19 Health Services School Questionnaire

Form Approved

OMB No: 0920-0445

Expiration Date: xx/xx/xxxx

Health Services
School Questionnaire

11 January 2011

§

Public reporting burden for this collection of information is estimated to average 50 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).

Health Services
School Questionnaire

Questions

Module 1

Student Health Records 1–5

Required Immunizations 6–11

Tuberculosis Testing 12–16

Procedures for Student Medication 17–25

Funding/Medicaid 26–27

School-Based Health Centers 28–29

Promotion 30

Communication 31-32

Module 2

Screening 33–34

School Nurse Staffing 35–42

Collaboration 43–46

Educational Requirements 47–51

Other Staffing 52–59

Module 3

Facilities and Equipment 60–67

Health Services Records and Reports 68–71

Injury Reports 72–74

Illness Reports 75–80

Health Services Provision 81–89

Other Services 90–93

Services at Other Sites 94–96

Health Services Coordinator 97–115

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 PERSONAL INTERVIEW TECHNOLOGY. THE INTERVIEWER WILL READ THE QUESTIONS ALOUD AND TYPE RESPONSES TO THE QUESTIONS INTO THE LAPTOP 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. What is your job title at the school? (In which role do you spend more time?)

1) Principal 2) Asst. Principal/Other School Administrator 3) School Secretary 4) Physical Ed Teacher 5) Athletic Director 6) Health Ed Teacher 7) Other Teacher 8) Food Service Manager 9) Commercial Food Service Provider 10) Other School Food Service Staff 11) Guidance Counselor

12) Social Worker 13) Psychologist 14) Other Mental Health/ Social Services Provider 15) Nurse 16) Health Aide 17) Physician 18) Other Health Services Provider 19) SBHC Health Services Staff 20) SBHC Mental Health/ Social Services Staff 50) Other Staff

SHOW CARD 1

The first questions ask about student records.

As I read the items on this card, please tell me if each is obtained by your school and kept in any type of student record.

2. Does your school obtain and keep…

Yes No

1. A physical health history? 1 2

2. An emotional or mental health history? 1 2

3. Tuberculosis screening results? 1 2

4. Other screening records, such as vision or hearing? 1 2

5. Medication needs? 1 2

6. Dietary needs or restrictions? 1 2

7. Severe food or other allergies? 1 2

8. Physical activity restrictions? 1 2

9. Asthma action plans? 1 2

10. Emergency contact information? 1 2

11. An authorization for emergency treatment? 1 2

12. Insurance coverage information? 1 2

(Q2 Continued)

13. Student weight status, such as body mass index, or BMI? 1 2

14. Reasons for student absences…………………………………….1 2

3. During the past 12 months, has your school requested any student health information, including immunization records, from a healthcare provider?

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q6

4. During the past 12 months, has any healthcare provider refused to share student health information, including immunization records, with your school?

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q6

5. Did any healthcare provider refuse to share this information because a HIPAA, or Health Insurance Portability and Accountability Act, authorization had not been obtained from the student’s parents?

Yes 1

No 2

The next questions are about immunizations.

IF THIS IS A MIDDLE OR HIGH SCHOOL, SKIP TO THE INSTRUCTIONS BEFORE Q7.

6. Please tell me if each of the following immunizations are required for entry into kindergarten or first grade.

Yes No

1. A second measles vaccine 1 2

2. A polio vaccine 1 2

3. A pertussis vaccine 1 2

4. A tetanus vaccine 1 2

5. A hepatitis A vaccine 1 2

6. A hepatitis B vaccine 1 2

7. A chicken pox or varicella vaccine 1 2

ANSWER Q7 FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO Q8.

7. Please tell me if each of the following immunizations are required for entry into your school.

Yes No

1. A second measles vaccine 1 2

2. A hepatitis A vaccine 1 2

3. A hepatitis B vaccine 1 2

4. A chicken pox or varicella vaccine 1 2

5. A tetanus-diphtheria-pertussis, or TdAP, vaccine 1 2

6. A meningococcal conjugate vaccine 1 2

7. A human papillomavirus, or HPV, vaccine 1 2

8. Which of the following statements best describes your school’s practices related to whether students are excluded from attending classes if they have not received the required immunizations for entry into your school? Please do not include students who are exempt from immunization requirements for medical, religious, or philosophical reasons.

Students who have not received the required
immunizations for school entry
are immediately excluded from
attending classes 1 SKIP TO Q10

Students who have not received the required
immunizations for school entry
are allowed to attend classes for a specified
number of days and then excluded 2

This school does not exclude students from
attending classes if they have not received
the required immunizations for school entry 3 SKIP TO Q10

9. How many days can students who have not received the required immunizations attend class?

Days

10. Does your school require students to receive an influenza vaccine annually?

Yes 1

No 2

11. Does your school allow students to be exempted from required immunizations for…

Yes No

1. Medical reasons? 1 2

2. Religious reasons? 1 2

3. Personal beliefs? 1 2

The next question asks about requirements for tuberculosis, or TB, screening for students prior to school entry. By “screening,” I mean the identification of students meeting certain risk criteria, for example those born or recently living in other countries. Students meeting these criteria would then be referred for TB testing or required to provide evidence of medical clearance.

12. Please tell me which one of the following statements best describes the requirement for tuberculosis or TB screening of students prior to school entry.

