Form Approved OMB No: 0920-0445 Expiration Date: 11/30/2008 Mental Health and Social Services District Questionnaire Mental Health and Social Services District Questionnaire Questions Provision of Services 1 - 5 Collaboration 6 - 7 Promotion 8 Evaluation 9 Staffing Characteristics 10 - 24 School-Based Health Center Services 25 - 26 Services Provided at Other Sites 27 - 31 Mental Health and Social Services Coordinator 32 - 41 Public reporting burden for this collection of information is estimated to average 20 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 mental health and social 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. The following questions ask about standard mental health and social services, such as crisis intervention, alcohol or other drug use treatment, or identification of emotional disorders, offered to all students at a school. These services usually are provided by a school counselor, psychologist, or social worker but also could be provided at the school by staff from collaborating community agencies. Student assistance programs provide services designed to assist students experiencing personal or social problems that can impact school performance, physical health, or overall well-being. 1. Has your district adopted a policy stating that student assistance programs will be offered to all students? Yes 1 No 2 Some schools have teams of school staff who collaborate to provide assistance to students with disabilities or those who are experiencing academic difficulties or behavioral problems. These sometimes are called student support teams, student assistance teams, or student guidance teams. 2. Has your district adopted a policy stating that schools will create and maintain such teams? Yes 1 No 2 3. Has your district adopted a policy stating that school mental health or social services staff, for example school counselors, psychologists, or social workers will participate in the development of Individualized Education Programs, or IEPs, when indicated? Yes 1 No 2 4. Has your district adopted a policy stating that school mental health or social services staff will participate in the development of Individualized Health Plans, or IHPs, when indicated? Yes 1 No 2 5. Has your district adopted a policy stating that mental health or social services staff will participate in the development of 504 plans, when indicated? Yes 1 No 2 Now I’d like to ask you a few questions about collaboration on mental health and social services activities with other district-level staff and outside organizations. 6a. During the past 12 months, have district-level mental health or social services staff worked on mental health or social services activities with district-level health education staff? Yes 1 No 2 District does not have district-level health education staff 3 6b. What about with district-level physical education staff? Yes 1 No 2 District does not have district-level physical education staff 3 6c. 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 6d. What about with district-level health services staff? Yes 1 No 2 District does not have district-level health services staff 3 7. During the past 12 months, have district mental health and social services staff worked on school mental and social 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 8. During the past 12 months, has your district provided families with information on school mental health or social services? Yes 1 No 2 The next questions ask about different aspects of the district mental health or social services program that might have been evaluated during the past two years. 9a. During the past two years, has student use of school mental health or social services been evaluated? Yes 1 No 2 9b. What about the quality of school mental health or social services? Yes 1 No 2 9c. What about school mental health or social services policies? Yes 1 No 2 District does not have school mental health or social services policies 3 9d. What about mental health or social services staff development or in-service programs? Yes 1 No 2 District did not have mental health or social services staff development or in-service programs during the past two years 3 Now I’d like to ask about the minimum level of education required for mental health and social services staff in your district. 10. Based on policies adopted by your district, what is the minimum level of education required for a newly hired school counselor? Undergraduate degree in counseling 1 Undergraduate degree in any field 2 Master’s degree in counseling 3 Master’s degree in any field 4 Doctoral degree in counseling 5 Doctoral degree in any field 6 Other degree 7 Specific requirements are not described 8 11. Has your district adopted a policy stating that a newly hired school counselor will be ` licensed or certified by a state agency or board? Yes 1 No 2 State does not license or certify school counselors 3 12. Based on policies adopted by your district, what is the minimum level of education required for a newly hired school psychologist? Undergraduate degree in psychology 1 Undergraduate degree in any field 2 Master’s degree in psychology 3 Master’s degree in any field 4 Doctoral degree in psychology 5 Doctoral degree in any field 6 Other degree 7 Specific requirements are not described 8 13. Has your district adopted a policy stating that a newly hired school psychologist will be licensed or certified by a state agency or board? Yes 1 No 2 State does not license or certify school psychologists 3 14. Based on policies adopted by your district, what is the minimum level of education required for a newly hired school social worker? Undergraduate degree in social work 1 Undergraduate degree in any field 2 Master’s degree in social work 3 Master’s degree in any field 4 Doctoral degree in social work 5 Doctoral degree in any field 6 Other degree 7 Specific requirements are not described 8 15. Has your district adopted a policy stating that a newly hired school social worker will be licensed or certified by a state agency or board? Yes 1 No 2 State does not license or certify school social workers 3 16. Has your district adopted a policy stating that newly hired school mental health or social services staff will earn continuing education credits on mental health or social services topics? Yes 1 No 2 The next questions ask about your district’s policies regarding mental health and social services staffing at schools in your district. 17. Has your district adopted a policy stating that each elementary school will have at least one full-time school counselor? Yes 1 No 2 18. Has your district adopted a policy stating that each middle or junior high school will have at least one full-time school counselor? Yes 1 No 2 19. Has your district adopted a policy stating that each senior high school will have at least one full-time school counselor? Yes 1 No 2 20. Has your district adopted a policy stating that each school will have someone to oversee or coordinate mental health or social services at the school? Yes 1 No 2 My next questions are about staff development which might include workshops, conferences, continuing education, graduate courses, or any other kind of in-service. 