21 Healthy and Safe School Environment School Questionnaire
School Health Policies and Practices Study 2012
Appendix G-18 Healthy&Safe Environment_School
School Data Collection
OMB: 0920-0445
Form
Approved
OMB No: 0920-0445
Expiration Date: xx/xx/xxxx
Healthy
and Safe School Environment
School Questionnaire
7 January 2011
Public reporting burden for this collection of information is estimated to average 75 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).
Healthy and Safe School
Environment
School Questionnaire
Questions
MODULE 1
General School Environment 1–28
Violence Prevention 29–51
Tobacco Use Prevention 52–79
Alcohol Use Prevention 80–84
Illegal Drug Use Prevention 85–94
Injury Prevention and Safety 95–116
MODULE 2
Physical School Environment 117–142
MODULE 3
Crisis Preparedness, Response, and Recovery 143–153
Family Involvement 154–156
Community Service and Service Learning 156–161
Physical Activity 162–179
Foods and Beverages Available Outside of the School Meal Program 180–218
School Health Coordination 219–244
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.
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) School Counselor
12) Social Worker
13) Psychologist
14) Other Mental Health/
Social Services Provider15) Nurse
16) Health Aide
17) Physician
18) Other Health Services Provider
19) SBHC Health Services Staff
20) SBHC Mental Health/
Social Services Staff21) Facilities or Maintenance Director
22) Other Facilities or Maintenance Staff
50) Other Staff
During this interview, I will ask about policies and practices that affect the health, safety and security of the school environment at this school, such as measures taken to reduce violence, and to reduce alcohol or other drug use at school. When I ask about “policies,” I mean any mandate issued by the state, the local school board, or any other agency that affects your school environment. Please consider any policies officially adopted by your school or district, including policies developed by your school or (district/diocese), as well as policies built on model federal or state policies. In addition, I will ask about practices that you might follow to promote the health and well-being of students. Please keep in mind that I will be asking only about policies and practices, not about standard classroom instruction on these topics. If I ask about things that do not apply to this school or that your school does not do, please bear with me.
How many students are currently enrolled in…
Kindergarten? Students
1st grade? Students
2nd grade? Students
3rd grade? Students
4th grade? Students
5th grade? Students
6th grade? Students
7th grade? Students
8th grade? Students
9th grade? Students
10th grade? Students
11th grade? Students
12th grade? Students
The next questions ask about physical features in and around your school.
Other than restroom sinks, does your school have hand washing facilities or hand sanitizers available for students to use?
Yes 1
No 2
Does your school provide students with access to a free source of drinking water, such as fountains, dispensers, or bottled sources, throughout the school day?
Yes 1
No 2
Are students permitted to have a drinking water bottle with them during the school day?
Yes, throughout the school day 1
Yes, during certain periods of the school day 2
No 3
Does your school have a school garden?
Yes 1
No 2
My next questions focus on safety and security measures.
Is this school a “closed campus,” meaning that students are not allowed to leave school during the school day, including during lunchtime?
Yes 1
No 2
During the school day, are staff or adult volunteers assigned to monitor…
Yes No
School halls during classes? 1 2
School halls between classes? 1 2
Bathrooms? 1 2
School grounds? 1 2
ANSWER Q9 FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO Q10.
Does this school routinely conduct locker searches?
Yes 1
No 2
School does not have lockers 3
Are students at this school required to wear school uniforms?
Yes 1 SKIP TO Q12A
No 2
Is there a dress code at your school?
Yes 1
No 2
12a. Are students at your school required to wear identification badges?
Yes 1
No 2
12b. What about school faculty and staff?
Yes 1
No 2
12c. What about visitors to your school? These identification badges can include adhesive stickers with hand-written names.
Yes 1
No 2
During the school day, does your school use…
Yes No
Security or surveillance cameras, either inside
or outside the building? 1 2Metal detectors, including wands? 1 2
Communication devices, such as cell phones,
2-way radios, walkie-talkies, or intercoms
for security purposes? 1 2
At your school, are students required to refrain from using personal communication devices, such as cell phones, during the school day?
Yes 1
No 2
I’m going to ask about different types of security staff that this school might use. During
the regular school day, does your school use…
Yes No
Police or school resource officers? 1 2
Security guards? 1 2
IF THIS SCHOOL USES SECURITY STAFF (Q15A OR B IS “YES”) CONTINUE WITH Q16. OTHERWISE, SKIP TO Q17.
Are any of the security staff at your school armed?
Yes 1
No 2
At your school, do students receive a student handbook, code of conduct, or other document that outlines school policies, rules, regulations and standards for behavior that students are expected to follow?
Yes 1
No 2 SKIP TO THE INTRODUCTION TO Q20
Are students required to acknowledge receipt of the student handbook, code of conduct, or other document?
Yes 1
No 2
Does the student handbook, code of conduct, or other document inform students about rules related to…
Yes No
The use of personal communication devices,
such as cell phones? 1 2Physical fighting? 1 2
Weapon possession or use? 1 2
Gang activity? 1 2
Bullying? 1 2
Electronic aggression or cyber-bullying? 1 2
Cigarette smoking? 1 2
Smokeless tobacco use? 1 2
Alcohol use? 1 2
Illegal drug possession or use? 1 2
FOR ELEMENTARY SCHOOLS ONLY
Playground safety? 1 2
The next questions are related to transportation.
What is the posted speed limit in your school zone during peak school travel times? (If there is more than one posted speed limit, what is the highest?)
15 mph or lower 1
20 mph 2
25 mph 3
30 mph 4
35 mph or higher 5
What percentage of students in your school live within one mile of a school building entrance?
10% or less 1
11–20% 2
21–30% 3
31–40% 4
41–50% 5
51–60% 6
61–70% 7
71–80% 8
81–90% 9
Greater than 90% 10
Hazard busing occurs when students are bused relatively short distances to school (about one mile or less) because their walk route is deemed to be hazardous. These hazards might include lack of sidewalks, high traffic volume, unmarked crossings, railroad crossings, or major arterial roads. Does your school use hazard busing for any students?
Yes 1
No 2
Does your school support or promote the use of public transportation for its students to travel to and from school?
Yes 1
No 2
No public transportation available 3
Does your school support or promote the use of public transportation for its faculty and staff to travel to and from school?
Yes 1
No 2
No public transportation available 3
Has your school implemented an engine idling reduction program for…
School
does
not have
Yes No school buses
School buses? 1 2 3
Cars? 1 2
Delivery trucks? 1 2
The next questions ask about joint use agreements.
A joint use agreement is a formal agreement between the school or school district and another public or private entity to jointly use either school facilities or community facilities to share costs and responsibilities. For example, joint use agreements might be designed to increase access to spaces for recreation and physical activity, library services, school health centers, preschool programs, child care centers, before- or after-school programs, adult education, or other programs that benefit students and the community. These could be indoor or outdoor education or recreational facilities.
Does your school, either directly or through the school district, have such an agreement for shared use of school or community property? Do not include situations where the community can use school property but no formal agreement with another entity exists.
Yes 1
No 2 SKIP TO Q29
Does this agreement apply to the use of facilities for…
Yes No
Indoor recreation or physical activity? 1 2
Outdoor recreation or physical activity? 1 2
Library services? 1 2
Preschool or child care programs? 1 2
Before or after school programs? 1 2
Adult education programs? 1 2
Other activities or programs? 1 2
Does your school, either directly or through the school district, have a joint use agreement with…
Yes No
A local parks or recreation department? 1 2
A local youth organization, such as the YMCA,
Boys or Girls Clubs, or the Boy Scouts or Girl Scouts? 1 2A local faith-based organization? 1 2
A local health club? 1 2
Any other public or private entity? 1 2
Now I would like to ask about your school’s policies regarding violence.
During the 2010–11 school year, were there four or more times that students at your school were caught physically fighting?
Yes 1
No 2 SKIP TO THE INTRODUCTION TO Q32
SHOW CARD 1
Which of the things listed on this card helped determine what actions the school took when students were caught physically fighting?