TB screening is required prior to
school entry for all students 1

TB screening is not required prior to
school entry for any students 2

Now I’m going to ask about the requirements for tuberculosis or TB testing for students prior to school entry. By “testing,” I mean a clinical test for TB.

13. Please tell me which one of the following three statements best describes the requirement for tuberculosis or TB testing of students prior to school entry.

TB testing is required prior to school entry
based on the results of TB screening 1

TB testing is required prior to school entry
for all students 2

TB testing is not required prior to school entry
for any students 3

14. Which of the following three statements best describes your school’s requirements for periodic TB testing after school entry? Please do not include TB testing that might be done after exposure to TB at school or a school-sponsored event. For the purposes of this question, “periodic” means that the test is repeated at regular intervals (e.g., annually) or at a specific time (e.g., at the beginning of 5th grade).

Periodic TB testing is required
for all students 1

Periodic TB testing is required only
for students previously identified
through screening 2

Periodic TB testing is not required
for any students 3

IF Q13 IS 3 AND Q14 IS 3, SKIP TO THE INTRODUCTION TO Q17.

IF Q14 IS 3 AND Q13 IS 1 OR 2, SKIP TO Q16. OTHERWISE, CONTINUE TO Q15.

15. Which of the following three statements best describes your school’s requirements for how often (these) students are tested? Again, please do not include TB testing that might be done after exposure to TB at school or a school-sponsored event.

(These) students are tested in one
particular grade 1

(These) students are tested in more than
one grade, but not every year 2

Or, (these) students are tested every year 3

16. Which method is required to be used to provide evidence of a negative TB test?

Skin test not otherwise specified 1

Other skin test 2

Chest x-ray 3

Blood test (i.e., interferon-gamma
release assays) 4

No specific testing method is required 5

Now I’d like to ask you a few questions about your school’s procedures regarding medication administration to students at school. I will be asking about prescription and over-the-counter drugs separately.

17. Who is allowed to administer prescription medications to students?
    MARK ALL THAT APPLY

School nurse 1

School physician 2

School health aide 3

Teachers 4

Other school staff, such as principals
or secretaries 5

No teachers or staff are allowed
to administer prescription medications 6

18. Who is allowed to administer over-the-counter medications to students?
    MARK ALL THAT APPLY

School nurse 1

School physician 2

School health aide 3

Teachers 4

Other school staff, such as principals
or secretaries 5

No teachers or staff are allowed
to administer over-the-counter medications 6

IF Q17 OR Q18 IS 3, 4, OR 5 CONTINUE. OTHERWISE, SKIP TO Q25.

19. When someone other than a school nurse or school physician administers prescription medications to students, are these individuals required to be licensed or certified to administer medications?

Yes 1

No 2

20. When someone other than a school nurse or school physician administers over-the-counter medications to students, are such staff required to be licensed or certified to administer medications?

Yes 1

No 2

21. Are all staff who administer prescription medications to students required to be trained to administer medications?

Yes 1

No 2

22. Are all staff who administer over-the-counter medications to students required to be trained to administer medications?

Yes 1

No 2

SHOW CARD 2

23. Looking at this card, please tell me what documentation is required before school nurses, teachers, or any other school staff may administer prescription medications to a student.
    MARK ALL THAT APPLY

Written instructions from the physician
or prescriber 1

Written request from the parent or guardian 2

Written information on possible side-effects 3

None of these 4

24. Looking at this card, please tell me what documentation is required before school nurses, teachers, or any other school staff may administer over-the-counter medications to a student.
    MARK ALL THAT APPLY

Written instructions from the physician 1

Written request from the parent or guardian 2

Written information on possible side-effects 3

None of these 4

25. At your school, would a student ever be permitted to carry and self-administer…

Yes No

1. A prescription quick-relief inhaler? 1 2

2. An epinephrine auto-injector, such as an EpiPen^®? 1 2

3. Insulin or other injected medications? 1 2

4. Any other prescribed medications? 1 2

5. Any over-the-counter medications? 1 2

The next question asks about funding for standard health services at your school. For the purposes of this question, “standard” means services offered to all students at your school.

26. At your school, how are standard health services funded?
    MARK ALL THAT APPLY

School district budget 1

Medicaid 2

State Children’s Health Insurance Program,
or SCHIP 3

Private insurance 4

Public grants 5

Private grants 6

Other 7

The next question asks about whether your school serves as a Medicaid provider by providing standard health services to students.

27. Does your school serve as a Medicaid provider by providing health services to students?

Yes 1

No 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. Some school-based health centers offer mental health and social services, which are usually provided by a psychologist, social worker, or other mental health or social services professional. In answering these questions, please do not include traveling or mobile health centers.

28. Does your school have a school-based health center that offers health services to students?

Yes 1

No 2

29. Does your school have a school-based health center that offers mental health and social services to students?

Yes 1

No 2

The next question asks about promotion of standard health services that might occur at your school. By “standard,” I mean services offered to all students in your school.

30. During the past 12 months, has your school…

Yes No

1. Met with a parents’ organization, such as the PTA,
   to discuss standard school health services? 1 2

2. Provided families of all students with information
   on standard school health services? 1 2

3. Invited family members of all students to tour
   the standard school health services facilities? 1 2

4. Collected suggestions from students about school
   health services? 1 2

5. Collected suggestions from students’ families about
   school health services? 1 2

The next questions ask about communication that might occur during an infectious disease outbreak (such as flu) at your school.

