree in any field 4 Graduate degree in nursing 5 Graduate degree in any field 6 No specific requirements described 7 52a. Based on policies adopted by your district, will a newly hired school nurse have a Licensed Practical Nurse’s or LPN’s license? Yes 1 No 2 52b. What about a Registered Nurse’s or RN’s license? Yes 1 No 2 53. Based on policies adopted by your district, will a newly hired school nurse have… Yes No NA a. A national school nurse certification from the National Board for Certification of School Nurses? 1 2 b. A state school nurse certification? 1 2 3 54. Has your district adopted a policy stating that school nurses will earn continuing education credits on health services topics? Yes 1 No 2 Now I’d like to ask about your district’s policies for staffing schools with health services staff. 55. Has your district adopted a policy specifying a maximum student-to-school nurse ratio? Yes 1 No 2 56. Has your district adopted a policy stating that each school will have at least one full-time school nurse? Yes 1 No 2 57. 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 The next questions ask about staff development that may have been offered to school nurses during the past two years. This might include workshops, conferences, continuing education, graduate courses, or any other kind of in-service. 58. During the past two years, has your district provided funding for or offered staff development to school nurses on… Yes No a. First aid? 1 2 b. CPR? 1 2 c. Administration of medications? 1 2 d. Immunizations? 1 2 e. Identification or school-based management of acute illnesses? 1 2 f. Identification or school-based management of chronic health conditions, such as asthma or diabetes? 1 2 g. Tracking of students with chronic health conditions? 1 2 h. Case management for students with chronic health conditions, such as asthma or diabetes? 1 2 i. Case management for students with disabilities? 1 2 j. Sports physicals? 1 2 k. Oral health problems? 1 2 l. Administration of fluoride rinses? 1 2 m. Application of dental sealants? 1 2 n. Prenatal care? 1 2 o. Identification or treatment of STDs? 1 2 p. Infectious disease prevention, for example hand hygiene or food safety? 1 2 59. During the past two years, has your district provided funding for or offered staff development to school nurses on… Yes No a. Nutrition and dietary behavior counseling? 1 2 b. Physical activity and fitness counseling? 1 2 c. Pregnancy prevention? 1 2 d. HIV prevention? 1 2 e. STD prevention? 1 2 f. Suicide prevention? 1 2 g. Tobacco use prevention? 1 2 h. Alcohol or other drug use prevention? 1 2 i. Violence prevention, for example bullying, fighting, or homicide? 1 2 j. Injury prevention and safety counseling? 1 2 60. During the past two years, has your district provided funding for or offered staff development to school nurses on… Yes No a. Teaching self-management of chronic health conditions, such as asthma or diabetes? 1 2 b. Tobacco use cessation? 1 2 c. Alcohol or other drug use treatment? 1 2 d. Crisis intervention for personal problems? 1 2 e. Emergency preparedness? 1 2 f. Identification of emotional or behavioral disorders, such as anxiety, depression, or ADHD? 1 2 g. Counseling for emotional or behavioral disorders, such as anxiety, depression, or ADHD? 1 2 h. Stress management? 1 2 i. Weight management? 1 2 j. Eating disorders treatment? 1 2 k. HIV counseling, testing, and referral? 1 2 l. Identification of or referral for physical, sexual, or emotional abuse? 1 2 m. After-school programs such as day-care or supervised recreation? 1 2 n. Services for gay, lesbian, or bisexual students? 1 2 o. Child care options for teen mothers? 1 2 p. Enrollment in WIC or accessing food stamps or food banks? 1 2 q. Enrollment in Medicaid or SCHIP? 1 2 r. Accessing benefits for students with disabilities? 1 2 s. Foodborne illness outbreak detection and response? 1 2 t. Federal laws that protect the privacy of student health information, for example HIPAA or FERPA? 1 2 Now I’d like to ask you about organizations in your district that might employ school nurses. 61. In your district, are school nurses employed by… Yes No a. The 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 The next question asks about your district’s policy regarding school health aide supervision requirements. By “supervision,” I mean training and monitoring. 62. Has your district adopted a policy stating that school health aides will work under the supervision of a nurse or physician at all times? Yes 1 No 2 School health aides are not employed by the district 3 -->SKIP TO THE INTRODUCTION TO Q64 IF Q13C IS “NO,” SKIP TO THE INTRODUCTION TO Q64. 63. Has your district adopted a policy stating that school health aides will complete training on medication administration? Yes 1 No 2 The next questions ask about staff development for teachers and other school staff. 64. During the past two years, has your district provided funding for or offered staff development to any teachers or other school staff on… Yes No a. HIV infection or AIDS, including information about infection control procedures, such as standard or universal precautions, or policies about HIV-infected school staff and students? 1 2 b. Severe food or other allergies? 1 2 c. Chronic health conditions, including information about policies and procedures for chronic disease management, recognizing and responding to severe symptoms, or reducing triggers? 1 2 d. Infectious disease prevention, such as hand hygiene or food safety? 1 2 The next question asks about model policies that may be provided to schools in your district. This might include policies developed by your state, or those based on model policies developed elsewhere. 65. Does your district provide model policies to schools on… Yes No a. HIV infection or AIDS? 1 2 b. Severe food or other allergies? 1 2 c. Chronic health conditions, such as asthma or diabetes? 