MARK ALL THAT APPLY
Zero-tolerance 1
Effect or severity of the violation 2
Grade level of student 3
Victim versus perpetrator status 4
Repeat offender status 5
None 6
SHOW CARD 2
When students were caught physically fighting, how often were they…
Almost
Some- Always
or
Never Rarely times Always N/A
Referred to a school counselor? 1 2 3 4 5
Referred to a school administrator? 1 2 3 4
Referred to peer mediation? 1 2 3 4 5
Encouraged, but not required,
to participate in an assistance
or education program? 1 2 3 4 5Required to participate in an assistance
or education program? 1 2 3 4 5Referred to legal authorities? 1 2 3 4 5
Placed in detention? 1 2 3 4 5
Given in-school suspension? 1 2 3 4 5
Not allowed to participate in
extracurricular activities
or interscholastic sports? 1 2 3 4 5Suspended from school? 1 2 3 4
Expelled from school? 1 2 3 4
Reassigned to an alternative school? 1 2 3 4 5
During the 2010–11 school year, were there four or more times that students at your school were caught using or possessing a weapon?
Yes 1
No 2 SKIP TO THE INTRODUCTION TO Q35
SHOW CARD 3
Which of the things listed on this card helped determine what actions the school took
when students were caught using or possessing a weapon?
MARK ALL THAT APPLY
Zero-tolerance 1
Effect or severity of the violation 2
Grade level of student 3
Repeat offender status 4
Type of weapon 5
Use versus possession 6
None 7
SHOW CARD 4
When students were caught using or possessing a weapon, how often were they…
Almost
Some- Always or
Never Rarely times Always N/A
Referred to a school counselor? 1 2 3 4 5
Referred to a school administrator? 1 2 3 4
Encouraged, but not required,
to participate in an assistance
or education program? 1 2 3 4 5Required to participate in an assistance
or education program? 1 2 3 4 5Referred to legal authorities? 1 2 3 4 5
Place in detention? 1 2 3 4 5
Given in-school suspension? 1 2 3 4 5
Not allowed to participate in
extracurricular activities or
interscholastic sports? 1 2 3 4 5Suspended from school? 1 2 3 4
Expelled from school? 1 2 3 4
Reassigned to an alternative school? 1 2 3 4 5
Has this school adopted a policy prohibiting gang activity, such as recruiting or wearing gang colors, symbols, or other gang attire?
Yes 1
No 2
Now, I’d like to ask about procedures that your school might use to involve students, families, and other community members in your violence prevention efforts.
During the past two years, have…
Yes No
Students helped develop, communicate, or implement
violence prevention policies or activities? 1 2Students’ families helped develop, communicate,
or implement violence prevention policies or activities? 1 2Community members helped develop, communicate,
or implement violence prevention policies or activities? 1 2
Does your school post signs marking a weapons-free school zone, that is, a specified distance from school grounds where weapons are not allowed?
Yes 1
No 2
The next questions ask about bullying. By “bullying,” I mean when one or more students tease, threaten, spread rumors about, hit, shove, or hurt another student over and over again. It is not bullying when two students of about the same strength or power argue or fight or tease each other in a friendly way.
Has this school adopted a policy prohibiting bullying on school property?
Yes 1
No 2
Has this school adopted a policy prohibiting bullying at off-campus, school-sponsored events?
Yes 1
No 2
During the 2010–11 school year, were there four or more times that students at your school were caught bullying?
Yes 1
No 2 SKIP TO THE INTRODUCTION TO Q43
SHOW CARD 5
Which of the things listed on this card helped determine what actions the school took when students were caught bullying?
MARK ALL THAT APPLY
Zero-tolerance 1
Effect or severity of the violation 2
Grade level of student 3
Repeat offender status 4
Type of bullying
(for example, physical or verbal) 5
None 6
When students were caught bullying, how often were they…
Almost
Some- Always
or
Never Rarely times Always N/A
Referred to a school counselor? 1 2 3 4 5
Referred to a school administrator? 1 2 3 4
Referred to peer mediation? 1 2 3 4 5
Encouraged, but not required,
to participate in an assistance
or education program? 1 2 3 4 5Required to participate in
an assistance or education program? 1 2 3 4 5Referred to legal authorities? 1 2 3 4
Placed in detention? 1 2 3 4 5
Given in-school suspension? 1 2 3 4 5
Not allowed to participate in
extracurricular activities or
interscholastic sports? 1 2 3 4 5Suspended from school? 1 2 3 4
Expelled from school? 1 2 3 4
Reassigned to an alternative school? 1 2 3 4 5
The next questions as about electronic aggression, sometimes called cyber-bullying. By “electronic aggression,” I mean when students use a cell phone, the Internet, or other communication devices to send or post text, pictures, or videos intended to threaten, harass, humiliate, or intimidate other students or staff.
Has your school adopted a policy prohibiting electronic aggression or cyber-bullying on school property?
Yes 1
No 2
Has your school adopted a policy prohibiting electronic aggression or cyber-bullying at off‑campus, school-sponsored events?
Yes 1
No 2
Has your school adopted a policy prohibiting any electronic aggression or cyber-bullying that interferes with the educational environment, even if it does not occur on school property or at school-sponsored events?
Yes 1
No 2
During the 2010–11 school year, were there four or more times that students at your school were caught engaging in electronic aggression or cyber-bullying?
Yes 1
No 2 SKIP TO Q49
SHOW CARD 6
Which of the things listed on this card helped determine what actions the school took when students were caught engaging in electronic aggression or cyber-bullying?
MARK ALL THAT APPLY
Zero-tolerance 1
Effect or severity of the violation 2
Grade level of student 3
Repeat offender status 4
None 5
SHOW CARD 2
When students were caught engaging in electronic aggression or cyber- bullying, how often were they…
Almost
Some- Always
or
Never Rarely times Always N/A
Referred to a school counselor? 1 2 3 4 5
Referred to a school administrator? 1 2 3 4
Referred to peer mediation? 1 2 3 4 5
Encouraged, but not required,
to participate in an assistance
or education program? 1 2 3 4 5Required to participate in an assistance
or education program? 1 2 3 4 5Referred to legal authorities? 1 2 3 4
Placed in detention? 1 2 3 4 5
Given in-school suspension? 1 2 3 4 5
Not allowed to participate in
extracurricular activities or
interscholastic sports? 1 2 3 4 5Suspended from school? 1 2 3 4
Expelled from school? 1 2 3 4
Reassigned to an alternative school? 1 2 3 4 5
The next questions ask about school-wide programs to prevent behaviors related to violence. When answering these questions, please do not include instruction on these topics that occurs only in health education classes or courses.
Does your school have or participate in…
Yes No
A program to prevent dating violence? 1 2
A program to prevent gang violence? 1 2
A program to prevent bullying? 1 2
Does this school have a plan for the actions to be taken when a student at risk for suicide is identified?
Yes 1
No 2 SKIP TO THE
INTRODUCTION
TO Q52
Does this plan require that…
Yes No
The student’s family will be informed? 1 2
The student will be referred to a mental health provider? 1 2
A visit with a mental health provider will be documented
before the student returns to school? 1 2
The next questions ask about your school’s policies regarding tobacco use.
Has this school adopted a policy prohibiting cigarette smoking by students?
Yes 1
No 2 SKIP TO Q54
Does your school’s policy specifically prohibit cigarette smoking by students…
Yes No
In school buildings? 1 2
Outside on school grounds, including parking lots
and playing fields? 1 2On school buses or other vehicles used
to transport students? 1 2At off-campus, school-sponsored events? 1 2
During the 2010–11 school year, were there four or more times that students at your school were caught smoking cigarettes?
Yes 1
No 2 SKIP TO Q57
SHOW CARD 6
Which of the things listed on this card helped determine what actions the school took when students were caught smoking cigarettes?
MARK ALL THAT APPLY
Zero-tolerance 1
Effect or severity of the violation 2
Grade level of student 3
Repeat offender status 4
None 5
SHOW CARD 4
When students were caught smoking cigarettes, how often were they…
Almost
Some- Always
or
Never Rarely times Always N/A
Referred to a school counselor? 1 2 3 4 5
Referred to a school administrator? 1 2 3 4
Encouraged, but not required,
to participate in an assistance,
education, or cessation program? 1 2 3 4 5Required to participate in an assistance
education, or cessation program? 1 2 3 4 5Referred to legal authorities? 1 2 3 4 5
Place in detention? 1 2 3 4 5
Given in-school suspension? 1 2 3 4 5
Not allowed to participate in
extracurricular activities or
interscholastic sports? 1 2 3 4 5Suspended from school? 1 2 3 4
Expelled from school? 1 2 3 4
Reassigned to an alternative school? 1 2 3 4 5
Has this school adopted a policy prohibiting cigar or pipe smoking by students?