31. During the past 12 months, has your school…

Yes No N/A

1. Sent letters or emails, or posted

information on a school Web site to

inform students and families about

an infectious disease outbreak at school? 1 2 3

2. Sent letters or emails, or posted
   information on a school Web site to
   inform students and families about how to

prevent infectious diseases, such as the flu? 1 2

32. During the past 12 months, has your school…

Yes No N/A

1. Sent letters or emails, or posted
   information on a school Web site to
   inform faculty and staff about an
   infectious disease outbreak at school? 1 2 3

2. Sent letters or emails, or posted
   information on a school Web site to
   inform faculty and staff about how to
   prevent infectious diseases, such as the flu? 1 2

The next questions ask about student health screenings that might be conducted at your school. By “student health screenings,” I mean screenings conducted for most students in the school or in certain grades in the school. Please do not include screenings conducted for special populations of students, for example, screenings conducted only for special education students. Please think about screenings done in any grade while a student attends your school.

33. Are most students from the designated grade or grades screened at your school for…

Yes No

1. Hearing problems? 1 2

2. Vision problems? 1 2

3. Oral health problems? 1 2

4. Weight status using body mass index, or BMI? 1 2

5. Scoliosis? 1 2

6. Mental health problems? 1 2

IF THIS SCHOOL DOES NOT CONDUCT ANY HEALTH SCREENINGS FOR THE ABOVE LISTED ITEMS (Q33A–F ARE “NO”), SKIP TO THE INTRODUCTION TO Q35.

SHOW CARD 3

34. Looking at this card, please tell me what your school does when a student’s screening for [Q33A–F] indicates a potential problem.
    MARK ALL THAT APPLY

Notify the student’s parents or guardians 1

Notify the student’s teachers 2

Provide referrals to community
healthcare providers 3

None of the above 4

Now I’d like to ask about school nurses. By “school nurse,” I mean any nurse, whether employed by the school, district, health department, or any other employer, who provides any standard health services to students at your school. By “standard,” I mean services offered to all students in your school. Please include contracted providers, regular school staff, and volunteers.

35. Is there a school nurse who provides standard health services to students at your school?

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q46

36. How many RNs provide standard health services to students at your school?

RNs

IF Q36 IS 0, SKIP TO Q38.

37. I would like to find out about the time each RN spends at your school. During the past 30 days, how many hours per week on average has/have the RN(s) spent at your school?

RN 1 Hours/week

RN 2 Hours/week

RN 3 Hours/week

RN 4 Hours/week

38. Now I would like to know how many LPNs provide standard health services at your school?

LPNs

IF Q38 IS 0, SKIP TO THE INTRODUCTION TO Q40.

39. I would like to find out about the time each LPN spends at your school. During the past 30 days, how many hours per week on average has/have the LPN(s) spent at your school?

LPN 1 Hours/week

LPN 2 Hours/week

LPN 3 Hours/week

LPN 4 Hours/week

In the following questions, a school nurse can be either an LPN or an RN.

40. Does the school nurse participate in the development of Individualized Education Programs, or IEPs, when indicated?

Yes 1

No 2

41. Does the school nurse participate in the development of Individualized Health Plans, or IHPs?

Yes 1

No 2

42. Does the school nurse participate in the development of 504 plans, when indicated?

Yes 1

No 2

The next question asks about health education provided by the school nurse that is part of a class or course. I will ask about health education provided to students outside of the classroom later in the questionnaire.

43. During the past 12 months, has the school nurse talked to or taught…

Yes No

ANSWER A–C FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO THE INSTRUCTION BEFORE Q43D.

1. A health education class at your school? 1 2

2. A physical education class? 1 2

3. Any other class at your school? 1 2

ANSWER D–F FOR ELEMENTARY SCHOOL ONLY. OTHERWISE, SKIP TO Q44A.

4. Students at your school as part of a health education
   lesson or unit? 1 2

5. Students at your school as part of a physical education
   unit or class? 1 2

6. Students at your school as part of any other lesson
   or unit? 1 2

44a. During the past 12 months, has the school nurse worked on standard school health services activities with health education staff from your school?

Yes 1

No 2

School does not have health education staff 3

44b. What about with physical education staff?

Yes 1

No 2

School does not have physical education staff 3

44c. What about with nutrition or food service staff?

Yes 1

No 2

School does not have nutrition
or food service staff 3

44d. What about with mental health or social services staff?

Yes 1

No 2

School does not have mental health
or social services staff 3

IF Q28 or Q29 IS “YES,” ASK Q44E, OTHERWISE SKIP TO Q45.

44e. What about with school-based health center staff?

Yes 1

No 2

45. During the past 12 months, has the school nurse worked on standard school health services activities for students with staff or members from…

Yes No N/A

1. A local health department? 1 2 3

2. A community healthcare provider? 1 2 3

3. A local hospital? 1 2 3

4. A local mental health or social
   services agency? 1 2 3

5. A local child welfare agency? 1 2 3

6. A health organization, such as the
   American Heart Association or
   the American Red Cross? 1 2 3

7. A local service club,
   such as the Rotary Club? 1 2 3

8. A local college or university? 1 2 3

9. A local business? 1 2

44. During the past two years, have…

Yes No

1. Students helped develop, communicate, or implement
   health services policies or activities? 1 2

2. Students’ families helped develop, communicate,
   or implement health services policies or activities? 1 2

3. Teachers helped develop, communicate, or implement
   health services policies or activities? 1 2

4. Other community members helped develop, communicate,
   or implement health services policies or activities? 1 2

The next questions ask about the education requirements for newly hired health services staff at your school.

