22 Mental Health and Social Services School Questionnaire

Form Approved

OMB No: 0920-0445

Expiration Date: xx/xx/xxxx

Mental Health and Social Services
School Questionnaire

7 January 2011

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Public reporting burden for this collection of information is estimated to average 30 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).

Mental Health and Social Services
School Questionnaire

Questions

Staffing Characteristics 1–19

Collaboration 20–22

Promotion 23

Facilities and Equipment 24–25

Provision of Mental Health and Social Services 26–36

Services Provided at Other Sites 37–40

Mental Health and Social Services Coordinator 41–56

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) School 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

This interview asks about standard mental health and social services. By “standard,” we mean services available to all students at your school. Mental health and social services include services such as crisis intervention, identification of emotional disorders, or assistance with enrolling in Medicaid. These services usually are provided by a school counselor, psychologist, or social worker but also could be provided at your school by staff from collaborating community agencies.

First, I would like to ask questions about staffing for standard mental health and social services at your school. Please include both contracted providers and regular school staff.

2. Is there a part-time or full-time school counselor who provides standard mental health or social services to students at your school? Do not include school counselors who provide only academic counseling or college or career placement.

Yes 1

No 2 SKIP TO Q5

3. How many part-time or full-time school counselors provide standard mental health or social services to students at your school?

_____ Counselors

4. During the past 30 days, how many hours per week on average has each school counselor spent at your school?

Counselor 1 _____ Hours/Week

Counselor 2 _____ Hours/Week

Counselor 3 _____ Hours/Week

Counselor 4 _____ Hours/Week

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

Undergraduate degree in counseling 1

Master’s degree in counseling 2

Other degree (Specify) 3

No specific education requirement 4

6. Is a newly hired school counselor required to be licensed, certified, or credentialed by a state agency or board?

Yes 1

No 2

State does not license, certify,
or credential school counselors 3

7. Is there a part-time or full-time school psychologist who provides standard mental health or social services to students at your school? Do not include school psychologists who only conduct psychological testing.

Yes 1

No 2 SKIP TO Q10

8. How many part-time or full-time school psychologists provide standard mental health or social services to students at your school?

_____ Psychologists

9. During the past 30 days, how many hours per week on average has each school psychologist spent at your school?

Psychologist 1 _____ Hours/Week

Psychologist 2 _____ Hours/Week

Psychologist 3 _____ Hours/Week

Psychologist 4 _____ Hours/Week

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

Undergraduate degree in psychology 1

Master’s degree in psychology 2

Doctorate in psychology 3

Other degree (Specify) 4

No specific education requirement 5

11. Is a newly hired school psychologist required to be licensed, certified, or credentialed by a state agency or board?

Yes 1

No 2

State does not license, certify,
or credential school psychologists 3

12. Is there a part-time or full-time school social worker who provides standard mental health or social services to students at your school?

Yes 1

No 2 SKIP TO Q15

13. How many part-time or full-time school social workers provide standard mental health or social services to students at your school?

_____ Social workers

14. During the past 30 days, how many hours per week on average has each school social worker spent at your school?

Social worker 1 _____ Hours/Week

Social worker 2 _____ Hours/Week

Social worker 3 _____ Hours/Week

Social worker 4 _____ Hours/Week

15. At your school, what is the minimum level of education required for a newly hired school social worker?

Undergraduate degree in social work 1

Master’s degree in social work 2

Other degree (Specify) 3

No specific education requirement 4

16. Is a newly hired school social worker required to be licensed, certified, or credentialed by a state agency or board?

Yes 1

No 2

State does not license, certify,
or credential school social workers 3

17. Are all school mental health or social services staff required to earn continuing education credits on mental health or social services topics?

Yes 1

No 2 SKIP TO Q19

18. How often are all school mental health and social services staff required to earn continuing education credits on mental health or social services topic?

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

IF THERE IS NO SCHOOL COUNSELOR, PSYCHOLOGIST, OR SOCIAL WORKER AT THIS SCHOOL (Q3, Q7, AND Q12 ARE “NO”), SKIP TO Q23.

19. During the past 12 months, has a school counselor, psychologist, or social worker at your school talked to or taught…

Yes No

ANSWER A AND B FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO THE INSTRUCTIONS BEFORE C.

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

2. Any other class at your school? 1 2

ANSWER C AND D FOR ELEMENTARY SCHOOL ONLY. OTHERWISE, SKIP TO Q20.

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

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

Now I’m going to ask you about collaboration among mental health or social services staff and other school and local agency staff.

20a. During the past 12 months, has a school counselor, psychologist, or social worker at your school worked on standard school mental health or social services activities with health education staff from your school?

Yes 1

No 2

School does not have health education staff 3

20b. What about with physical education staff from your school?

Yes 1

No 2

School does not have physical education staff 3

20c. What about with nutrition or food service staff from your school?

Yes 1

No 2

School does not have nutrition
or food service staff 3

20d. What about with health services staff from your school?

