2016 SCHOOL HEALTH PROFILES
SCHOOL PRINCIPAL QUESTIONNAIRE

This questionnaire will be used to assess school health programs and policies across your state or school district.  Your cooperation is essential for making the results of this survey comprehensive, accurate, and timely.  Your answers will be kept confidential.

INSTRUCTIONS
1.	This questionnaire should be completed by the principal (or the person acting in that capacity) and concerns only activities that occur in the school listed below for the grade span listed below.  Please consult with other people if you are not sure of an answer.
2.	Please use a #2 pencil to fill in the answer circles completely.  Do not fold, bend, or staple this questionnaire or mark outside the answer circles.
3.	Follow the instructions for each question.
4.	Return the questionnaire in the envelope provided.

Person completing this questionnaire

Name: _____________________________________________________________________
Title: ______________________________________________________________________
School name: _______________________________________________________________
District: ____________________________________________________________________
Telephone number: ___________________________________________________________

To be completed by the agency conducting the survey

School name: ________________________  Grade span: ____________________________

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2016 SCHOOL HEALTH PROFILES
PRINCIPAL QUESTIONNAIRE

1.	Has your school ever used the School Health Index or other self-assessment tool to assess your school’s policies, activities, and programs in the following areas? (Mark yes or no for each area.) 

	Area	Yes	No
a.	Physical activity	0	0
b.	Nutrition	0	0
c.	Tobacco-use prevention	0	0
d.	Asthma	0	0
e.	Injury and violence prevention	0	0
f.	HIV, STD, and teen pregnancy prevention	0	0

2.	The Elementary and Secondary Education Act requires certain schools to have a written School Improvement Plan (SIP). Many states and school districts also require schools to have a written SIP. Does your school’s written SIP include health-related objectives on any of the following topics? (Mark yes or no for each topic, or if your school does not have a SIP, mark “No SIP.”) 
	
	Topic	Yes	No	No SIP	
a.	Health education	0	0	0
b.	Physical education	0	0	0
c.	Physical activity	0	0	0 
d.	School meal programs	0	0	0
e.	Foods and beverages available at school 
outside the school meal programs	0	0	0
f.	Health services	0	0	0
g.	Counseling, psychological, and social 
	services 	0	0	0
h.	Physical environment	0	0	0
i.	Social and emotional climate	0	0	0
j.	Family engagement	0	0	0
k.	Community involvement	0	0	0
l.	Employee wellness	0	0	0

3.	During the past year, did your school review health and safety data such as Youth Risk Behavior Survey data or fitness data as part of your school’s improvement planning process? (Mark one response.)

a	Yes
b	No
c	Our school did not engage in an improvement planning process during the past year.

4.	Currently, does someone at your school oversee or coordinate school health and safety programs and activities? (Mark one response.)

a	Yes
b	No  

5.	Is there one or more than one group (e.g., school health council, committee, team) at your school that offers guidance on the development of policies or coordinates activities on health topics? (Mark one response.)
	
a	Yes
b	No     	Skip to Question 7

6.	During the past year, has any school health council, committee, or team at your school done any of the following activities? (Mark yes or no for each activity.)

		Activity	Yes	No
a.	Identified student health needs based on a review 
of relevant data	0	0
b.	Recommended new or revised health and safety policies 
and activities to school administrators or the school 
improvement team	0	0
c.	Sought funding or leveraged resources to support health
and safety priorities for students and staff	0	0
d.	Communicated the importance of health and safety policies 
and activities to district administrators, school administrators, 
parent-teacher groups, or community members	0	0
e.	Reviewed health-related curricula or instructional materials	0	0
f.	Assessed the availability of physical activity opportunities 
for students	0	0
g.	Developed a written plan for implementing a Comprehensive
	School Physical Activity Program (a multi-component approach that 
	provides opportunities for students to be physically active before, 
	during, and after school)	0	0 

7.	Does your school have any clubs that give students opportunities to learn about people different from them, such as students with disabilities, homeless youth, or people from different cultures? (Mark one response.)

a	Yes
b	No  

8.	During the past year, did your school offer each of the following activities for students to learn about people different from them, such as students with disabilities, homeless youth, or people from different cultures? (Mark yes or no for each activity.)

