Form 1 survey

Attachment 2: Data Collection Instruments

1. Administrator Survey

Admininistrator

OMB No.: 0925-0557
Expiration Date: 01/31/2009

2009–10
Health Behaviors in School-Age Children
Admininistrator Questionnaire
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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN:
PRA (0925-0557). Do not return the completed form to this address.

The purpose of this questionnaire is to assess physical education, nutrition, tobacco, violence, and health programs and
policies in your school. Follow the instructions for each question, checking the response that best represents your answer.
Thanks for your cooperation. Your answers will be kept confidentialy.

Instructions for Completing the Survey
 Read all the printed answers before marking your choice.
 Mark the circle for the one answer that best fits your situation.
 Use a No. 2 pencil.
 Make heavy marks that fill the circle for your answer.
 Erase cleanly any answer you wish to change.
 Please do not make stray marks of any kind.

2. Does this school offer students opportunities to
participate in intramural activities or physical
activity clubs?
(Mark one circle)
 No

Yes

The following four (4) questions ask about physical
education and after school physical activity
programs.
1. Is physical education (PE) required for students
in grades 6, 7, 8, 9, or 10 in this school?
 No (SKIP TO QUESTION 2)

Yes

Don’t know (SKIP TO QUESTION 2)

3. Which of these facilities for physical activity
exist in the indoor school area, the school
yard (within 200 meters), or in the school
neighborhood (200 yards to 2000 yards)?
(Mark “no” or “yes” for each item.)

1b. Please indicate the number of days per week
in which physical education (PE) classes
are required in your school for each of the
following grades: (Please mark one circle per
response for each item. If PE is not required for the
entire school year, please estimate average for full
school year, e.g., 3days/week for 1/3 of school year
= 1day/week average across full school year.)
0 days
1 day
2 days
3 days
4 days
5 days
This grade level is not in our school

a. Grade 6
b. Grade 7
c. Grade 8
d. Grade 9
e. Grade 10

1c. Please indicate how much time per week is
allocated to physical education (PE) classes
that are required in your school for each of the
following grades: (If PE is not required for the
entire school year, please indicate the number of
hours per week during those weeks it is required.)

Grade 6 ___hours ___minutes (per week)
 This grade level is not in our school
Grade 7 ___hours ___minutes (per week)
 This grade level is not in our school
Grade 8 ___hours ___minutes (per week)
 This grade level is not in our school
Grade 9 ___hours ___minutes (per week)

 This grade level is not in our school
Grade 10 ___hours ___minutes (per week)
 This grade level is not in our school

2

No
a. Gymnasium,

sport hall
b. Swimming

facilities
c. Football and/

or soccer field
d. Court space with
permanent
improvements
for other ball

activities
e. Areas for
boarding/skating
f. Open field space
with no markings
g. Playground

equipment
h. Activity trails

i. Green fields/
parks/nature

reserve
j. Wooded areas

k. Water (sea, river,
lake)

Yes

Have students access
to this in unstructured
school time? (Breaks,
free hours).
No
Yes

4. Does the school organize physical activities
during the school day outside Physical Education
classes? (Please mark one circle for each line)

7. Does your school’s cafeteria offer any of the
following options?
Every day
3-4 times a week
1-2 times a week
Less than once a week
Never

Yes, 3-5 days per week
Yes,1-2 days per week
Yes, 2-3 days per month
No

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a. Salad bar
b. Whole Grains
(i.e., whole grain bread, brown rice)
c. Vegetarian entrees

a. Before school hours
b. In lunchtime
c. In breaks
d. After school
e. Other times during the school day

8. Can students purchase any of the following
items from vending machines or at the school
store, cafeteria, or snack bar? (Please mark one
circle for each line)

The following six (6) questions ask about
nutrition-related policies and practices at this
school.

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5a. Which graders are allowed to leave campus
during their lunch period?
 No grades are allowed to leave campus.
Skip to question 6.

Mark all that apply

 1
 2
 3

 4
 5
 6

 7

8

9

Yes, daily
Yes, some days
No

a. Chocolate candy
b. Other kinds of candy
c. Salty snacks that are not low in fat,
such as regular potato chips
d. Salty snacks that are low in fat, such as
such as pretzels, baked chips, or other
low fat chips
e. Fruits
f. Vegetables
g. Soft drinks, sports drinks, or fruit drinks
that are not 100% juice
h. 100% fruit juice
i. Bottled water
j. Whole milk
k. Skim (non-fat) or low-fat milk
l. Chocolate milk
m. Warm drinks (coffee, tea, hot cocoa)
n. Yogurt
o. Regular cookies, crackers, cakes, pastries,
or other non-low-fat baked goods
p. Low-fat cookies, crackers, cakes,
pastries, or other low-fat baked goods
q. Pizza

 10
 11
 12

5b. Which of the following off-campus food sources
are close enough for students to walk or drive
to during lunch?
 Fast food restaurants
 Other restaurants, cafeterias, or diners
 Supermarkets, convenience stores, or other
stores

Off-campus lunch wagons or push carts
 Other food sources (Specify)
_______________________________________
6. How often do school organizations sell pizza or
other main entrée items during lunch?
 Every day
 Three to four times a week

One to two times a week

Less than once a week

Never

School district forbid organizations from selling
food during lunch periods

Don’t know

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9. Does this school… (Mark “no” or “yes” for each
item.)