45. At your school, what is the minimum level of education required for a newly hired school nurse?

Associate’s degree in nursing 1

Undergraduate degree in nursing 2

Graduate degree in nursing 3

Other (Specify) 4

No specific education requirement 5

School does not have school nurses 6 SKIP TO THE INTRODUCTION TO Q52

46. What is the minimum licensure requirement for a newly hired school nurse?

A Licensed Practical Nurse’s, or LPN’s, license 1

A Registered Nurse’s, or RN’s, license 2

No specific licensure requirement 3

47. What is the minimum certification requirement for a newly hired school nurse?

A national school nurse certification from
the National Board for Certification
of School Nurses 1

State school nurse certification 2

No specific certification requirement 3

48. Are all school nurses required to earn continuing education credits on health services topics?

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q52

49. How often are all school nurses required to earn continuing education credits on health service topics?

Every year 1

Every 2 to 3 years 2

Every 4 to 5 years 3

More than every 5 years 4

Other time frame 5

No specified time 6

Now I’d like to ask about school physicians.

50. Is there a part-time or full-time school physician who provides standard health services to students at your school?

Yes 1

No 2

51. Is there a school physician who can be called to consult as needed during the school day?

Yes 1

No 2

IF THERE IS NOT A PART-TIME OR FULL-TIME SCHOOL PHYSICIAN (Q52 IS “NO”), SKIP TO THE INTRODUCTION TO Q56.

52. How many part-time or full-time school physicians provide standard health services to students at your school?

Physicians

IF Q54 IS 0, SKIP TO THE INTRODUCTION TO Q56.

53. I would like to find out about the time that each physician spends at your school. During the past 30 days, how many hours per week on average has the physician spent at your school?

Physician 1 Hours/week

Physician 2 Hours/week

Physician 3 Hours/week

Physician 4 Hours/week

The next questions ask about school health aides.

54. Are there school health aides who help provide standard health services to students at your school?

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q59

55. Are school health aides at your school required to work under the supervision of an RN or physician at all times?

Yes 1

No 2

56. How many school health aides provide standard health services to students at your school?

School health aides

IF Q58 IS 0, SKIP TO THE INTRODUCTION TO Q60.

57. I would like to find out about the time each school health aide spends at your school. During the past 30 days, how many hours per week on average has/have the school health aide(s) spent at your school?

School health aide 1 Hours/week

School health aide 2 Hours/week

School health aide 3 Hours/week

School health aide 4 Hours/week

The next question is about the health services facilities and equipment that are available at your school. I am going to read a list of facilities and equipment that may be available for health services staff in your school to use.

58. Does your school have a sick room, nurse’s office, or other area reserved for providing standard health services?

Yes 1

No 2 SKIP TO Q64

59. Does this room, office, or area have a separate area that can be used to isolate students who might have a contagious illness?

Yes 1

No 2 SKIP TO Q64

60. What is the maximum number of students that can be isolated at one time?

Students

61. Does this room, office, or area have…

Yes No

1. A cot? 1 2

2. Face masks for sick students? 1 2

3. A fit-tested N95 respirator for each school health
   services staff member? 1 2

4. Hand sanitizer? 1 2

5. Gloves? 1 2

62. Where do students wait to receive health services if the nurse or other health services provider is busy?
    MARK ALL THAT APPLY

Main office 1

Designated sick room waiting area 2

Hallway 3

Some other location 4

63. You answered that students can wait to receive health services in the [FILL WITH SELECTED RESPONSES FROM Q64]. Adding up the maximum number of students who can be waiting in each area, what is the maximum number of students that can wait at one time?

Students

IF Q60 IS NO, THEN ASK Q66A-C. OTHERWISE, START WITH Q66D.

64. Does your school have…

Yes No

1. A cot? 1 2

2. Face masks for sick students? 1 2

3. A fit-tested N95 respirator for each school health services
   staff member? 1 2

4. An answering machine or voice mail reserved
   for health services staff? 1 2

5. A fax machine reserved for health services staff? 1 2

6. A computer with Internet access reserved for

health services staff? 1 2

7. A refrigerator reserved for standard health services? 1 2

8. A freezer reserved for standard health services? 1 2

9. A medical supply cabinet with a lock? 1 2

10. A separate medicine cabinet with a lock? 1 2

11. An electronic or beam balance scale? 1 2

12. A spring balance scale, such as a typical bathroom scale? 1 2

(Q66 Continued)

Yes No

13. A portable first aid kit? 1 2

14. A sharps container? 1 2

15. A stethoscope? 1 2

16. An audiometer? 1 2

17. A vision tester, eye chart, cards, or anything else
    to measure vision? 1 2

18. A stadiometer? 1 2

19. Measuring tape, wall chart, or anything else
    to measure height? 1 2

20. A blood pressure gauge and cuff? 1 2

21. A pen light? 1 2

22. An otoscope or ophthalmoscope? 1 2

23. A peak-flow meter, not just for a specific student’s use? 1 2

24. A scoliometer? 1 2

25. A glucose meter, not just for a specific student’s use? 1 2

26. A tympanometer? 1 2

27. A nebulizer, not just for a specific student’s use? 1 2

28. An albuterol inhaler, not just for a specific student’s use? 1 2

29. A self-inflating resuscitating device such as an ambu bag? 1 2

30. A c-spine immobilizer or neck brace? 1 2

31. An epinephrine auto-injector such as an EpiPen®,
    not just for a specific student’s use? 1 2

32. Suction equipment, not necessarily electric? 1 2

33. Oxygen, not just for a specific student’s use? 1 2

34. A pulse oximeter? 1 2

35. An automated external defibrillator? 1 2

65. Are the supplies needed to apply standard or universal precautions, including disposable gloves and bandages, available…