		Activity	Yes	No
a.	Lessons in class	0	0
b.	Special events sponsored by the school or community organizations 
(e.g., multicultural week, family night)	0	0

SEXUAL ORIENTATION

9.	Does your school have a student-led club that aims to create a safe, welcoming, and accepting school environment for all youth, regardless of sexual orientation or gender identity?  These clubs sometimes are called gay/straight alliances. (Mark one response.)

a	Yes
b	No

10.	Does your school engage in each of the following practices related to lesbian, gay, bisexual, transgender, or questioning (LGBTQ) youth? (Mark yes or no for each practice.)

		Practice								Yes	No
	a.	Identify “safe spaces” (e.g., a counselor’s office, designated
classroom, student organization) where LGBTQ youth can 
receive support from administrators, teachers, or other 
school staff 	0	0
b.         Prohibit harassment based on a student’s perceived or actual
sexual orientation or gender identity	0	0
c. 	Encourage staff to attend professional development on safe 
and supportive school environments for all students, regardless 
of sexual orientation or gender identity	0	0  
d.	Facilitate access to providers not on school property who have 
experience in providing health services, including HIV/STD 
testing and counseling, to LGBTQ youth	0	0
e.	Facilitate access to providers not on school property who have 
experience in providing social and psychological services to 
LGBTQ youth	0	0

BULLYING AND SEXUAL HARASSMENT

(Definitions: “Bullying” means when one or more students tease, threaten, spread rumors about, hit, shove, or hurt another student repeatedly. “Sexual harassment” means unwelcome conduct of a sexual nature, including unwelcome sexual advances, requests for sexual favors, and other verbal, nonverbal, or physical conduct of a sexual nature. “Electronic aggression,” sometimes called cyber-bullying, is a type of bullying or sexual harassment that occurs when students use a cell phone, the Internet, or other electronic communication devices to send or post text, pictures, or videos intended to threaten, harass, humiliate, or intimidate other students.)

11.	During the past year, did all staff at your school receive professional development on preventing, identifying, and responding to student bullying and sexual harassment, including electronic aggression? (Mark one response.)

a	Yes
b	No

12.	Does your school have a designated staff member to whom students can confidentially report student bullying and sexual harassment, including electronic aggression? (Mark one response.)

a	Yes
b	No

13.	Does your school use electronic (e.g., e-mails, school web site), paper (e.g., flyers, postcards), or oral (e.g., phone calls, parent seminars) communication to publicize and disseminate policies, rules, or regulations on bullying and sexual harassment, including electronic aggression? (Mark one response.)

a	Yes
b	No

REQUIRED PHYSICAL EDUCATION

(Definition: Required physical education means instruction that helps students develop the knowledge, attitudes, skills, and confidence needed to adopt and maintain a physically active lifestyle that students must receive for graduation or promotion from your school.)

14.	Is a required physical education course taught in each of the following grades in your school? (For each grade, mark yes or no, or if your school does not have that grade, mark “grade not taught in your school.”)
	 	
	Grade not taught
	Grade	Yes	No	in your school
a.	6	0	0	0
b.	7	0	0	0 
c.	8	0	0	0
d.	9	0	0	0
e.	10	0	0	0
f.	11	0	0	0
g.	12	0	0	0

PHYSICAL EDUCATION AND PHYSICAL ACTIVITY 

15.	During the past year, did any physical education teachers or specialists at your school receive professional development (e.g., workshops, conferences, continuing education, any other kind of in-service) on physical education or physical activity? (Mark one response.)

a	Yes
b	No

16.	Are those who teach physical education at your school provided with each of the following materials? (Mark yes or no for each material.)

	Material	Yes	No
a.	Goals, objectives, and expected outcomes for physical 
education	0	0
b.	A chart describing the annual scope and sequence of instruction 
for physical education	0	0
c.	Plans for how to assess student performance in physical 
education	0	0
d.	A written physical education curriculum	0	0
e.	Resources for fitness testing	0	0
f.	Physical activity monitoring devices, such as pedometers or 
heart rate monitors, for physical education	0	0

17.	Outside of physical education, do students participate in physical activity breaks in classrooms during the school day? (Mark one response.)

a	Yes
b	No

18.	Does your school offer opportunities for all students to participate in intramural sports programs or physical activity clubs?  (Intramural sports programs or physical activity clubs are any physical activity programs that are voluntary for students, in which students are given an equal opportunity to participate regardless of physical ability.) (Mark one response.)

a	Yes
b	No

19.	Does your school offer interscholastic sports to students? (Mark one response.)

a	Yes
b	No

20.	Does your school offer opportunities for students to participate in physical activity before the school day through organized physical activities or access to facilities or equipment for physical activity? (Mark one response.)