Yes 1

No 2

School does not have health services staff 3

20e. School-based health center staff from your school?

Yes 1

No 2

School does not have school-based
health center staff 3

21. During the past 12 months, has a school counselor, psychologist, or social worker worked on standard school mental health or social services activities for students with staff or members from…

Yes No N/A

1. A local health department? 1 2 3

2. A local hospital? 1 2 3

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

4. A local child welfare agency? 1 2 3

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

6. A local college or university? 1 2 3

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

8. A local business? 1 2

9. Communities in Schools? 1 2 3

20. During the past two years, have…

Yes No

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

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

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

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

The next questions ask about promotion of mental health or social services that might occur at your school.

21. During the past 12 months, has your school...

Yes No N/A

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

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

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

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

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

The next question asks about facilities and equipment that may be available for mental health or social services staff in your school to use.

22. Does your school have…

Yes No

1. A private room for counseling students? 1 2

2. A dedicated phone line for standard mental health
   or social services staff? 1 2

3. An answering machine or voice mail reserved
   for standard mental health or social services staff? 1 2

4. Locked storage space for files related to the standard
   mental health or social services provided to students? 1 2

23. Where in relation to your school’s main office is the primary location where students go to obtain standard mental health or social services? Are the services offered...

Within the same office suite
as the main office? 1

Within view of the main office? 2

Not within view of the main office? 3

I am going to ask about the activities of mental health or social services staff such as school counselors, psychologists, and social workers. Please do not include activities by teachers in the classroom or activities by nurses or physicians. I’ll find out about their activities during a different interview.

SHOW CARD 1

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

24. Do mental health or social services staff provide...

Yes No

1. Case management for students with emotional
   or behavioral problems? 1 2

2. Family counseling? 1 2

3. Group counseling? 1 2

4. Individual counseling? 1 2

5. Comprehensive assessment or intake evaluation? 1 2

6. Peer counseling or mediation? 1 2

7. Self-help or support groups? 1 2

IF Q26A–G ARE ALL “NO” SKIP TO THE INTRODUCTION TO Q29.

25. Who provides [each service listed in Q26A–G]?
    MARK ALL THAT APPLY

School counselor 1

School psychologist 2

School social worker 3

Other 4

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

School district budget 1

Medicaid 2

State Children’s Health Insurance Program (SCHIP) 3

Private insurance 4

Public grants 5

Private grants 6

Other 7

Student assistance programs provide services designed to assist students experiencing personal or social problems that can impact school performance, physical health, or overall well-being.

27. Is a student assistance program offered to students at your school?

Yes 1

No 2

Some schools have a team of school staff who collaborate to provide assistance to students with disabilities or those who are experiencing academic difficulties or behavioral problems. These sometimes are called student support teams, student assistance teams, or student guidance teams.

28. Does your school have such a team?

Yes 1

No 2 àSKIP TO Q32

29. Does this team include staff from collaborating community agencies?

Yes 1

No 2

30. Does someone from the mental health and social services staff participate in the development of Individualized Education Programs, or IEPs, when indicated?

Yes 1

No 2

31. Does someone from the mental health and social services staff participate in the development of Individualized Health Plans, or IHPs, when indicated?

Yes 1

No 2

32. Does someone from the mental health and social services staff participate in the development of 504 plans, when indicated?

Yes 1

No 2

33. During the past 12 months, has your school reviewed mental health or social services records to identify students with chronic mental health or social services problems or ways to prevent further occurrences of these problems?

Yes 1

No 2

School does not keep mental health
or social services records 3

34. Is there backup or after hours coverage when school mental health or social services staff are unavailable, for example after school or on weekends?

Yes 1

No 2

This next set of questions asks about mental health or social services delivered to students or families 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 mental health or social services professionals who work at school-linked health centers or who have a contract, memorandum of agreement, or other similar arrangement with the district or school to provide mental health or social services to students or families.

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

Yes 1

No 2 SKIP TO Q41

SHOW CARD 2

36. Which of the organizations or mental health or social services professionals listed on this card have arrangements to provide mental health or social services when needed to students or families 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 managed care organization 7

A private psychologist 8

A private psychiatrist 9

A private social worker 10

A private counselor 11

SHOW CARD 3

As I read the list printed on this card, please tell me if there are arrangements with any organizations or mental health or social services professionals to provide these services when needed to students or families from your school.

37. Are there arrangements with any organizations or mental health or social services professionals to provide...

Yes No

ANSWER A AND B FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO C.

1. Tobacco use cessation? 1 2

2. Alcohol or other drug use treatment? 1 2

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

4. Crisis intervention for personal problems? 1 2

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

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

7. Stress management? 1 2

8. Weight management? 1 2

ANSWER I AND J FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO K.

9. Eating disorders treatment? 1 2

10. HIV counseling, testing, and referral? 1 2

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

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

(Q39 continued)

Yes No

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

ANSWER N, O AND P FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO Q.