Yes 1
No 2
Has this school adopted a policy prohibiting smokeless tobacco use by students?
Yes 1
No 2 SKIP TO Q60
Does your school’s policy specifically prohibit smokeless tobacco use by students…
Yes No
In school buildings? 1 2
Outside on school grounds, including parking lots
and playing fields? 1 2On school buses or other vehicles used
to transport students? 1 2At off-campus, school-sponsored events? 1 2
During the 2010–11 school year, were there four or more times that students at your school were caught using smokeless tobacco?
Yes 1
No 2 SKIP TO Q63
SHOW CARD 6
Which of the things listed on this card helped determine what actions the school took when students were caught using smokeless tobacco?
MARK ALL THAT APPLY
Zero-tolerance 1
Effect or severity of the violation 2
Grade level of student 3
Repeat offender status 4
None 5
SHOW CARD 4
When students were caught using smokeless tobacco, how often were they…
Almost
Some- Always
or
Never Rarely times Always N/A
Referred to a school counselor? 1 2 3 4 5
Referred to a school administrator? 1 2 3 4
Encouraged, but not required,
to participate in an assistance,
education, or cessation program? 1 2 3 4 5Required to participate in an assistance,
education, or cessation program? 1 2 3 4 5Referred to legal authorities? 1 2 3 4 5
Place in detention? 1 2 3 4 5
Given in-school suspension? 1 2 3 4 5
Not allowed to participate in
extracurricular activities or
interscholastic sports? 1 2 3 4 5Suspended from school? 1 2 3 4
Expelled from school? 1 2 3 4
Reassigned to an alternative school? 1 2 3 4 5
Is tobacco advertising prohibited…
Yes No
In school buildings? 1 2
Outside on school grounds, including parking lots
and playing fields? 1 2On school buses or other vehicles used
to transport students? 1 2At off-campus, school-sponsored events? 1 2
Through sponsorship of school events? 1 2
Are students at your school prohibited from wearing tobacco brand-name apparel or carrying merchandise with tobacco company names, logos, or cartoon characters on it?
Yes 1
No 2
Now, I’d like to ask about procedures that your school might use to involve students, families, and other community members in your tobacco use prevention efforts.
During the past two years, have…
Yes No
Students helped develop, communicate, or implement
tobacco use prevention policies or activities? 1 2Students’ families helped develop, communicate,
or implement tobacco use prevention policies or activities? 1 2Community members helped develop, communicate,
or implement tobacco use prevention policies or activities? 1 2
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?
Yes 1
No 2
ANSWER Q67 FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO THE INTRODUCTION TO Q68.
Does your school have or participate in a youth empowerment or advocacy program related to tobacco use prevention?
Yes 1
No 2
These next questions are about tobacco use by faculty and staff.
Has this school adopted a policy prohibiting cigarette smoking by faculty and staff during any school-related activity?
Yes 1
No 2 SKIP TO Q70
Does your school’s policy specifically prohibit cigarette smoking by faculty and staff…
Yes No
In school buildings? 1 2
Outside on school grounds, including parking lots
and playing fields? 1 2On school buses or other vehicles used
to transport students? 1 2At off-campus, school-sponsored events? 1 2
Has this school adopted a policy prohibiting cigar or pipe smoking by faculty and staff during any school-related activity?
Yes 1
No 2
Has this school adopted a policy prohibiting smokeless tobacco use by faculty and staff during any school-related activity?
Yes 1
No 2 SKIP TO THE INSTRUCTIONS BEFORE Q73
Does your school’s policy specifically prohibit smokeless tobacco use by faculty and staff…
Yes No
In school buildings? 1 2
Outside on school grounds, including parking lots
and playing fields? 1 2On school buses or other vehicles used
to transport students? 1 2At off-campus, school-sponsored events? 1 2
IF Q68, Q70, AND Q71 ARE ALL “NO,” SKIP TO THE INTRODUCTION TO Q74. OTHERWISE, CONTINUE.
Does your school have procedures to inform faculty and staff…
Yes No
About rules related to tobacco use by faculty and staff? 1 2
About what happens if they break the rules? 1 2
These next questions are about tobacco use by school visitors. By “visitors,” I mean anyone other than students or faculty and staff, including family members, community members, contractors, and repair workers. These people might visit school during or outside of school hours.
Has this school adopted a policy prohibiting cigarette smoking by school visitors?
Yes 1
No 2 SKIP TO Q76
Does your school’s policy specifically prohibit cigarette smoking by school visitors…
Yes No
In school buildings? 1 2
Outside on school grounds, including parking lots
and playing fields? 1 2On school buses or other vehicles used
to transport students? 1 2At off-campus, school-sponsored events? 1 2
Has this school adopted a policy prohibiting cigar or pipe smoking by school visitors?
Yes 1
No 2
Has this school adopted a policy prohibiting smokeless tobacco use by school visitors?
Yes 1
No 2 SKIP TO THE INSTRUCTIONS BEFORE Q79
Does your school’s policy specifically prohibit smokeless tobacco use by school visitors…
Yes No
In school buildings? 1 2
Outside on school grounds, including parking lots
and playing fields? 1 2On school buses or other vehicles used
to transport students? 1 2At off-campus, school-sponsored events? 1 2
IF THIS SCHOOL HAS ADOPTED ANY POLICIES PROHIBITING TOBACCO USE BY SCHOOL VISITORS (Q74, Q76 OR Q77 IS “YES”), ANSWER Q79. OTHERWISE, SKIP TO THE INTRODUCTION TO Q80.
Does your school have procedures to inform school visitors…
Yes No
About rules related to tobacco use by visitors? 1 2
About what happens if they break the rules? 1 2
Now I would like to ask about alcohol use among students at your school.
During the 2010–11 school year, were there four or more times that students at your school were caught drinking alcohol?
Yes 1
No 2 SKIP TO THE INTRODUCTION TO Q83
SHOW CARD 6
Which of the things listed on this card helped determine what actions the school took when students were caught drinking alcohol?
MARK ALL THAT APPLY
Zero-tolerance 1
Effect or severity of the violation 2
Grade level of student 3
Repeat offender status 4
None 5
SHOW CARD 4
When students were caught drinking alcohol, how often were they…
Almost
Some- Always
or
Never Rarely times Always N/A
Referred to a school counselor? 1 2 3 4 5
Referred to a school administrator? 1 2 3 4
Encouraged, but not required,
to participate in an assistance,
education, or cessation program? 1 2 3 4 5Required to participate in an assistance,
education, or cessation program? 1 2 3 4 5Referred to legal authorities? 1 2 3 4 5
Place in detention? 1 2 3 4 5
Given in-school suspension? 1 2 3 4 5
Not allowed to participate in
extracurricular activities or
interscholastic sports? 1 2 3 4 5Suspended from school? 1 2 3 4
Expelled from school? 1 2 3 4
Reassigned to an alternative school? 1 2 3 4 5
Now, I’d like to ask about procedures that your school might use to involve students, families, and other community members in your alcohol use prevention efforts.
During the past two years, have…
Yes No
Students helped develop, communicate, or implement
alcohol use prevention policies or activities? 1 2Students’ families helped develop, communicate,
or implement alcohol use prevention policies or activities? 1 2Community members helped develop, communicate,
or implement alcohol use prevention policies or activities? 1 2
Does your school have or participate in a community-based alcohol use prevention program?
Yes 1
No 2
The next questions ask about illegal drug use among students at your school.
During the 2010–11 school year, were there four or more times that students at your school were caught possessing or using illegal drugs?
Yes 1
No 2 SKIP TO THE INTRODUCTION TO Q89
SHOW CARD 7
Which of the things listed on this card helped determine what actions the school took when students were caught possessing or using illegal drugs?