a	Yes
b	No

21.	Does your school, either directly or through the school district, have a joint use agreement for shared use of school or community physical activity or sports facilities? (A joint use agreement is a formal agreement between a school or school district and another public or private entity to jointly use either school facilities or community facilities to share costs and responsibilities.)  (Mark one response.)

a	Yes
b	No

TOBACCO-USE PREVENTION POLICIES

22.	Has your school adopted a policy prohibiting tobacco use? (Mark one response.)

a	Yes
b	No	Skip to Question 26

23.	Does the tobacco-use prevention policy specifically prohibit use of each type of tobacco for each of the following groups during any school-related activity? (Mark yes or no for each type of tobacco for each group.)

	Students	Faculty/Staff	Visitors
	Type of tobacco	Yes	No	Yes	No	Yes	No
a.	Cigarettes	0	0	0	0	0	0
b.	Smokeless tobacco (e.g., chewing 
	tobacco, snuff, dip, snus)	0	0	0	0	0	0
c.	Cigars	0	0	0	0	0	0
d.	Pipes	0	0	0	0	0	0
e.	Electronic vapor products (e.g., e-cigarettes,
	vape pipes, hookah pens)	0	0	0	0	0	0

24.	Does the tobacco-use prevention policy specifically prohibit tobacco use during each of the following times for each of the following groups? (Mark yes or no for each time for each group.)

	Students	Faculty/Staff	Visitors
	Time	Yes	No	Yes	No	Yes	No
a.	During school hours	0	0	0	0	0	0
b.	During non-school hours 	0	0	0	0	0	0

25.	Does the tobacco-use prevention policy specifically prohibit tobacco use in each of the following locations for each of the following groups? (Mark yes or no for each location for each group.)

	Students	Faculty/Staff	Visitors
	Location	Yes	No	Yes	No	Yes	No
a.	In school buildings	0	0	0	0	0	0
b.	Outside on school grounds, including
	parking lots and playing fields	0	0	0	0	0	0
c.	On school buses or other vehicles
	used to transport students	0	0	0	0	0	0
d.	At off-campus, school-sponsored
	events	0	0	0	0	0	0

26.	Does your school post signs marking a tobacco-free school zone, that is, a specified distance from school grounds where tobacco use is not allowed? (Mark one response.)

a	Yes
b	No

27.	Does your school provide tobacco cessation services for each of the following groups? (Mark yes or no for each group.)

	Group	Yes	No
a.	Faculty and staff	0	0
b.	Students	0	0

28.	Does your school have arrangements with any organizations or health care professionals not on school property to provide tobacco cessation services for each of the following groups? (Mark yes or no for each group.)

	Group	Yes	No
a.	Faculty and staff	0	0
b.	Students	0	0

NUTRITION-RELATED POLICIES AND PRACTICES

29.	When foods or beverages are offered at school celebrations, how often are fruits or non-fried vegetables offered? (Mark one response.)

a	Foods or beverages are not offered at school celebrations
b	Never
c	Rarely
d	Sometimes
e	Always or almost always

30.	Can students purchase snack foods or beverages from one or more vending machines at the school or at a school store, canteen, or snack bar? (Mark one response.)

a	Yes
b	No      	Skip to Question 32

31.	Can students purchase each of the following snack foods or beverages from vending machines or at the school store, canteen, or snack bar? (Mark yes or no for each food or beverage.)

	Food or beverage	Yes	No
a.	Chocolate candy	0	0
b.	Other kinds of candy	0	0
c.	Salty snacks that are not low in fat (e.g., regular potato chips)	0	0
d.	Low sodium or “no added salt” pretzels, crackers, or chips	0	0
e.	Cookies, crackers, cakes, pastries, or other baked goods that 
are not low in fat	0	0
f.	Ice cream or frozen yogurt that is not low in fat	0	0
g.	2% or whole milk (plain or flavored)	0	0
h.	Nonfat or 1% (low-fat) milk (plain) 	0	0
i.	Water ices or frozen slushes that do not contain juice	0	0
j.	Soda pop or fruit drinks that are not 100% juice	0	0
k.	Sports drinks (e.g., Gatorade)	0	0
l.	Energy drinks (e.g., Red Bull, Monster) 	0	0
m.	Bottled water	0	0
n.	100% fruit or vegetable juice	0	0
o.	Foods or beverages containing caffeine	0	0
p.	Fruits (not fruit juice)	0	0
q.	Non-fried vegetables (not vegetable juice)	0	0