Yes No

1. In all classrooms? 1 2

2. In the gymnasium, on playgrounds,
   or on playing fields? 1 2

3. On school buses or in other vehicles used
   to transport students? 1 2

66. At your school, is there a system to keep track of why students are absent?

Yes 1

No 2

67. At your school, is there a system to track student visits to the school nurse?

Yes 1

No 2 SKIP TO Q71

68. Is this system linked to other student information, such as absentee records?

Yes 1

No 2

69. During the past 12 months, has your school reviewed health services records to identify students with chronic problems or possible outbreaks at school?

Yes 1

No 2

School does not keep health services records 3

The next questions ask about your school’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 healthcare professional.

70. Has your school adopted a policy stating that a school staff member will complete a report after a student is seriously injured on school property?

Yes 1

No 2 SKIP TO Q75

71. Does your school have a standard student injury report form?

Yes 1

No 2 SKIP TO Q75

72. During the past 12 months, has your school reviewed student injury reports to identify hazardous school areas or activities or ways to prevent injuries?

Yes 1

No 2

73. Does your school report notifiable diseases among students to the state or local health department?

Yes 1

No 2

The next question asks about 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 healthcare professional.

74. After a student experiences a serious illness at school, does a school staff member complete an illness report?

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q78

75. During the past 12 months, has your school reviewed student illness reports to identify ways to prevent further occurrences of serious illness?

Yes 1

No 2

The next questions ask about school practices for keeping students home when they are sick.

76. At your school, are students with a fever above a certain temperature sent home?

Yes 1

No 2 SKIP TO Q80

77. What is that temperature?

78. Does your school have rules regarding how long a student must stay home with an infectious illness?

Yes 1

No 2

The next questions ask about services that may be provided to students.

SHOW CARD 4

79. As I read the list of services printed on this card, please tell me if each is provided to students as part of standard health services at your school. Does your school provide…

Yes No

1. First aid? 1 2

2. CPR? 1 2

3. Administration of medications? 1 2

4. Seasonal influenza vaccine? 1 2

5. Immunizations other than seasonal influenza? 1 2

6. Identification or school-based management
   of acute illnesses? 1 2

7. Identification or school-based management of chronic
   health conditions, such as asthma or diabetes? 1 2

8. Tracking students with chronic health conditions? 1 2

9. Case management for students with chronic health
   conditions, such as asthma or diabetes? 1 2

10. Case management for students with disabilities? 1 2

11. Administration of sports physicals? 1 2

12. Identification of or referrals for oral health problems? 1 2

13. Administration of topical fluorides, such as mouthrinses,
    varnish, or supplements? 1 2

14. Application of dental sealants? 1 2

ANSWER O–Q FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO Q82.

15. Prenatal care referrals? 1 2

16. Identification or treatment of STDs? 1 2

17. Contraceptives? 1 2

IF Q81A–Q ARE ALL “NO,” SKIP TO THE INTRODUCTION TO Q83.

80. Who provides [the services listed in Q81A–Q]?
    MARK ALL THAT APPLY

School nurse 1

School physician 2

School health aide 3

School counselor 4

School psychologist 5

School social worker 6

Other 7

IF THIS IS AN ELEMENTARY SCHOOL, SKIP TO THE INTRODUCTION TO Q84.

81. Does your school make condoms available to any students?

Yes 1

No 2

ANSWER Q84 IF IMMUNIZATIONS ARE PROVIDED AT THIS SCHOOL (Q81E IS YES). OTHERWISE, SKIP TO THE INTRODUCTION TO Q87.

SHOW CARD 5

As I read the list of immunizations on this card, please tell me if each is provided to students as part of standard health services at your school.

82. Does your school provide…

Yes No

1. A measles-containing vaccine, such as MMR? 1 2

2. A polio vaccine, such as IPV? 1 2

IF THIS IS AN ELEMENTARY SCHOOL, ASK Q84C. OTHERWISE, SKIP TO Q84D.

3. A tetanus-diphtheria-pertussis, or DTaP, vaccine
   for children 7 years of age or younger? 1 2

4. A tetanus-diphtheria-pertussis, or TdAP, vaccine
   for children over the age of 7? 1 2

5. An influenza vaccine? 1 2

6. A hepatitis A vaccine? 1 2

7. A hepatitis B vaccine? 1 2

8. A chicken pox or varicella vaccine? 1 2

9. A meningococcal conjugate vaccine? 1 2

10. A human papillomavirus, or HPV, vaccine? 1 2

83. During the past 12 months, has your school hosted a school-located seasonal influenza, or flu, vaccination clinic?

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q87

84. Who was eligible to receive vaccinations at this clinic?

Yes No

1. Students? 1 2

2. Faculty and staff? 1 2

3. Students’ families? 1 2

4. Other community members? 1 2

The next questions are about medically fragile students who are dependent on nursing services or special technologies to enhance or sustain their lives.