1 2 d. Infectious disease prevention, such as hand hygiene or food safety? 1 2 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. 66. Currently, how many school-based health centers offer health services to students in your district? _____ School-based health centers IF Q66 IS 0, SKIP TO THE INTRODUCTION TO Q69. 67. In your district, do any school-based health centers serve as Medicaid providers, by providing health services to students? Yes 1 No 2 68. Currently, does your district provide any funding for any of your school-based health centers? Yes 1 No 2 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. 69. Currently, does your district have such arrangements to provide health services when needed to students in your district? Yes 1 No 2 -->SKIP TO Q72 The next question asks which organizations or health care professionals have arrangements with your district to provide health services to students when needed. 70. Does your district have arrangements with… Yes No a. A school-linked health center? 1 2 b. A community health clinic? 1 2 c. A local health department? 1 2 d. A local hospital? 1 2 e. A local mental health or social services agency? 1 2 f. A university or medical school? 1 2 g. A managed care organization? 1 2 h. A private physician? 1 2 i. A private dentist? 1 2 The next question asks about arrangements your district may have with organizations or health care professionals to provide health services at other sites. 71. Does your district have arrangements with any organizations or health care professionals to provide… Yes No a. Primary care? 1 2 b. Prescriptions for medications? 1 2 c. Immunizations? 1 2 d. Identification or school-based management of acute illnesses? 1 2 e. Identification or school-based management of chronic health conditions, such as asthma or diabetes? 1 2 f. Case management for students with chronic health conditions, such as asthma or diabetes? 1 2 g. Case management for students with disabilities? 1 2 h. Administration of sports physicals? 1 2 i. Oral health care or oral health care referrals? 1 2 j. Administration of fluoride rinses? 1 2 k. Application of dental sealants? 1 2 l. Lab tests? 1 2 m. Prenatal care or prenatal care referrals? 1 2 n. Identification or treatment of STDs? 1 2 72. Currently, does someone in your district oversee or coordinate school health services? Yes 1 No 2 -->That is the last question. Thank you very much for taking the time to complete this interview. 73. Are you this person? Yes 1 No 2 -->That is the last question. Thank you very much for taking the time to complete this interview. 74. 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 The last set of questions ask about your educational background. 75. What is the highest grade or year of education you have completed? Less than high school 1 -->That is the last question. Thank you very much for taking the time to complete this interview. High school or GED 2 -->That is the last question. Thank you very much for taking the time to complete this interview. Associate’s degree 3 Undergraduate degree 4 Master’s degree 5 Doctoral degree 6 76. What did you major in? MARK ALL THAT APPLY Nursing 1 Public health 2 Biology or other science 3 Health care administration or business 4 Counseling, psychology, or social work 5 Education 6 Other 7 IF Q75 IS 3, SKIP TO Q80. 77. Did you have an undergraduate minor? Yes 1 No 2 -->SKIP TO THE INSTRUCTIONS BEFORE Q79 78. What did you minor in? MARK ALL THAT APPLY Nursing 1 Public health 2 Biology or other science 3 Health care administration or business 4 Counseling, psychology, or social work 5 Education 6 Other 7 IF Q75 IS 3 OR 4, SKIP TO Q80. 79. In what area or areas was your graduate work? MARK ALL THAT APPLY Nursing 1 Public health 2 Biology or other science 3 Health care administration or business 4 Counseling, psychology, or social work 5 Education 6 Other 7 80. Do you have… Yes No a. An LPN’s license? 1 2 b. An RN’s license? 1 2 c. A CNP’s license? 1 2 d. A physician’s—MD’s or DO’s—license? 1 2 81. Do you have… Yes No N/A a. A national school nurse certification from the National Board for Certification of School Nurses? 1 2 b. A state school nurse certification? 1 2 3 Thank you very much for taking the time to participate in this study. If you would like more information about this study or would like clarification of any questions in this survey, please call 800-287-1815. Health Services District Questionnaire – Public Use Version 2 Health Services District Questionnaire – Public Use Version 36 Health Services District Questionnaire – Public Use Version Special Instructions Health Services District Questionnaire – Public Use Version 2 Health Services District Questionnaire – Public Use Version Special Instructions Student Health Records District Configuration Student Health Records Required Immunizations Required Immunizations Required Immunizations Required Immunizations Tuberculosis Testing Tuberculosis Testing Tuberculosis Testing Tuberculosis Testing Procedures for Student Medication Procedures for Student Medication Procedures for Student Medication Procedures for Student Medication Procedures for Student Medication Approach to Student and Staff with HIV or AIDS Approach to Students or Staff with HIV or AIDS Medicaid Collaboration Collaboration Collaboration Evaluation Evaluation Injury Reports Standard Precautions Standard Precautions Illness Reports Screening Screening Screening Screening Screening Other Services Other Services Other Services Other Services Staffing Characteristics Staffing Characteristics Staffing Characteristics Staffing Characteristics Model Policies School-Based Health Center Services School-Based Health Center Services Services Provided at Other Sites Services at Other Sites Services at Other Sites Services at Other Sites Health Services Coordinator Health Services Coordinator Health Services Coordinator Health Services Coordinator