MARK ALL THAT APPLY
Zero-tolerance 1
Effect or severity of the violation 2
Grade level of student 3
Repeat offender status 4
Type of drug 5
None 6
SHOW CARD 4
When students were caught possessing or using illegal drugs, how often were they…
Almost
Some- Always
or
Never Rarely times Always N/A
Referred to a school counselor? 1 2 3 4 5
Referred to a school administrator? 1 2 3 4
Encouraged, but not required,
to participate in an assistance,
education, or cessation program? 1 2 3 4 5Required to participate in an assistance,
education, or cessation program? 1 2 3 4 5Referred to legal authorities? 1 2 3 4 5
Placed in detention? 1 2 3 4 5
Given in-school suspension? 1 2 3 4 5
Not allowed to participate in
extracurricular activities or
interscholastic sports? 1 2 3 4 5Suspended from school? 1 2 3 4
Expelled from school? 1 2 3 4
Reassigned to an alternative school? 1 2 3 4 5
Now, I’d like to ask about procedures that your school might use to involve or inform students, families, and other community members in your illegal drug use prevention efforts.
During the past two years, have…
Yes No
Students helped develop, communicate, or implement
illegal drug use prevention policies or activities? 1 2Students’ families helped develop, communicate, or
implement illegal drug use prevention policies or activities? 1 2Community members helped develop, communicate, or
implement illegal drug use prevention policies or activities? 1 2
Does your school post signs marking a drug-free school zone, that is, a specified distance from school grounds where illegal drugs are not allowed?
Yes 1
No 2
Does your school have or participate in a community-based illegal drug use prevention program?
Yes 1
No 2
ANSWER Q91 FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO THE INTRODUCTION TO Q95.
The next questions ask about student drug testing.
Does your school conduct any drug testing on students?
Yes 1
No 2 SKIP TO THE INTRODUCTION TO Q95
IF ANSWER TO Q91 IS YES, THEN ASK:
The next questions ask about how students are chosen for drug testing at your school.
Yes No
ANSWER “A” FOR PRIVATE SCHOOLS ONLY, OTHERWISE SKIP TO “B”
Is student drug testing conducted randomly, with the entire
student population subject to testing? 1 2Is student drug testing conducted randomly among
members of specific groups of students, such as athletes,
students who participate in other extracurricular activities,
or student drivers? 1 2Is student drug testing conducted when it is suspected
that a student is using drugs at school, that is, for cause? 1 2Is student drug testing voluntary for all students
or for specific groups of students? 1 2Are students chosen for drug testing using criteria
other than the ones we just discussed? 1 2
Does your school test for…
Yes No
Alcohol? 1 2
Nicotine? 1 2
Cocaine? 1 2
Marijuana? 1 2
Opiates, for example, heroin or morphine? 1 2
Amphetamines, for example, methamphetamine or Ecstasy? 1 2
Phencyclidine, that is, PCP? 1 2
Steroids? 1 2
SHOW CARD 8
Which of the methods on this card does your school use to conduct drug testing?
MARK ALL THAT APPLY
Breathalyzer (breath alcohol test) 1
Urine 2
Hair 3
Saliva 4
Sweat 5
Other 6
The next questions ask about injury prevention and safety procedures related to sports or playground activities, school lab or workshop activities, the use of school vehicles, and fire safety.
During the past 12 months, have the following been inspected and provided with the appropriate maintenance?
ANSWER A FOR ELEMENTARY AND MIDDLE SCHOOL ONLY. OTHERWISE, SKIP TO B.
Yes No NA
Playground facilities and equipment,
such as playing surfaces, benches,
monkey bars, and swings 1 2 3Indoor athletic facilities and equipment,
such as playing surfaces, benches,
tumbling mats, and weight lifting
equipment 1 2 3Outdoor athletic equipment,
such as playing fields and bleachers 1 2 3Special classroom areas, such as
chemistry labs, workshops, and art rooms. 1 2 3Other areas of the school, such as halls,
stairs, and regular classrooms 1 2 3Smoke alarms 1 2 3
Fire extinguishers 1 2 3
Sprinkler systems 1 2 3
Lighting inside school buildings 1 2 3
Lighting outside school buildings 1 2 3
Automated external defibrillators (AED) 1 2 3
Are students required to wear appropriate protective gear when engaged in…
Yes No NA
Classes such as wood shop or metal shop? 1 2 3
Lab activities for photography, chemistry,
biology, or other science classes? 1 2 3
Are students required to use hearing protection devices during classes or activities where they are exposed to potentially unsafe noise levels, such as industrial arts classes or marching band? By “hearing protection devices,” I mean any piece of equipment or apparatus that is made to reduce the loudness of sound, such as earplugs or earmuffs.
Yes 1
No 2
ANSWER Q98–104 FOR ELEMENTARY SCHOOL ONLY. OTHERWISE, SKIP TO THE INTRODUCTION TO Q105.
Does your school use the safety checklist and equipment guidelines published in the Handbook for Public Playground Safety by the U.S. Consumer Product Safety Commission?
Yes 1
No 2
Does your school have rules related to playground safety?
Yes 1
No 2 SKIP TO Q105 IF A HIGH SCHOOL, OTHERWISE, SKIP TO Q107
Does your school post rules for the safe use of specific types of playground equipment, such as swings, slides, or climbing structures?
Yes 1
No 2
During the 2010–2011 school year, were there four or more times that students were caught breaking playground safety rules?
Yes 1
No 2 SKIP TO Q105
SHOW CARD 9
Which of the things listed on this card helped determine what actions the school took when students were caught breaking playground safety rules?
Effect or severity of the violation 1
Whether an injury resulted from the violation 2
Grade level of student 3
Victim versus perpetrator status 4
Repeat offender status 5
None 6
When students were caught breaking playground safety rules, how often were they…
Almost
Some- Always or
Never Rarely times Always
Provided verbal redirection
by a playground monitor? 1 2 3 4Required to refrain from playing
for a designated time period? 1 2 3 4Not allowed to participate in
the next scheduled recess period?
(e.g., the next day) 1 2 3 4Placed in detention? 1 2 3 4
Suspended from school? 1 2 3 4
When students were caught breaking playground safety rules, how often were students’ families notified?
Never 1
Rarely 2
Sometimes 3
Almost always or always 4
ASK Q105 IF HIGH SCHOOL, OTHERWISE, SKIP TO Q106
Schools often establish rules that students must follow to use a school’s parking facilities. These rules are sometimes outlined in a parking permit agreement. Does your school’s parking permit agreement specifically require seat belt use?
Yes 1
No 2
School does not have
parking permit agreement 3
Does your school have a procedure to monitor seat belt use on school property?
Yes 1
No 2
During the past two years, have…
Yes No
Students helped develop, communicate, or implement
injury prevention and safety policies or activities? 1 2Students’ families helped develop, communicate,
or implement injury prevention and safety policies
or activities? 1 2Community members helped develop, communicate,
or implement injury prevention and safety policies
or activities? 1 2
Has your school ever been sued because of an injury that occurred on school property or at an off-campus, school-sponsored event? Please include any claim filed with a court, regardless of the outcome.
Yes 1
No 2
The next questions ask about sun safety.
During the past 12 months, how often were outdoor activities scheduled to avoid times when the sun was at peak intensity?
Never 1
Rarely 2
Sometimes 3
Almost always or always 4
How would you describe the shade available to students while outside when the sun is at peak intensity? Consider shade created by trees, covered or sheltered areas, or canopies in outdoor spaces.
No shade for students to use during
any outdoor activity 1
Enough shade for sedentary activities
such as eating or
outdoor
classroom instruction 2
Enough shade available for both
sedentary and active
activities
(such as recess or physical education) 3
Are any of the following strategies used to support or promote sunscreen use among students?
Yes No
Parents are asked to ensure students apply sunscreen
before school 1 2Teachers allow time for students to apply sunscreen
at school 1 2Teachers remind students to apply sunscreen
before going outside 1 2The school makes sunscreen available for students to use 1 2
Does your school encourage students to wear protective clothing, such as long sleeve shirts or long pants, when in the sun during the school day?