32.	During this school year, has your school done any of the following? (Mark yes or no for each.)
		Yes	No
a.	Priced nutritious foods and beverages at a lower cost while
increasing the price of less nutritious foods and beverages	0	0
b.	Collected suggestions from students, families, and school
staff on nutritious food preferences and strategies to promote
healthy eating	0	0
c.	Provided information to students or families on the nutrition
and caloric content of foods available	0	0
d.	Conducted taste tests to determine food preferences for
nutritious items	0	0
e.	Provided opportunities for students to visit the cafeteria to
learn about food safety, food preparation, or other nutrition-
related topics	0	0
f.	Served locally or regionally grown foods in the cafeteria 
or classrooms	0	0
g.	Planted a school food or vegetable garden	0	0
h.	Placed fruits and vegetables near the cafeteria cashier, where they
are easy to access	0	0
i.	Used attractive displays for fruits and vegetables in the 
cafeteria	0	0
j.	Offered a self-serve salad bar to students	0	0
k.	Labeled healthful foods with appealing names
(e.g., crunchy carrots)	0	0
l.	Encouraged students to drink plain water	0	0
m.	Prohibited school staff from giving students food or food coupons
as a reward for good behavior or good academic performance	0	0
n.	Prohibited less nutritious foods and beverages (e.g., candy, baked 
goods) from being sold for fundraising purposes	0	0

33.	Does your school prohibit advertisements for candy, fast food restaurants, or soft drinks in each of the following locations? (Mark yes or no for each location.)

	Location	Yes	No
a.	In school buildings	0	0
b.	On school grounds including on the outside of the school
building, on playing fields, or other areas of the campus	0	0
c.	On school buses or other vehicles used to transport students	0	0
d.	In school publications (e.g., newsletters, newspapers, web sites,
other school publications)	0	0
e.	In curricula or other educational materials (including assignment 
books, school supplies, book covers, and electronic media)	0	0

34.	Are students permitted to have a drinking water bottle with them during the school day? (Mark one response.)

a	Yes, in all locations
b	Yes, in certain locations
c	No

35.	Does your school offer a free source of drinking water in the following locations? (Mark yes or no for each location, or mark NA if your school does not have that location.)

	Location 	Yes	No	NA
a.	Cafeteria during breakfast	0	0	0
b.	Cafeteria during lunch	0	0	0
c.	Gymnasium or other indoor physical activity facilities	0	0	0
d.	Outdoor physical activity facilities and sports fields	0	0	0
e.	Hallways throughout the school	0	0	0

HEALTH SERVICES

36.	Is there a full-time registered nurse who provides health services to students at your school?  (A full-time nurse means that a nurse is at the school during all school hours, 5 days per week.) (Mark one response.)

a	Yes
b	No

37.	Is there a part-time registered nurse who provides health services to students at your school? (A part-time nurse means that a nurse is at the school less than 5 days a week, less than all school hours, or both.)  (Mark one response.)

a	Yes
b	No

38. 	Does your school have a school-based health center that offers health services to students? (School-based health centers are places on school campus 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.) (Mark one response.)

a	Yes
b	No

39.	Does your school provide the following services to students? (Mark yes or no for each service.)

		Service	Yes	No
a. 	HIV testing	0	0
b.	HIV treatment (ongoing medical care for persons living with HIV)	0	0
c. 	STD testing	0	0
d.	STD treatment	0	0
e. 	Pregnancy testing	0	0
f. 	Provision of condoms	0	0
g.	Provision of condom-compatible lubricants (i.e., water- or 
silicone-based) 	0	0
h. 	Provision of contraceptives other than condoms (e.g., birth control 
pill, birth control shot, intrauterine device [IUD])	0	0
i.	Prenatal care	0	0
j. 	Human papillomavirus (HPV) vaccine administration	0	0

40.	Does your school provide students with referrals to any organizations or health care professionals not on school property for the following services? (Mark yes or no for each service.)

