Form 1 CPTED School Site Data Form

APPENDIX F

CPTED School Site Data Form

Form Approved

OMB No. 0920-XXXX

Exp. Date:

Public Reporting burden of this collection of information is estimated at 120 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 NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-XXXX).

CPTED SCHOOL SITE DATA FORM

Thank you for taking the time to complete the information for this School Site Data Form. The School Site Data Form provides information essential to our study of the physical environment and design of schools and its effects on student perceptions and experience of school safety. The study is a major part of the Centers for Disease Control and Prevention efforts to improve school safety and reduce the threat of physical or social-emotional injury on campus. Most of the information requested here is factual and will be drawn from school records, or from knowledge of school environment and policy. Whenever possible, we have pre-filled information. In these instances, please review this information for accuracy and currency, and make corrections if necessary. This information is critical to understanding the environment in which the learning process takes place at your school. We will NOT include your name, your schools’ name, or any other identifying facts when we present the study or publish its results. The study findings will be summarized and reported in group form. If you have any questions about the profile or how to answer specific questions, please give xxxxxx a call at (xxx) xxx-xxxx. She/he is more than happy to assist in any way she/he can. Again, thank you for your assistance with this important study.

1. School Identification

1.1) School Name:

1.2) Address:

City

State

Zip

1.3) Principal’s Name:

1.3.1) Number of years principal at this school:

1.4) Person completing this profile:

1.4.1) Job title of person completing profile:

1.4.2) Number of years person completing profile at this school:

1.4.3) Phone number of person completing profile:

1.4.4) Email address for person completing profile:

1.5) Date of Profile Information Completion:

2. Scheduling

2.1) Starting date for your 2011-2012 academic school year ______/______/______

2.2) Ending date for your 2011-2012 academic school year ______/______/______

2.3) Official School day: ______ AM - ______ PM

2.3.1) Students are allowed on campus at ______ AM

2.3.2) Students must leave campus by ______ PM

2.4) Lunch hours: 1^st lunch ______ AM/PM

2^nd lunch ______ AM/PM

3^rd lunch ______ AM/PM

4^th lunch ______ AM/PM

2.5) Number of class periods in a school day: _________

2.6) Minutes per school period: _________

2.7) Number of classroom changes most students make in a typical day? _________

[Count going to lunch and then returning to the same or a different classroom as two classroom changes. Do not count morning arrival or afternoon departure.]

3. School and Community

3.1) Which of the following best describes your school? [Circle one response.]

(a) Regular school

(b) Charter school

(c) Have magnet program for part of school

(d) Total magnet school

(e) Other (specify) ___________________________________________

3.2) Are there any schools-within-schools at this facility?
[Please count alternative, vocational, gifted, and other school-wide programs.]

(a) Yes. If yes, describe: ___________________________________________

(b) No

3.3) Is your school located in a:

1. Rural area

2. Suburban area

3. Urban area

3.4) Are there community uses of the school during normal school hours?

(a) Yes. If yes, describe: ___________________________________________

(b) No

3.5) On average, what percentage of students come by:

(a) Bus _________%

(b) Parents or other adult transportation _________%

(c) Foot _________%

(d) Bike _________%

(e) Public Transit _________%

3.6) What is the earliest pick up time for students riding a school bus? _________ AM

3.7) What is the approximate average ride time for students on a school bus? _________ minutes

4. School Facility

4.1) Which of the following best describes your school facility, excluding any portable buildings?

	YES	NO	NUMBER OF BUILDINGS
4.1.1) One story, single building			Not applicable
4.1.2) One story, multiple buildings		
4.1.3) Two-story, single building			Not applicable
4.1.4) Two-story, multiple buildings		
4.1.5) One & two story multiple buildings		

4.2) In what year was the school originally built? ____________

4.3) Has the school been expanded, modified, or renovated since the year it was built?

(a) Yes; in what year(s): ______________________

(b) No

4.3.1) If you answered (a) Yes to question 4.3, please provide a brief description of the nature and scope of the modifications that have been made.

4.4) On how many total acres does your school campus reside? _________ Total number of acres

4.5) What is the total square footage of your school? _________ Total square footage

4.6) What is the student capacity for the current facility? ________ Number of students

4.7) How many portables are currently being used? ________ Number of portables

4.8) How many points of entry does your entire school have? ________ Number of points of entry

[A point of entry with more than one door counts as one entry.] [Do not count alarmed emergency exits.]

5. School Population

Students

5.1) For the 2011-2012 school year what is the total enrollment at your school? ____________

5.2) For the 2011-2012 school year, what percentage of your enrolled population is in:

[Respond for each grade.]

(a) ______% 6th grade

(b) ______% 7th grade

(c) ______% 8th grade

(d) ______% Other grade

5.3) For the 2011-2012 school year, what percentage of your enrolled population is:

(a) Hispanic or Latino ______%

5.4) For the 2011-2012 school year, what percentage of your enrolled population is:

(a) American Indian or Alaska Native ______%

(b) Asian ______%

(c) Black or African American ______%

(d) Native Hawaiian or Other Pacific Islander ______%

(e) White ______%

(f) Other _______________________________ ______%

5.5) For the 2011-2012 school year, what percentage of your enrolled population fit the following criteria?

(a) Eligible for free or reduced-price lunch ______%

(b) Limited English proficient (LEP) ______%

(c) Special education students ______%

(d) Male ______%

5.6) For the 2011-2012 school year, what percentage of your students’ parents are members of the Parent Teacher Association (PTA) or the Parent, Teacher, and Student Association (PTSA)? [Respond for each grade.]