Yes 1
No 2
Does your school encourage students to wear hats or visors when in the sun during the school day?
Yes 1 SKIP TO Q115
No 2
Are students prohibited from wearing hats or visors when in the sun during the school day?
Yes 1
No 2
Does your school encourage students to wear sunglasses when in the sun during the school day?
Yes 1 SKIP TO Q117
No 2
Are students prohibited from wearing sunglasses when in the sun during the school day?
Yes 1
No 2
The next section asks about the physical school environment, such as building maintenance, indoor air quality, pest control, and chemicals.
Does your school conduct periodic inspections…
Yes No
For condensation in and around the school facilities? 1 2
Of the building foundation, walls, and roof for cracks,
leaks, or past water damage? 1 2For mold? 1 2
Of the plumbing system? 1 2
Of the heating, ventilation, and air conditioning system,
or HVAC, system? 1 2That test drinking water outlets for lead? 1 2
For clutter that prevents effective cleaning
and maintenance? 1 2
In what year was this school’s main instructional building constructed?
In what year was the last major renovation of the main instructional building? By “major renovation” I mean a significant rehabilitation of the interior of the building; of major systems in the building such as the heating, ventilation, and air conditioning system; or of the building envelope, that is, the outer shell of the building such as the foundation, roof, walls, doors and windows. Major renovations would also include building new attached and/or detached permanent additions to original buildings such as a new classroom wing or gymnasium.
IF Q118 IS PRIOR TO 1980, ANSWER Q120 AND Q121. OTHERWISE, SKIP TO 122.
During the past 12 months, has your school conducted an inspection for cracked or peeling paint that may contain lead?
Yes 1
No 2
Lead paint previously identified
and remediated 3
During the past 12 months, has your school conducted an inspection for caulking around windows and doors that may contain PCBs?
Yes 1
No 2
PCBs in caulking previously identified
and remediated 3
How often does your school conduct a campus wide inspection for pests such as ants, roaches, bees, mice, or rats? By “campus wide,” I mean inside the buildings and on the school grounds.
Weekly 1
Monthly 2
Quarterly 3
Every 6 months 4
Once per year 5
As needed 6
Other time frame 7
How often does your school notify staff, students, and families prior to the application of pesticides?
Never 1
Each time 2
Once per year 3
Other time frame 4
School does not apply pesticides 5
During the past 12 months, how often…
Almost
Some- Always
or
Never Rarely times Always N/A
Were ASHRAE standards
for ventilation maintained? 1 2 3 4Were openings in walls, floors, doors,
and windows sealed with caulk
or weather stripping? 1 2 3 4 5Were vegetation, shrubs, and wood mulch
kept at least one foot away from buildings
to control pests? 1 2 3 4 5Was eating allowed only in designated areas
to control pests? 1 2 3 4Was waste stored in plastic, glass,
or metal containers with tight lids
so that it was inaccessible to pests? 1 2 3 4Were cracks in the pavement
and sidewalks repaired? 1 2 3 4 5Were infested or diseased plants
removed? 1 2 3 4 5Were spot treatments and baiting used
rather than widespread applications
of pesticides? 1 2 3 4 5Were indoor and outdoor areas that had
been treated with pesticides marked? 1 2 3 4 5
For the next questions, please answer based on what your school does in those months when school is in session.
How often does your school clean student lockers, cubbies, or inside of desks in order to remove any food remains?
Daily 1
Weekly 2
Monthly 3
Quarterly 4
Every 6 months 5
Once per year 6
As needed 7
Other time frame 8
How often does your school clean or sanitize desk tops?
Daily 1
Weekly 2
Monthly 3
Quarterly 4
Every 6 months 5
Once per year 6
As needed 7
Other time frame 8
How often does your school disinfect trash containers?
Daily 1
Weekly 2
Monthly 3
Quarterly 4
Every 6 months 5
Once per year 6
As needed 7
Other time frame 8
Does your school have a plan for how to address mold problems?
Yes 1
No 2
During the past 12 months, did your school respond to moisture-related issues, such as floods, leaks, or condensation within 48 hours or less?
Yes 1
No 2
No moisture-related issues during the past
12 months 3
Does your school have an indoor air quality management program?
Yes 1
No 2 SKIP TO Q131
Is your program based on EPA’s Indoor Air Quality Tools for Schools?
Yes 1
No 2
Has your school ever been tested for radon?
Yes 1
No 2
Does your school operate its own water system, that is, the school obtains drinking water from its own well, spring, or small reservoir?
Yes 1 SKIP TO Q136
No 2
During the past 12 months, was your school’s drinking water tested for…
Yes No
Bacteria? 1 2
Coliforms? 1 2
Other contaminants? 1 2
IF Q134A, Q134B, OR Q134C IS “YES,” ANSWER Q135. OTHERWISE, SKIP TO Q136.
Were the results of this/these test(s) provided to…
Yes No
School faculty and staff? 1 2
Students’ families? 1 2
Students? 1 2
Does your school flush drinking water outlets after periods of non-use, such as after weekends or school vacations?
Yes 1
No 2
The next question asks about low-emitting products, which are products designed to give off low levels of fumes or vapors. These products might include floor covering, furniture, paint, cleaners, markers, textiles, or adhesives.
Has your school adopted a policy to purchase low-emitting products for use in and around the school and school grounds, including in art classes, industrial art classes, and science laboratories?
Yes 1
No 2
The next questions ask about hazardous materials. Hazardous materials are chemicals or materials that may be harmful to people or the environment. Some examples are paint, chemicals used for science experiments or art classes, cleaning products, and pesticides.
Does your school have a plan for how to reduce the use of hazardous materials or chemicals?
Yes 1
No 2
Does your school keep an inventory of hazardous materials or chemicals in the school?
Yes 1
No 2 SKIP TO Q141
How often is the inventory reviewed or updated?
Daily 1
Weekly 2
Monthly 3
Quarterly 4
Every 6 months 5
Once per year 6
As needed 7
Other time frame 8
Are custodial or maintenance staff at this school required to receive training on…
Yes No
Use of hazardous materials? 1 2
Labeling of hazardous materials? 1 2
Storage of hazardous materials? 1 2
Disposal of hazardous materials? 1 2
How to reduce the use of hazardous materials? 1 2
How to address mold problems? 1 2
Indoor air quality? 1 2
School drinking water quality? 1 2
Pest management practices that limit the use of pesticides? 1 2
Are all teachers at your school who use hazardous materials or chemicals, such as science teachers, art teachers, or vocational education teachers, required to receive training on…
Yes No
Use of hazardous materials? 1 2
Labeling of hazardous materials? 1 2
Storage of hazardous materials? 1 2
Disposal of hazardous materials? 1 2
How to reduce the use of hazardous materials? 1 2
The next questions ask about crisis preparedness, response, and recovery in the event of a natural disaster or other emergency situation.
SHOW CARD 10
Which of the following best describes your school’s plan to address crisis preparedness, response, and recovery in the event of a natural disaster or other emergency or crisis situation?
This school does not have such a plan 1 SKIP TO Q149
This school uses a plan provided
by the district 2 SKIP
TO Q147
This school uses a district-level plan that has
been adapted to
meet our school’s needs 3
This school has its own plan 4
Did your school use any materials from the U.S. Department of Education, such as Practical Information on Crisis Planning: A Guide for Schools and Communities, to develop the plan?
Yes 1
No 2
In developing the crisis preparedness, response, and recovery plan, did your school work with staff or members from…
Yes No
A local fire department? 1 2
A local law enforcement agency? 1 2
Local emergency medical services? 1 2
The local public transportation department? 1 2
A local health department? 1 2
A local mental health or social services agency? 1 2
A local hospital? 1 2
A local homeland security office
or emergency management office? 1 2
Did your school work with students, families, or other community members to develop the crisis preparedness, response, and recovery plan?