85. Currently, how many medically fragile students are enrolled at your school?

Medically fragile students

IF THERE ARE NO MEDICALLY FRAGILE STUDENTS AT THIS SCHOOL (Q87 IS ZERO), SKIP TO THE INTRODUCTION TO Q90.

86. During the past 12 months, which of the following health services were provided to these medically fragile students as part of standard health services at your school?

Services was
Yes No not needed

1. Catheterizations 1 2 3

2. Stoma care 1 2 3

3. Tube feedings 1 2 3

4. Respirator care 1 2 3

5. Suctioning 1 2 3

6. Tracheostomy care 1 2 3

7. IV medications 1 2 3

IF ANY Q88A–Q88G IS “YES,” ASK Q89. OTHERWISE, SKIP TO Q90.

87. During the past 12 months, who provided these health services to students at your school?
    MARK ALL THAT APPLY

School nurse 1

School physician 2

School health aide 3

Other 4

The next questions ask about other ways that health services and mental health and social services staff might help students. As I ask these questions, please think about the activities of health services and mental health and social services staff such as school nurses, physicians, health aides, psychologists, social workers, and counselors, or others who provide standard health services or mental health and social services at your school. Do not include activities of teachers in the classroom. I’ll find out about their activities during a different interview.

88. Does the school provide the following services to students at the school in one-on-one or small-group sessions?

Yes No

1. Nutrition and dietary behavior counseling 1 2

2. Physical activity and fitness counseling 1 2

ANSWER C–E FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO Q90F.

3. Pregnancy prevention 1 2

4. HIV prevention 1 2

5. STD prevention 1 2

6. Suicide prevention 1 2

7. Tobacco use prevention 1 2

8. Alcohol or other drug use prevention 1 2

9. Violence prevention, for example bullying, fighting,
   or dating violence prevention 1 2

10. Injury prevention and safety counseling 1 2

IF Q90A–Q90J ARE ALL “NO,” SKIP TO Q92. OTHERWISE, CONTINUE TO Q91.

89. Who provides [the services listed in Q90A–J] in one-on-one or small-group sessions?
    MARK ALL THAT APPLY

School nurse 1

School physician 2

School health aide 3

School counselor 4

School psychologist 5

School social worker 6

Other 7

SHOW CARD 6

As I read the list of services printed on this card, please tell me if each is provided by health services or mental health and social services staff to students at the school.

90. Does the school provide…

Yes No

1. Instruction on self-management of chronic health
   conditions, such as asthma or diabetes? 1 2

2. Referrals for chronic health conditions, such as asthma
   or diabetes? 1 2

ANSWER C AND D FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO E.

3. Tobacco use cessation? 1 2

4. Alcohol or other drug use treatment? 1 2

5. Counseling after a natural disaster or other emergency
   or crisis situation? 1 2

6. Crisis intervention for personal problems? 1 2

7. Identification of emotional or behavioral disorders,
   such as anxiety, depression, or ADHD? 1 2

8. Counseling for emotional or behavioral disorders,
   such as anxiety, depression, or ADHD? 1 2

9. Stress management? 1 2

10. Weight management? 1 2

ANSWER K AND L FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO M.

11. Eating disorders treatment? 1 2

12. HIV counseling or referral ……………………………………….1 2

13. Identification of or referral for physical, sexual,
    or emotional abuse? 1 2

14. Identification of or referral for students with family
    problems, such as parental divorce, substance abuse,
    or violence? 1 2

(Q92 continued)

Yes No

15. Referrals for after-school programs for students,
    such as supervised recreation? 1 2

ANSWER P–R FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO THE INSTRUCTIONS BEFORE Q93.

16. Referrals for child care for teen mothers? 1 2

17. Services specifically for gay, lesbian,
    or bisexual students? 1 2

18. Job readiness skills programs? 1 2

19. Assistance with enrolling in WIC or accessing
    food stamps or food banks? 1 2

20. Assistance with securing temporary
    or permanent housing? 1 2

21. Assistance with enrolling in Medicaid or SCHIP? 1 2

22. Assistance with accessing benefits for students
    with disabilities? 1 2

IF Q92A–V ARE ALL “NO,” SKIP TO THE INTRODUCTION TO Q94. OTHERWISE, CONTINUE TO Q93.

91. Who provides [the services listed in Q92A–V]?
    MARK ALL THAT APPLY

School nurse 1

School physician 2

School health aide 3

School counselor 4

School psychologist 5

School social worker 6

Other 7

This next set of questions asks about health services delivered to students from your school 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 healthcare 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.

92. Currently, do any organizations or healthcare professionals have a contract, memorandum of agreement, or other similar arrangement to provide health services to students from your school?

Yes 1

No 2 SKIP TO Q98

SHOW CARD 7

93. Which of the organizations or healthcare professionals listed on this card have arrangements to provide health services to students from your school?
    MARK ALL THAT APPLY

A school-linked health center 1

A community health clinic
or health center 2

A local health department 3

A local hospital 4

A local mental health or social
services agency 5

A university or medical school 6

A dental or dental hygiene school 7

A managed care organization 8

A private physician 9

A private dentist 10

SHOW CARD 8

As I read the list of services printed on this card, please tell me if there are arrangements with any organizations or healthcare professionals to provide these services to students from your school.