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

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

16. Job readiness skills programs? 1 2

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

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

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

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

SHOW CARD 4

As I read the list on this card, please tell me if there are arrangements with any organizations or mental health or social services professionals to provide to these services when needed to students or families from your school.

38. Are there arrangements with any organizations or mental health or social services professionals to provide...

Yes No

1. Case management for students with emotional
   or behavioral problems? 1 2

2. Family counseling? 1 2

3. Group counseling? 1 2

4. Individual counseling? 1 2

5. Comprehensive assessment or intake evaluation? 1 2

6. Peer counseling or mediation? 1 2

7. Self-help or support groups? 1 2

39. Currently, does someone at your school oversee or coordinate standard mental health and social services?

Yes 1

No 2 That is the last question.
Thank you very much for taking the time to complete this interview.

40. Are you this person?

Yes 1

No 2 That is the last question.
Thank you very much for taking the time to complete this interview.

SHOW CARD 5

41. Please tell me who you work for.
    MARK ALL THAT APPLY

School district 1

This school 2

A local mental health
or social services agency 3

Other 4

Now, I’d like to ask you some questions about your educational background.

42. Do you have an undergraduate degree?

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q51

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

Counseling 1

Psychology 2

Social work 3

Education 4

Other (Specify) 5

44. Did you have an undergraduate minor?

Yes 1

No 2 SKIP TO Q48

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

Counseling 1

Psychology 2

Social work 3

Education 4

Other (Specify) 5

46. Do you have a graduate degree?

Yes 1

No 2 SKIP TO Q50

47. In what area or areas?
    MARK ALL THAT APPLY

Counseling 1

Psychology 2

Social work 3

Education 4

Other (Specify) 5

48. Are you currently licensed, certified, or credentialed by a state agency or board to provide school mental health or social services?

Yes 1

No 2

State does not license, certify,
or credential school mental health
or social services professionals 3

SHOW CARD 6

Finally, I’d like to ask you a few questions on professional development. This might include workshops, conferences, continuing education, graduate courses, or any other kind of in-service.

As I read the list of topics printed on this card, please tell me if you received any professional development on each topic during the past two years.

49. During the past two years, did you receive any professional development on…

Yes No

1. Tobacco use cessation? 1 2

2. Alcohol or other drug use treatment? 1 2

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

4. Crisis intervention for personal problems? 1 2

5. Emergency preparedness? 1 2

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

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

(Q51 continued)

8. Stress management? 1 2

9. Weight management? 1 2

10. Eating disorders treatment? 1 2

11. HIV counseling, testing and referrals? 1 2

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

13. Identification of or referrals for students with family

problems, such as parental divorce, substance abuse

or violence? 1 2

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

15. Child care options for teen mothers? 1 2

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

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

18. Securing temporary or permanent housing? 1 2

19. Enrolling in Medicaid or SCHIP? 1 2

20. Accessing benefits for students with disabilities? 1 2

21. Job readiness skills programs? 1 2

SHOW CARD 6

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

Tobacco use cessation 1

Alcohol or other drug use treatment 2

Counseling after a natural disaster
or other emergency or crisis situation 3

Crisis intervention for personal problems 4

Emergency preparedness 5

Identification of emotional
or behavioral disorders, such as
anxiety, depression, or ADHD 6

Counseling for emotional
or behavioral disorders, such as
anxiety, depression, or ADHD 7

(Q52 continued)

Stress management 8

Weight management 9

Eating disorders treatment 10

HIV counseling, testing, and referral 11

Identification of or referral for physical,
sexual, or emotional abuse 12

Identification of or referrals for students
with family problems, such as parental
divorce, substance abuse, or violence 13

After-school programs for students
supervised recreation 14

Child care options for teen mothers 15

Services specifically for gay, lesbian,
or bisexual students 16

Enrolling in WIC or accessing
food stamps or food banks 17

Securing temporary or permanent housing 18

Enrolling in Medicaid or SCHIP 19

Accessing benefits for students with
disabilities 20

Job readiness skills programs 21

None of these 22

SHOW CARD 7

51. 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

52. 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, such as bullying,
fighting, or dating violence prevention 9

Injury prevention and safety counseling 10

None of these 11

SHOW CARD 8

53. Finally, during the past two years, have you received any professional development on…

Yes No

1. Case management for students with emotional
   or behavioral problems? 1 2

2. Family counseling? 1 2

3. Group counseling? 1 2

4. Individual counseling? 1 2

5. Comprehensive assessment or intake evaluation? 1 2

6. Peer counseling or mediation? 1 2

7. Self-help or support groups? 1 2

8. Student assistance programs? ……………………………………1 2

9. Student support teams? ………………………………………….1 2

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

Case management for students
with emotional or behavioral problems 1

Family counseling 2

Group counseling 3

Individual counseling 4

Comprehensive assessment
or intake evaluation 5

Peer counseling or mediation 6

Self-help or support groups 7

Student assistance programs 8

Student support teams 9

None of these 10

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?

( ) -

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

Mental Health and Social Services School Questionnaire—Public Use Version