Yes 1
No 2
Does the crisis preparedness, response, and recovery plan used by your school include…
Yes No
Evacuation plans? 1 2
Procedures to stop people from leaving or entering
school buildings, that is, lock down plans? 1 2Procedures to control the exterior of the building
and school grounds? 1 2Plans to seek immediate shelter and remain in that area
during a chemical, biological, or radiological emergency
rather than evacuating, or shelter-in-place plans? 1 2Requirements to conduct regular emergency drills,
other than fire drills? 1 2Family reunification procedures? 1 2
Provisions for students and staff with special needs? 1 2
Plans to resume normal activities after buildings
or facilities have been damaged? 1 2Provision of mental health services for students, faculty,
and staff after a crisis has occurred, for example to treat
post-traumatic stress disorder? 1 2Mechanisms for communicating with school personnel? 1 2
Establishment of an incident command system? 1 2
Procedures for responding to media inquiries? 1 2
Mechanisms for communicating the plan
to students’ families? 1 2Requirements to periodically review and revise
emergency response plans? 1 2Procedures for responding to pandemic flu or other
infectious disease outbreaks? 1 2Procedures for implementing unplanned school dismissal
or school closure? 1 2
During the past two years, has your school provided training on the crisis preparedness, response, and recovery plan to…
Yes No
School faculty and staff? 1 2
Students? 1 2
Students’ families? 1 2
During the past two years, has your school provided training on crisis preparedness, response, and recovery to students’ families?
Yes 1
No 2
IF Q143 IS 1 OR 2, SKIP TO Q151.
During the past 12 months, has your school’s crisis preparedness, response, and recovery plan been evaluated or assessed?
Yes 1
No 2
Some communities have a group of local agencies that coordinates crisis preparedness, response, and recovery efforts. Such a group might be called a local emergency planning committee, an emergency management team, or something else. Is your school a member of such a group?
Yes 1
No 2
No such group 3
Is your school designated to serve as a staging area or a community shelter during local emergencies?
Yes 1
No 2
Does your school have a National Oceanic and Atmospheric Administration, or NOAA, weather radio?
Yes 1
No 2
SHOW CARD 11
The next questions ask about family involvement in school. This card lists some ways faculty might promote family involvement in school.
During the past 12 months, how many of your school’s faculty…
None Some Most All N/A
Provided students’ families with a way
to communicate directly with teachers,
such as voicemail or an e-mail address?
Would you say none, some, most, or all? 1 2 3 4Provided families with the opportunity
to review curricula? 1 2 3 4Provided families with copies
of assignments? 1 2 3 4Contacted families to communicate
about problems with their child? 1 2 3 4 5Contacted families to communicate
praise about their child? 1 2 3 4Encouraged families to volunteer
at the school, for example by asking
parents for assistance with fundraising
efforts or to serve as a chaperone
for school trips? 1 2 3 4Discussed with families ways
to reinforce learning at home? 1 2 3 4Requested that families regularly review
and sign homework assignments? 1 2 3 4 5Encouraged families to attend
parent-teacher conferences? 1 2 3 4 5Encouraged family participation in
parent-teacher association (PTA)
meetings? 1 2 3 4 5
Are students at this school involved in developing school or classroom rules?
Yes 1
No 2
A parent information and resource center is a designated place in a school where parents can meet with other parents, teachers or school administrators to learn about and volunteer for school events or programs. These centers may also disseminate materials or provide services, such as parent workshops or conferences. Does your school have a parent information and resource center?
Yes 1
No 2
The next questions ask about community service and service-learning. By “community service,” I mean unpaid work that helps the community. By “service-learning,” I mean a particular type of community service that is designed to meet specific learning objectives for a course.
Does your school provide community service opportunities for students?
Yes 1
No 2 SKIP TO Q159
At your school, is community service…
Yes No
Required for all students? 1 2
IF Q158A IS “YES,” THEN SKIP TO Q159.
Required for students in specific grades? 1 2
Required for students who meet specific criteria,
for example honor students? 1 2Voluntary for all students? 1 2
Does your school provide service-learning opportunities for students?
Yes 1
No 2 SKIP TO Q161
At your school, is service-learning…
Yes No
Required for all students? 1 2
IF Q160A IS “YES,” THEN SKIP TO Q161.
Required for students in specific grades? 1 2
Required for students in specific courses? 1 2
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?
Yes 1
No 2
The next questions ask about physical activity.
ANSWER Q162-Q173 FOR ELEMENTARY SCHOOL ONLY. OTHERWISE, SKIP TO THE INSTRUCTIONS BEFORE Q174.
I would like to ask about times when students participate in regularly scheduled recess at this school. Please do not include activities that students engage in during physical education class.
In what grade or grades do students participate in regularly scheduled recess during the school day?
MARK ALL THAT APPLY
Kindergarten 0
1st Grade 1
2nd Grade 2
3rd Grade 3
4th Grade 4
5th Grade 5
6th Grade 6
None 7 SKIP TO Q174
On average, how many days per week are the students scheduled to have recess?
Days/Week
On average, how many minutes each day do students spend in recess?
Minutes
About how many classes have regularly scheduled recess immediately before lunch?
None 1
Less than half 2
Half 3
More than half 4
All 5
About how many classes have regularly scheduled recess immediately after lunch?
None 1
Less than half 2
Half 3
More than half 4
All 5
Are faculty and staff at this school allowed to exclude students from all or part of recess as punishment for bad behavior?
Yes 1
No 2 SKIP TO Q169
Are faculty and staff at this school discouraged from excluding students from all or part of recess as punishment for bad behavior?
Yes 1
No 2
Which of the following statements best describes how recess is structured at your school?
Students engage in free play
or physical activity 1
Students are required to use
physical activity or fitness
stations 2
Other (Specify) 3
Is recess held outdoors, weather permitting?
Yes 1
No 2
IF Q170=1 THEN DISPLAY TEXT IN PARENTHESIS
(When students cannot go outside for recess,) which of the following statements best describes what happens during recess time?
Students participate in physical activity
in the gymnasium,
multi-purpose room,
or cafeteria 1
Students participate in physical activity
in regular
classrooms 2
Students watch a DVD/video (do not include
physical activity
DVDs/videos) 3
Other (Specify) 4
Do students participate in regular physical activity breaks, outside of physical education class and recess, during the school day?
Yes 1
No 2
Does your school have a specified time or event for school-wide physical activity outside of physical education classes and recess, for example during morning announcements?
Yes 1
No 2
ANSWER Q174 FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO Q175.
Do students participate in regular physical activity breaks, outside of physical education class, during the school day?
Yes 1
No 2
Does your school have a specified time or event for school-wide physical activity outside of physical education classes, for example during morning announcements?
Yes 1
No 2
Does your school do any of the following activities to support or promote walking or biking to and from school?
Yes No
Use paid or volunteer crossing guards 1 2
Use a walking school bus 1 2
Use law enforcement officials to promote traffic safety
near the school 1 2Use law enforcement officials to prevent crime
near the school 1 2Provide bicycle racks at school 1 2
Provide promotional materials to students or parents
such as safety tips or maps of bicycle
or walking routes to school 1 2Use traffic calming devices to slow driving speeds
near the school 1 2Use reduced speed limits in a specified school zone
during peak school travel times 1 2
On an average school day, what percentage of students walk or bike TO your school in the morning?
10% or less 1
11–20% 2
21–30% 3
31–40% 4
41–50% 5
51–60% 6
61–70% 7
71–80% 8
81–90% 9
More than 90% 10
On an average school day, what percentage of students walk or bike home (or to some other destination) FROM your school in the afternoon?
10% or less 1
11–20% 2
21–30% 3
31–40% 4
41–50% 5
51–60% 6
61–70% 7
71–80% 8
81–90% 9
More than 90% 10
Does your school prohibit students from walking or biking to or from school?
Yes 1
No 2
The next questions ask about influences on students’ dietary behavior while at school.
Are faculty and staff at this school prohibited from using food or food coupons as a reward for good behavior or good academic performance?
Yes 1 SKIP Q182
No 2
Are faculty and staff at your school discouraged from using food or food coupons as a reward for good behavior or good academic performance?
Yes 1
No 2
Does your school prohibit withholding food or restricting the types of foods available as a form of punishment?
Yes 1 SKIP TO THE
INTRODUCTION TO Q184
No 2
Does your school discourage withholding food or restricting the types of foods available as a form of punishment?
Yes 1
No 2
Next, I’ll ask about policies your school might have adopted on foods offered at specific events or venues. Do not include foods offered in the cafeteria, vending machines, or school store.