94. Are there arrangements to provide…

Yes No

1. Primary care? 1 2

2. Prescriptions for medications? 1 2

3. Seasonal influenza vaccine? 1 2

4. Immunizations other than seasonal influenza? 1 2

5. Identification or school-based management
   of acute illnesses? 1 2

6. Identification or school-based management of chronic
   health conditions, such as asthma or diabetes? 1 2

7. Case management for students with chronic health
   conditions, such as asthma or diabetes? 1 2

8. Case management for students with disabilities? 1 2

9. Administration of sports physicals? 1 2

10. Oral healthcare or oral healthcare referrals? 1 2

11. Administration of topical fluorides, such as mouthrinses,
    varnish, or supplements? 1 2

12. Application of dental sealants? 1 2

13. Lab tests? 1 2

ANSWER N–P FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO Q98.

14. Prenatal care or prenatal care referrals? 1 2

15. Identification or treatment of STDs? 1 2

16. Contraceptives? 1 2

As I read the list on this card, please tell me if there are arrangements with any organizations or healthcare professionals to provide these services when needed to students or families from your school in one-on-one or small-group sessions.

95. Are there arrangements to provide...

Yes No

1. Nutrition and dietary behavior counseling? 1 2

2. Physical activity and fitness counseling? 1 2

ANSWER C, D, AND E FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO F.

3. Pregnancy prevention? 1 2

4. HIV prevention? 1 2

5. STD prevention? 1 2

6. Suicide prevention? 1 2

7. Tobacco use prevention? 1 2

8. Alcohol or other drug use prevention? 1 2

9. Violence prevention, for example bullying, fighting,
   or dating violence prevention? 1 2

10. Injury prevention and safety counseling? 1 2

96. Currently, does someone at your school oversee or coordinate standard health services?

Yes 1

No 2 SKIP TO Q115

97. Are you this person?

Yes 1

No 2 SKIP TO Q115

IF Q1 IS 15, CONTINUE. OTHERWISE, SKIP TO Q101.

98. Counting this year as a full year and including years as a school nurse at any other schools, how many years have you been a school nurse?

Years

SHOW CARD 9

99. Looking at this card, please tell me who you work for.
    MARK ALL THAT APPLY

School district 1

This school 2

A local health department 3

A local hospital 4

Other 5

Now I’d like to ask a few questions about your educational background.

100. What is the highest grade or year of education you have completed?

High school or GED 1 SKIP TO THE INTRODUCTION TO Q107

Associate’s degree 2

Undergraduate degree 3

Master’s degree 4

Doctoral degree 5

101. What did you major in?
     MARK ALL THAT APPLY

Nursing 1

Biology or other science 2

Counseling, psychology, or social work 3

Education 4

Other (Specify) 5

IF Q102 IS 2, SKIP TO Q107.

102. Did you have an undergraduate minor?

Yes 1

No 2 SKIP TO THE INSTUCTIONS BEFORE Q106

103. What did you minor in?
     MARK ALL THAT APPLY

Nursing 1

Biology or other science 2

Counseling, psychology, or social work 3

Education 4

Other (Specify) 5

IF Q102 IS 4 OR 5, ANSWER Q106. OTHERWISE, SKIP TO Q107.

104. In what area or areas was your graduate work?
     MARK ALL THAT APPLY

Nursing 1

Public health 2

Biology or other science 3

Healthcare administration or business 4

Counseling, psychology, or social work 5

Education 6

Other 7

105. Do you have…

Yes No

1. An LPN’s license? 1 2

2. An RN’s license? 1 2

3. A CNP’s license? 1 2

106. Do you have…

State does not
offer school
Yes No nurse certification

1. A national school nurse certification
   from the National Board for Certification
   of School Nurses? 1 2

2. A state school nurse certification? 1 2 3

The next questions ask about professional development.

SHOW CARD 10

As I read the list of topics on this card, please tell me if you received any professional development on each topic during the past two years. This might include workshops, conferences, continuing education, graduate courses, or any other kind of in-service.

107. During the past two years, have you received any professional development on…

Yes No

1. First aid? 1 2

2. CPR

3. Administration of medications? 1 2

4. Seasonal influenza vaccine? 1 2

5. Immunizations other than seasonal influenza? 1 2

6. Identification or school-based management
   of acute illnesses? 1 2

7. Identification or school-based management of chronic
   health conditions, such as asthma or diabetes? 1 2

8. Tracking students with chronic health conditions? 1 2

9. Case management for students with chronic health
   conditions, such as asthma or diabetes? 1 2

10. Case management for students with disabilities? 1 2

11. Sports physicals? 1 2

12. Oral health problems? 1 2

13. Administration of topical fluorides, such as mouthrinses,
    varnish, or supplements? 1 2

14. Dental sealants? 1 2

15. Prenatal care? 1 2

16. Identification or treatment of STDs? 1 2

17. Contraceptives? 1 2

18. Infectious disease prevention, such as hand hygiene
    or food safety? 1 2

SHOW CARD 11

108. Which of these topics would you like to receive further professional development on?
     MARK ALL THAT APPLY

First aid 1

CPR 2

Administration of medications 3

Seasonal influenza vaccine 4

Immunizations other than seasonal influenza 5

Identification or school-based management
of acute illnesses 6

Identification or school-based management
of chronic health conditions,
such as asthma or diabetes 7

Tracking students with chronic
health conditions 8

Case management for students
with chronic health conditions,
such as asthma or diabetes 9

Case management for students
with disabilities 10

Sports physicals 11

Oral health problems 12

Administration of topical fluorides,
such as mouthrinses, varnish,
or supplements 13

Dental sealants 14

Prenatal care 15

Identification or treatment of STDs 16

Contraceptives 17

Infectious disease prevention,
such as hand hygiene or food safety 18

None of these 19

SHOW CARD 12

As I read the list of topics on this card, please tell me if you received any professional development on each topic during the past two years. This might include workshops, conferences, continuing education, graduate courses, or any other kind of in-service.