No
Yes
a. Offer a la carte breakfast items

to students?
b. Participate in the USDA
reimbursable School Breakfast

Program?
c. Offer any other breakfast meals

to students?

The next two (2) questions are about staff and student development.
14. During the past three years, did the school
facilitate staff development (such as workshops,
conferences, courses, continuing education, or
any other kind of in-service training) on the
following topics? (Please mark one circle for each line)
Yes , for the cafeteria personnel
Yes, for the teachers
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Yes, for the principal (school leadership)
No

10. Does this school… (Mark “no” or “yes” for each
item.)

No
Yes
a. Offer a la carte lunch items

to students?
b. Participate in the USDA
reimbursable School Lunch

Program?
c. Offer any other lunch meals

to students?

a. Nutrition
b. Physical activity
c. ICT (information and communication
technology/computer use)
15. In the past 3 years, which of the following
programs/projects have your school
participated in? (Mark “no” or “yes” for each item.)

No

a. Physical activity program
b. Nutrition program

c. Bullying and/or violence

prevention program

d. Anti-smoking program (e.g.:

smoke-free classes)
e. Alcohol and/or drugs program

f. Sex education program

11. On a typical day, about how many students are
eligible for free/reduced price meals? (Write in
the number of students or percentage)

_______________ number of students
or

_______________ percentage (%) of students

The following two (2) questions ask about tobacco
use policy at this school.

16. Does your school have a written plan for
responding to violence at the school?
(Mark one response.)
 No

Yes

12. Has this school adopted a policy prohibiting
tobacco use by faculty and staff? (Mark one
response)
 No (SKIP TO QUESTION 13)

Yes

The following two (2) questions ask about student
health screenings that might be conducted at this
school. Please think about screenings done in any
grade while a student attends this school.

13. Does that policy specifically prohibit tobacco
use by faculty and staff in any of the following
locations? (Mark “no” or “yes” for each item.)

No

a. In school buildings
b. On school grounds

c. In school buses or other vehicles

used to transport students
d. At off-campus, school-sponsored
events

Yes

17. Are most students from this school screened at
the school for any of the following? (Mark “no”
or “yes” for each item.)

No
Yes

a. Height and weight (or body mass)
b. Hearing problems

c. Vision problems

d. Oral health problems

Yes

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18. Please indicate what the school does when
a student’s screening indicates a potential
problem. (Mark “no” or “yes” for each item.)

The following two (2) questions ask about health
education programs in this school.

Yes

21. Please indicate the number of days per week
in which health education (HE) classes
are required in your school for each of the
following grades: (Please mark one circle for
each response for each item. If HE is not required
throughout the school year, please estimate average
for full school year, e.g., 3 days/week for 1/3 of school
year = 1day/week average across full school year.)

The following two (2) questions ask about mental
health and social services provided at this school.
Please include both contracted providers and
regular school staff.

This grade level is not in our school
5 days
4 days
3 days
2 days
1 day
0 days

a. Notify the student’s parents or

guardians
b. Notify the student’s teachers
c. ot applicable—no health
screenings

No

19. Are there part-time or full-time guidance
counselors, psychologists, or social workers
who provide standard mental health or social
services to students at this school? (Mark one
response)
 No (SKIP TO QUESTION 21)

Yes

a. Grade 6
b. Grade 7
c. Grade 8
d. Grade 9
e.
Grade 10

20. During the past 30 days, how many hours per
week in total have the guidance counselors,
psychologists, and/or social workers spent at
this school? (Mark one response)
 Fewer than 5 hours

5 to 10 hours

11 to 15 hours

16 to 20 hours

21 hours or more

22. During this school year, which of the following
topics have been included in a required health
education course in grades 6 through 10? (Mark
one circle for each item.)
10th Grade
9th Grade
8th Grade
7th Grade
6th Grade

a. Accident or injury prevention
b. Alcohol or other drug use

prevention
c. Dental and oral health

d. Emotional and mental health
e. Growth and development
f. Physical activity and fitness
g. Tobacco use prevention
h. Bullying prevention

i. Fighting prevention

j. Homicide prevention

k. Nutrition and dietary behavior
l. HIV (Human immunodeficiency
virus) prevention

m. Human sexuality
n. Pregnancy prevention
o. STI (sexually transmitted
infection) prevention
p. Suicide prevention
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The following question asks about your current
position.

______________________________________________

23. What is your position in this school? (Mark one
response)
 Principal

Assistant or Vice Principal

Other administrator

Other, (specify: _______________________.)

______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________

Thank you for your responses. Please seal this
completed questionnaire in the envelope provided
and give to the HBSC data collector who visits your
school.

______________________________________________
______________________________________________
______________________________________________

COMMENTS

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This is the end of the survey.
If there is time, please go back and review each question to be sure you have answered all the questions and followed the directions.
THANK YOU VERY MUCH FOR YOUR HELP!

Admini

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