21. During the past two years, has your district provided funding for or offered staff development to mental health or social services staff on… Yes No a. Tobacco use cessation? 1 2 b. Alcohol or other drug use treatment? 1 2 c. Counseling after a natural disaster or other emergency or crisis situation? 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. Identification of or referral for physical, sexual, or emotional abuse? 1 2 l. Identification of or referral for students with family problems, such as parental divorce, substance abuse, or violence? 1 2 m. HIV counseling, testing, and referral? 1 2 n. After-school programs such as day-care or supervised recreation? 1 2 o. Services for gay, lesbian, or bisexual students? 1 2 p. Child care options for teen mothers? 1 2 q. Enrollment in WIC or accessing food stamps or food banks? 1 2 r. Enrollment in Medicaid or SCHIP? 1 2 s. Job readiness skills programs? 1 2 t. Ways to promote a positive school climate? 1 2 22. During the past two years, has your district provided funding for or offered staff development to mental health or social services staff 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. Sexually transmitted disease or 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 23. During the past two years, has your district provided funding for or offered staff development to mental health or social services staff on… Yes No a. Case management for students with emotional or behavioral problems? 1 2 b. Case management for students with chronic health conditions, such as asthma or diabetes? 1 2 c. Family counseling? 1 2 d. Group counseling? 1 2 e. Individual counseling? 1 2 f. Comprehensive assessment or intake evaluation? 1 2 g. Peer counseling or mediation? 1 2 h. Self-help or support groups? 1 2 24. During the past two years, has your district provided model policies or other guidance to schools on providing mental health or social services to students? Yes 1 No 2 The next question asks about mental health and social services offered at school-based health centers – that is, health centers on school property where enrolled students can receive mental health and social services, including diagnostic and treatment services. These services are usually provided by a psychologist, social worker, counselor, or other mental health or social services professional. Please do not include a traveling or mobile health center. 25. Currently, how many school-based health centers offer mental health and social services to students in your district? _____ School-based health centers IF Q25 IS 0, SKIP TO INTRODUCTION TO Q27. 26. In your district, do any school-based health centers serve as Medicaid providers, by providing mental health or social services to students? Yes 1 No 2 This next set of questions asks about mental health and social 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 mental health and social services 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 mental health or social services to students. 27. Currently, does your district have such arrangements to provide mental health or social services when needed to students in your district? Yes 1 No 2 -->SKIP TO Q32 The next question asks which mental health or social services organizations or professionals have arrangements with your district to provide mental health or social services to students when needed. 28. 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 psychologist? 1 2 i. A private psychiatrist? 1 2 j. A private social worker? 1 2 k. A private counselor? 1 2 29. Does your district have arrangements with any organizations or mental health or social services professionals to provide… Yes No a. Tobacco use cessation? 1 2 b. Alcohol or other drug use treatment? 1 2 c. Counseling after a natural disaster or other emergency or crisis situation? 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. Identification of or referral for physical, sexual, or emotional abuse? 1 2 k. Identification of or referral for students with family problems, such as parental divorce, substance abuse, or violence? 1 2 l. HIV counseling, testing, and referral? 1 2 m. Referrals for after-school programs such as day- care or supervised recreation? 1 2 n. Services for gay, lesbian, or bisexual students? 1 2 o. Referrals for child care for teen mothers? 1 2 p. Assistance with enrolling in WIC or accessing food stamps or food banks? 1 2 q. Assistance with enrolling in Medicaid or SCHIP? 1 2 r. Job readiness skills programs? 1 2 The next question asks about services provided at other sites to students when needed in one-on- one or small group sessions. 30. Does your district have arrangements with mental health or social services organizations or professionals to 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 31. Does your district have arrangements with mental health or social services organizations or professionals to provide. . . Yes No a. Case management for students with emotional or behavioral problems? 1 2 b. Case management for students with chronic health conditions, such as asthma or diabetes? 1 2 c. Family counseling? 1 2 d. Group counseling? 1 2 e. Individual counseling? 1 2 f. Comprehensive assessment or intake evaluation? 1 2 g. Peer counseling or mediation? 1 2 h. Self-help or support groups? 1 2 32. Currently, does someone in your district oversee or coordinate school mental health and social services? Yes 1 No 2 -->That is the last question. Thank you very much for taking the time to complete this questionnaire. 33. 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. 34. Do you work for the school district? Yes 1 No 2 Finally, I’d like to ask you some questions about your educational background. 35. Do you have an undergraduate degree? Yes 1 No 2 -->That is the last question. Thank you very much for taking the time to complete this questionnaire. 36. What did you major in? MARK ALL THAT APPLY Counseling 1 Psychology 2 Social work 3 Nursing 4 Health care administration or business 5 Biology or other science 6 Education 7 Other 8 37. Did you have an undergraduate minor? Yes 1 No 2 -->SKIP TO Q39 38. What did you minor in? MARK ALL THAT APPLY Counseling 1 Psychology 2 Social work 3 Nursing 4 Health care administration or business 5 Biology or other science 6 Education 7 Other 8 39. Do you have a graduate degree? Yes 1 No 2 -->SKIP TO Q41 40. In what area or areas? MARK ALL THAT APPLY Counseling 1 Psychology 2 Social work 3 Nursing 4 Medicine 5 Health care administration or business 6 Biology or other science 7 Education 8 Other 9 41. Are you licensed or certified by a state agency or board to provide school mental health or social services? Yes 1 No 2 State does not license or certify school mental health or social services professionals 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.