109. During the past two years, have you received any professional development on…

Yes No

1. Nutrition and dietary behavior counseling? 1 2

2. Physical activity and fitness counseling? 1 2

3. Pregnancy prevention? 1 2

4. HIV prevention? 1 2

5. STD prevention? 1 2

6. Suicide prevention? 1 2

7. Tobacco use prevention? 1 2

8. Alcohol or other drug use prevention? 1 2

9. Violence prevention, for example bullying, fighting,
   or dating violence prevention? 1 2

10. Injury prevention and safety counseling? 1 2

110. Which of these topics would you like to receive further professional development on?
     MARK ALL THAT APPLY

Nutrition and dietary behavior counseling 1

Physical activity and fitness counseling 2

Pregnancy prevention 3

HIV prevention 4

STD prevention 5

Suicide prevention 6

Tobacco use prevention 7

Alcohol or other drug use prevention 8

Violence prevention, for example bullying,
fighting, or dating violence prevention 9

Injury prevention and safety counseling 10

None of these 11

SHOW CARD 13

As I read the list of topics on this card, please tell me if you received any professional development on each topic during the past two years. This might include workshops, conferences, continuing education, graduate courses, or any other kind of in-service.

111. During the past two years, have you received any professional development on…

Yes No

1. Teaching self-management of chronic health conditions,
   such as asthma or diabetes? 1 2

2. Referrals for chronic health conditions, such as asthma
   or diabetes? 1 2

3. Tobacco use cessation? 1 2

4. Alcohol or other drug use treatment? 1 2

5. Counseling after a natural disaster or other emergency
   or crisis situation? 1 2

6. Crisis intervention for personal problems? 1 2

7. Emergency preparedness? 1 2

8. Identification of emotional or behavioral disorders,
   such as anxiety, depression, or ADHD? 1 2

9. Counseling for emotional or behavioral disorders,
   such as anxiety, depression, or ADHD? 1 2

10. Stress management? 1 2

11. Weight management? 1 2

12. Eating disorders treatment? 1 2

13. HIV counseling, testing and referral? ……………………………1 2

14. Identification of or referral for physical, sexual,
    or emotional abuse? 1 2

15. Identification of or referral for students with family
    problems, such as parental divorce, substance abuse,
    or violence? 1 2

16. After-school programs for students,
    such as supervised recreation? 1 2

17. Child care options for teen mothers? 1 2

18. Services specifically for gay, lesbian, or bisexual students? 1 2

(Q113 continued)

Yes No

19. Enrolling in WIC or accessing
    food stamps or food banks? 1 2

20. Securing temporary or permanent housing? 1 2

21. Enrolling in Medicaid or SCHIP? 1 2

22. Accessing benefits for students
    with disabilities? 1 2

23. Job readiness skills programs? 1 2

24. Infectious disease, outbreak detection and response? 1 2

25. Federal laws that protect the privacy of student health
    information, for example HIPAA or FERPA? 1 2

26. Accurately measuring student height and weight? 1 2

27. Calculating student weight status using body mass index,
    or BMI? 1 2

112. Which of these topics would you like to receive further professional development on?
     MARK ALL THAT APPLY

Teaching self-management
of chronic health conditions,
such as asthma or diabetes 1

Referrals for chronic health conditions,
such as asthma or diabetes 2

Tobacco use cessation 3

Alcohol or other drug use treatment 4

Counseling after a natural disaster
or other emergency or crisis situation 5

Crisis intervention for personal problems 6

Emergency preparedness 7

Identification of emotional or behavioral
disorders, such as anxiety, depression,
or ADHD 8

Counseling for emotional or behavioral
disorders, such as anxiety, depression,
or ADHD 9

(Q114 continued)

Stress management 10

Weight management 11

Eating disorders treatment 12

HIV counseling, testing, and referral……………..13

Identification of or referral for physical,
sexual, or emotional abuse 14

Identification of or referral for students
with family problems, such as parental
divorce, substance abuse, or violence? 15

After-school programs
for students, such as supervised recreation 16

Child care options for teen mothers 17

Services specifically for gay, lesbian,
or bisexual students 18

Enrolling in WIC
or accessing food stamps or food banks 19

Securing temporary or permenant housing 20

Enrolling in Medicaid
or SCHIP 21

Accessing benefits
for students with disabilities 22

Job readiness skills programs 23

Infectious disease, outbreak detection

And response 24

Federal laws that protect the privacy
of student health information,
for example HIPAA or FERPA 25

Accurately measuring student height
and weight 26

Calculating student weight status using
body mass index, or BMI 27

None of these 28

113. My supervisor may wish to call you to ask about how I conducted this interview. Would you please tell me a telephone number where we might reach you starting with the area code?

( ) -

1) Daytime or

2) Evening/Weekend

Thank you very much for taking the time to complete this interview.

Health Services School Questionnaire—Public Use Version