Has your school adopted a policy stating that, if food is served at student parties, fruits or vegetables will be among the foods offered?
Yes 1
No 2
School does not have student parties 3
Has your school adopted a policy stating that, if food is served in after-school or extended day programs, fruits or vegetables will be among the foods offered?
Yes 1
No 2
School does not have after-school
or extended day programs 3
Has your school adopted a policy stating that fruits or vegetables will be among the foods offered at concession stands?
Yes 1
No 2
School does not have concession stands 3
Has your school adopted a policy stating that, if food is served at student parties, whole grain foods will be among the foods offered?
Yes 1
No 2
School does not have student parties 3
Has your school adopted a policy stating that, if food is served in after-school or extended day programs, whole grain foods will be among the foods offered?
Yes 1
No 2
School does not have after-school
or extended day programs 3
Has your school adopted a policy stating that whole grain foods will be among the foods offered at concession stands?
Yes 1
No 2
School does not have concession stands 3
Has your school adopted a policy stating that, if beverages are served at student parties, healthful beverages such as water or low-fat milk will be among the beverages offered?
Yes 1
No 2
School does not have student parties 3
Has your school adopted a policy stating that, if beverages are served in after-school or extended day programs, healthful beverages such as water or low-fat milk will be among the beverages offered?
Yes 1
No 2
School does not have after-school
or extended day programs 3
Has your school adopted a policy stating that healthful beverages such as water or low-fat milk will be among the beverages offered at concession stands?
Yes 1
No 2
School does not have concession stands 3
The next question asks about the availability of junk foods in schools. Junk foods are foods or beverages that have low nutrient density, that is, they provide calories primarily through fats or added sugars and have minimal amounts of vitamins and minerals.
Has your school adopted a policy prohibiting junk foods from being offered at student parties?
Yes 1
No 2
School does not have student parties 3
Has your school adopted a policy prohibiting junk foods from being offered in after-school or extended day programs?
Yes 1
No 2
School does not have after-school
or extended day programs 3
Has your school adopted a policy prohibiting junk foods from being offered at concession stands?
Yes 1
No 2
School does not have concession stands 3
The next questions ask about foods and beverages available in vending machines, school stores, canteens, or snack bars.
Can students purchase food or beverages from…
Yes No
One or more vending machines at the school? 1 2
A school store, canteen, or snack bar? 1 2
IF Q196A AND Q196B ARE “NO,” SKIP TO Q205. OTHERWISE, CONTINUE TO Q197.
Can students purchase the following from vending machines or school stores?
Yes No
Chocolate candy 1 2
Other kinds of candy 1 2
Cookies, crackers, cakes, pastries, or other baked goods
that are not low in fat 1 2Salty snacks that are not low in fat,
such as regular potato chips 1 2Ice cream or frozen yogurt that is not low in fat 1 2
2% or whole milk (plain or flavored) 1 2
Water ices or frozen slushes that do not contain juice 1 2
IF Q197A–G ARE “NO,” SKIP TO Q199.
Can students purchase these items…
Yes No
Before classes begin in the morning? 1 2
During any school hours when meals are not being served? 1 2
During school lunch periods? 1 2
Can students purchase the following from vending machines or school stores?
Yes No
Low-fat cookies, crackers, cakes, pastries,
or other low-fat baked goods 1 2Salty snacks that are low in fat, such as pretzels,
baked chips, or other low-fat chips 1 2Snacks such as pretzels, crackers, or chips
that are low in sodium 1 2Bread sticks, rolls, bagels, pita bread,
or other bread products 1 2Whole grain bread products, such as bread sticks, rolls,
or bagels 1 2Low-fat or fat-free ice cream, frozen yogurt,
or sherbet 1 2Low-fat or non-fat yogurt 1 2
Fruits or vegetables, not juice 1 2
100% fruit juice 1 2
100% vegetable juice 1 2
1% or skim milk 1 2
Bottled water 1 2
IF Q199A–L ARE “NO,” SKIP TO Q201.
Can students purchase these items…
Yes No
Before classes begin in the morning? 1 2
During any school hours when meals are not being served? 1 2
During school lunch periods? 1 2
Can students purchase the following from vending machines or school stores?
Yes No
Soda pop or fruit drinks that are not 100% juice 1 2
Sports drinks, such as Gatorade™ 1 2
Coffee, coffee drinks, or any kind of tea 1 2
Sugar-sweetened beverages, such as lemonade,
sweetened tea or coffee drinks, flavored milk, Snapple,
or Sunny Delight 1 2Energy drinks, such as Red Bull or Jolt 1 2
IF Q201A–E ARE “NO,” SKIP TO Q203.
Can students purchase these items…
Yes No
Before classes begin in the morning? 1 2
During any school hours when meals are not being served? 1 2
During school lunch periods? 1 2
Does your school intentionally price nutritious foods such as fruits, vegetables, and whole grain foods at a lower cost than junk food?
Yes 1
No 2
Does your school intentionally price healthful beverages such as water at a lower cost than sugar-sweetened beverages?
Yes 1
No 2
During the past 12 months, have any organizations at this school, such as student clubs, sports teams, or the PTA sold food at school or in the community to raise money?
Yes 1
No 2 SKIP TO Q210
During the past 12 months, have any of the following items been sold as part of fundraising for any school organization?
Yes No
Chocolate candy 1 2
Other kinds of candy 1 2
Soda pop or fruit drinks that are not 100% juice 1 2
Sports drinks, such as Gatorade™ 1 2
Cookies, crackers, cakes, pastries, or other baked goods
that are not low in fat 1 2
IF Q206A–E ARE “NO,” SKIP TO Q208.
Could students purchase these items…
Yes No
Before school classes began in the morning? 1 2
During any school hours when meals
were not being served? 1 2During school lunch periods? 1 2
During the past 12 months, have any of the following items been sold as part of fundraising for any school organization?
Yes No
Fruits or vegetables 1 2
100% fruit juice or vegetable juice 1 2
Low-fat cookies, crackers, cakes, pastries,
or other low-fat baked goods 1 2
IF Q208A–C ARE “NO,” SKIP TO Q210.
Could students purchase these items…
Yes No
Before classes began in the morning? 1 2
During any school hours when meals were not being served? 1 2
During school lunch periods? 1 2
Does this school hold fundraiser nights at fast food restaurants where a portion of the sales made on a particular night benefit the school?
Yes 1
No 2
IF Q201A AND Q201B ARE “NO,” ANSWER Q211. OTHERWISE, SKIP TO Q212.
Does this school sell soft drinks to students in any venue? Please include sports drinks, soda pop, or fruit drinks that are not 100% juice.
Yes 1
No 2 SKIP TO Q215
Does your school receive a specified percentage of soft drink sales receipts?
Yes 1
No 2 SKIP TO Q214
Does your school receive incentives, such as cash awards or donations of equipment, supplies, or other donations, once receipts total a specified amount?
Yes 1
No 2
Is your school prohibited from selling soft drinks produced by more than one company?
Yes 1
No 2
Are soft drink companies allowed to advertise soft drinks, such as sports drinks, soda pop, or fruit drinks…
School
does not
have vending
Yes No machines
On vending machines? 1 2 3
Elsewhere in the school building? 1 2
On school grounds, including on the outside
of the school building, on playing fields,
or other areas of the campus? 1 2On school buses or other vehicles used
to transport students? 1 2
Does your school allow advertisements for junk food or fast food restaurants on school property?
Yes 1
No 2
Does your school use any educational materials that promote junk food, fast food restaurants, or soft drinks?
Yes 1
No 2
At this school, are junk food, fast food restaurants, or soft drinks promoted through the distribution of products, such as t-shirts, hats, and book covers to students?
Yes 1
No 2
The next questions ask about school health coordination.
Is there one or more than one group—for example, a school health council, committee, or team—at this school that offers guidance on the development of policies or coordinates activities that are health-related?
Yes 1
No 2 SKIP TO THE INTRODUCTION TO Q225
Do any of these groups address…
Yes No
Tobacco use prevention? 1 2
Alcohol or other drug use prevention? 1 2
Food service or nutrition? 1 2
Physical education or physical activity? 1 2
ANSWER E–G FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO H.