		Service	Yes	No
a.	HIV testing	0	0
b.	HIV treatment (ongoing medical care for persons living with HIV)	0	0
c.	nPEP (non-occupational post-exposure prophylaxis for HIV--
	a short course of medication given within 72 hours of exposure to
	infectious bodily fluids from a person known to be HIV positive) 	0	0	
d.	STD testing	0	0
e.	STD treatment	0	0
f.	Pregnancy testing	0	0
g.	Provision of condoms	0	0
h.	Provision of condom-compatible lubricants (i.e., water- or 
	silicone-based) 	0	0
i.	Provision of contraceptives other than condoms (e.g., birth control 
	pill, birth control shot, intrauterine device [IUD])	0	0
j.	Prenatal care	0	0
k.	Human papillomavirus (HPV) vaccine administration	0	0

41.	Does your school have a protocol that ensures students with a chronic condition that may require daily or emergency management (e.g., asthma, diabetes, food allergies) are enrolled in private, state, or federally funded insurance programs if eligible? (Mark one response.)

a	Yes
b	No

42.	Does your school routinely use school records to identify and track students with a current diagnosis of the following chronic conditions? School records might include student emergency cards, medication records, health room visit information, emergency care and daily management plans, physical exam forms, or parent notes. (Mark yes or no for each condition.)

	Condition 	Yes	No
a.	Asthma	0	0
b.	Food allergies	0	0
c.	Diabetes	0	0
d.	Epilepsy or seizure disorder	0	0
e.	Obesity	0	0
f.	Hypertension/high blood pressure	0	0

43.	Does your school provide referrals to any organizations or health care professionals not on school property for students diagnosed with or suspected to have any of the following chronic conditions? Include referrals to school-based health centers, even if they are located on school property. (Mark yes or no for each condition.)

	Condition 	Yes	No
a.	Asthma	0	0
b.	Food allergies	0	0
c.	Diabetes	0	0
d.	Epilepsy or seizure disorder	0	0
e.	Obesity	0	0
f.	Hypertension/high blood pressure	0	0

44.	Which of the following best describes your school’s practices regarding parental consent and notification when sexual or reproductive health services, such as STD testing or pregnancy testing, are provided by your school? (Mark one response.) 

a	This school does not provide any sexual or reproductive health services.
b	Parental consent is required before any sexual or reproductive health services are provided.
c	Parental consent is not required for sexual or reproductive health services and parents are provided with information about services provided only upon request.
d	Parental consent is not required for sexual or reproductive health services, but parents may be notified depending on the service provided.
e	Parental consent is not required for sexual or reproductive health services, but parents are notified about all services provided.
f	Parental consent is not required for sexual or reproductive health services and parents are not notified about any services provided.

45.	Which of the following best describes your school’s practices regarding parental consent and notification when sexual or reproductive health services, such as STD testing or pregnancy testing, are referred by your school? (Mark one response.) 

a	This school does not refer any sexual or reproductive health services.
b	Parental consent is required before any sexual or reproductive health services are referred.
c	Parental consent is not required for sexual or reproductive health services and parents are provided with information about referrals provided only upon request.
d	Parental consent is not required for sexual or reproductive health services, but parents may be notified depending on the referral provided.
e 	Parental consent is not required for sexual or reproductive health services, but parents are notified about all referrals provided.
f	Parental consent is not required for sexual or reproductive health services and parents are not notified about any referrals provided.

FAMILY AND COMMUNITY INVOLVEMENT

46.	During this school year, has your school done any of the following activities? (Mark yes or no for each activity.)

Activity	Yes	No
a.	Provided parents and families with information about how 
to communicate with their child about sex	0	0
b.	Provided parents with information about how to monitor 
their child (e.g., setting parental expectations, keeping track 
of their child, responding when their child breaks the rules) 	0	0
c.	Involved parents as school volunteers in the delivery of health 
education activities and services	0	0
d.	Linked parents and families to health services and programs in 
the community	0	0

47.	Does your school use electronic (e.g., e-mails, school web site), paper (e.g., flyers, postcards), or oral (e.g., phone calls, parent seminars) communication to inform parents about school health services and programs? (Mark one response.)

a	Yes
b	No

48.	Does your school participate in a program in which family or community members serve as role models to students or mentor students, such as the Big Brothers Big Sisters program? (Mark one response.)

a	Yes
b	No

49.	Service learning is a particular type of community service that is designed to meet specific learning objectives for a course. Does your school provide service-learning opportunities for students? (Mark one response.)

a	Yes
b	No

50.	Does your school provide peer tutoring opportunities for students? (Mark one response.)

a	Yes
b	No

51.	During the past two years, have students’ families helped develop or implement policies and programs related to school health? (Mark one response.)

a	Yes
b    No

Thank you for your responses.  Please return this questionnaire.