Pregnancy prevention? 1 2
Human immunodeficiency virus, or HIV, prevention? 1 2
Other sexually transmitted disease, or STD, prevention? 1 2
Violence prevention, for example fighting, bullying, fighting, or
dating violence prevention? 1 2
Injury prevention and safety? 1 2
Health education? 1 2
Health services? 1 2
Mental health or social services? 1 2
The psychological and social environment,
or school climate? 1 2Faculty and staff health promotion? 1 2
Family and community involvement
in school health programs? 1 2Physical school environment? 1 2
(Q220 continued)
Yes No
Crisis preparedness, response, and recovery? 1 2
Management of chronic health conditions,
such as asthma or diabetes? 1 2Management of infectious diseases such as influenza
or foodborne illness 1 2Management of food allergies……………………………………1 2
Local wellness policies 1 2
SHOW CARD 12
Looking at this card, please tell me who is included on any school health council, committee, or team.
MARK ALL THAT APPLY
FOR ELEMENTARY SCHOOLS ONLY
Elementary school classroom teachers 0
FOR ALL SCHOOLS
Health education teachers 1
Physical education teachers 2
Health services staff (e.g., school nurses) 3
Nutrition or food service staff 4
Mental health or social services staff 5
Maintenance or transportation staff 6
Technology staff 7
Library or media center staff 8
District administrators 9
School-level administrators 10
Students 11
Students’ parents or families 12
SHOW CARD 13
Looking at this card, please tell me if these local agencies or organizations are represented on any school health council, committee, or team.
MARK ALL THAT APPLY
Health department 1
Mental health or social service agencies 2
Healthcare providers,
such as pediatricians or dentists 3
Health organizations,
such as the local Red Cross chapter 4
Youth organizations,
such as the Boys and Girls Clubs 5
Businesses 6
Hospitals 7
Service clubs, such as the Rotary Club 8
Public safety agencies,
such as police, fire, or emergency
services 9
Faith-based organizations 10
Other local government agencies 11
Do any of these groups…
Yes No
Identify student health needs based on a review
of relevant data, such as Youth Risk Behavior Survey Data? 1 2Develop or review a school-wide health and safety plan? 1 2
Recommend new or revised health and safety policies
and activities to the Superintendent or the school board? 1 2Seek funding or leverage resources to support
school health and safety priorities for students and staff? 1 2Recommend or review health-related curricula
or instructional materials? 1 2Communicate the importance of health and safety
policies and activities with the school board, school,
and community? 1 2
For the next question, please think about the school health council, committee, or team that met the most during the past 12 months.
During the past 12 months, how many times did this group met?
0 times 1
1 or 2 times 2
3 or 4 times 3
5 or 6 times 4
More than 6 times 5
The next questions ask about materials your school might have used to assess your school’s health and safety policies and activities.
Has your school ever used the School Health Index, or SHI, or other self-assessment tool to assess your school’s health and safety policies and activities?
Yes 1
No 2
The next questions ask about a plan your school might have developed to improve your school’s health and safety policies and activities.
Does your school have a health and safety plan to improve its health-related policies and activities for students and staff?
Yes 1
No 2 SKIP TO THE INTRODUCTION TO Q230
Did your school analyze the following types of data when developing the plan?
Yes No
Health behavior data, such as Youth Risk
Behavior Survey data 1 2Educational achievement data, such as standardized
test scores 1 2Educational data, such as absences, drop-outs,
or grade retention 1 2
(Q227 Continued)
Health services data, such as the number of
visits to the school nurse 1 2
Other types of data, such as school meal participation 1 2
Does the plan address any of the following school health-related areas?
Yes No
Health education 1 2
Physical education and physical activity 1 2
Nutrition services and foods and beverages
available at school 1 2Health services 1 2
Mental health and social services 1 2
Healthy and safe school environment 1 2
Faculty and staff health promotion 1 2
Family and community involvement 1 2
How often is the school’s health and safety plan reviewed?
Every year 1
Every 2 to 3 years 2
Every 4 to 5 years 3
More than every 5 years 4
As needed 5
Other time frame 6
Never 7
The next questions ask about a school improvement plan. The Elementary and Secondary Education Act requires certain schools to have a written School Improvement Plan, or SIP. Many states and school districts also require schools to have a written SIP. Such plans are developed to improve overall instructional and environmental policies and programs.
Does your school’s written SIP include health-related goals and objectives on any of the following topics?
INTERVIEWER INSTRUCTIONS: IF THE SCHOOL DOES NOT HAVE AN SIP, MARK NO SIP FOR EACH QUESTION.
Yes No No SIP
Health education 1 2 3
Physical education and physical activity 1 2 3
Nutrition services and foods and beverages
available at school 1 2 3Health services 1 2 3
Mental health and social services 1 2 3
Healthy and safe school environment 1 2 3
Faculty and staff health promotion 1 2 3
Family and community involvement 1 2 3
The next questions ask about school and community collaboration to improve your school’s health and safety policies and activities for students and staff.
During the past two years, did any community agencies, organizations, or healthcare providers provide resources, such as funding, materials, services, facilities, or data, to help protect and improve the health and safety of students and staff in your school?
Yes 1
No 2
During the past two years, did your school provide resources such as funding, materials, services, facilities, or data to help community agencies, organizations, or healthcare providers protect and improve the health and safety of students and staff?
Yes 1
No 2
The next questions ask about the person responsible for overseeing or coordinating all of the school’s health and safety policies and activities.
Currently, does someone at your school oversee or coordinate the school’s health and safety policies and activities, for example a school health coordinator?
Yes 1
No 2 SKIP TO END
Are you this person?
Yes 1
No 2 SKIP TO END
Have you ever received any training in your role as a coordinator of your school’s health and safety policies and activities, such as school health coordinator training provided by your school district, your state education or health agency, colleges, universities, or health organizations such as the American Cancer Society?
Yes 1
No 2
Are the following activities included in your responsibilities as coordinator of your school’s health and safety policies and activities?
Yes No NA
Developing or assisting in the development
of school health and safety policy language,
policy guidance, or other policy materials 1 2Securing funding or other resources
to support school health and safety policies
and activities 1 2Communicating school health and safety
priorities to decision-makers, such as
the school principal, the district’s
school health coordinator, or other
district-level administrators 1 2Facilitating linkages between the school’s
health-related programs and services,
and health-related resources
in the community 1 2Facilitating collaboration among school
staff responsible for the health and safety
of students and staff 1 2Serving as a liaison between the school
and those who oversee or implement
school health and safety policies and activities
at the district level 1 2Conducting school health council, committee,
or team meetings 1 2 3Managing implementation and evaluation
of the school’s health and safety plan 1 2 3Facilitating the provision of school health-related
professional development 1 2
Counting this year as a full year, how many years have you been responsible for coordinating school health and safety policies and activities?
Years
The last set of questions ask about your educational background.
Do you have an undergraduate degree?
Yes 1
No 2 SKIP TO END
What did you major in?
Health education 1
Physical education 2
Other education 3
Kinesiology, exercise physiology,
or exercise science 4
Nursing 5
Nutrition 6
Public health 7
Biology or other science 8
Home economics or family
and consumer science 9
Other 10
Did you have an undergraduate minor?
Yes 1
No 2 SKIP TO Q242
What did you minor in?
Health education 1
Physical education 2
Other education 3
Kinesiology, exercise physiology,
or exercise science 4
Nursing 5
Nutrition 6
Public health 7
Biology or other science 8
Home economics or family
and consumer science 9
Other 10
Do you have a graduate degree?
Yes 1
No 2 SKIP TO END
In what area or areas?
Health education 1
Physical education 2
Education administration 3
Other education 4
Kinesiology, exercise physiology,
or exercise science 5
Nursing 6
Nutrition 7
Public health 8
Biology or other science 9
Home economics or family
and consumer science 10
Other 11
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.
Healthy and Safe School
Environment School Questionnaire—National Review Version
| File Type | application/msword |
| Author | alice.m.roberts |
| Last Modified By | arp5 |
| File Modified | 2011-03-09 |
| File Created | 2011-03-03 |
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