(a) ______% 6th grade

(b) ______% 7th grade

(c) ______% 8th grade

5.7) Across 6^th, 7^th, and 8^th grades, how many students scored at the following percentiles on standardized tests for the past 2010-2011 school year?

(a) Above 90th percentile _______ Number of students

(b) 80th to 90th percentile _______ Number of students

(c) 70th to 79th percentile _______ Number of students

(d) 60th to 69th percentile _______ Number of students

(e) 50th to 59th percentile _______ Number of students

(f) Below 50th percentile _______ Number of students

(g) Below 15th percentile _______ Number of students

5.8) In the 2010-2011 school year, how many students transferred to or from your school after the school year had started?

[Please report on the total mobility, not just transfers due to disciplinary actions.] [If a student transferred more than once in the school year, count each transfer separately.]

(a) Transferred to the school _______ Number of students

(b) Transferred from the school _______ Number of students

5.9) In the 2010-2011 school year, how many unexcused absences occurred? _____________

5.10) In the 2010-2011 school year, how many instances of truancy were reported? _____________

5.11) On average, what percentage of your students were absent without excuse each day during the 2010-2011 school year? _____________

Staff Size by Position

Please indicate how many full- and part-time school personnel within each category are employed at your school site this school year (2011-2012).

	NUMBER FULL-TIME		NUMBER PART-TIME
5.12) Assistant Principals
5.13) Classroom Teachers
5.14) Classroom Aides or Volunteers
5.15) Special Education Teachers
5.16) Special Education Aides or Volunteers
5.17) Counselors/mental health professionals
5.18) Safety and Security Personnel

5.19) For classroom teachers, what is the average number of years of employment at the school? ______________

6. School Policies and Disciplinary Procedures

6.1) During the 2011-2012 school year, is it a policy of your school to do the following?

[If your school changed its policies during this school year, please answer according to the most recent.]

SCHOOL POLICIES [Check one response on each line.]	YES	NO
6.1.1) Require visitors to sign or check in		
6.1.2) Require visitors to sign or check out		
6.1.3) Control access to school buildings during school hours (e.g., locked or monitored doors)		
6.1.4) Control access to school grounds during school hours (e.g., locked or monitored gates)		
6.1.5) Require students to pass through metal detectors each day		
6.1.6) Require visitors to pass through metal detectors		
6.1.7) Perform one or more random metal detector checks on students		
6.1.8) Require most students to stay on campus at lunchtime		
6.1.9) Perform one or more random sweeps for contraband (e.g., drugs or weapons)		
6.1.10) Require drug testing for any students		
6.1.11) Require students to wear uniforms		
6.1.12) Enforce a dress code		
6.1.13) Provide a printed code of student conduct to students		
6.1.14) Provide a printed code of student conduct to parents		
6.1.15) Provide school lockers to students		
6.1.16) Require clear book bags on school grounds		
6.1.17) Ban book bags on school grounds		
6.1.18) Require students to wear badges or picture IDs		
6.1.19) Require faculty and staff to wear badges or picture IDs		
6.1.20) Provide telephones in most classrooms		
6.1.21) Prohibit all tobacco use on school grounds.		
6.1.22) Does the school have a written policy about bullying? (if NO skip to Q6.2)		
6.1.23) Is the written bullying policy included in a student handbook that goes home for student and parental review?		

6.2) In 2011-2012, please indicate if your school has the following structures or procedures in place. If so, please answer the questions concerning their operation.

6.2.1) Is there a procedure for peer mediation of student conflict or disciplinary matters in your school?

(a) Yes. If Yes, how many cases did it mediate during 2010-2011? ________

(b) No

6.2.2) Is there a standardized, formal method for students to contribute to school policy decisions at your school?

(a) Yes. If Yes: Please describe: ______________________________________________

(b) No

6.2.3) Is there a standardized, formal method for parents to contribute to school policy decisions at your school?

(a) Yes. If Yes: Please describe: ______________________________________________

(b) No

6.2) Please provide the following information concerning implementation of school policy.

When students are caught fighting, indicate whether and how frequently the following actions are taken…	Always, a Policy Requirement	Often, the Usual Sanction	Sometimes, Depending On Circumstances	Seldom, When Circumstances Require	Never, Not Available or Proscribed
6.3.1) Referred to school counselor?					
6.3.2) Referred to school administrator?					
6.3.3) Referred to peer mediation?					
6.3.4) Encouraged, but not required, to participate in an assistance program (e.g., anger management)?					
6.3.5) Required participation in an assistance program (e.g., anger management)?					
6.3.6) Referred to legal authorities?					
6.3.7) Placed in detention?					
6.3.8) Given in-school suspension?					
6.3.9) Not allowed to participate in extracurricular activities or interscholastic sports?					
6.3.10) Suspended from school?					
6.3.11) Expelled from school?					
6.3.12) Reassigned to an alternative school?					

7. Disciplinary Actions

7.1) In 2010-2011, please indicate the numbers of disciplinary actions of each of the following kind and reason that occurred at your school.

Type and Reason for Disciplinary Action	# of ACTIONS
7.1.1) Detentions for bullying, threats, or intimidation.
7.1.2) Suspensions*/expulsions for bullying, threats or intimidation.
7.1.3) Suspensions/expulsions for fights without physical injury requiring medical attention.
7.1.4) Suspensions/expulsions for fights with physical injury requiring medical attention.
7.1.5) Suspensions/expulsions for possession or use of tobacco at school.
7.1.6) Suspensions/expulsions for possession, use, or being under the influence of alcohol or drugs at school.
7.1.7) Suspensions/expulsions for possessing firearms at school.
7.1.8) Suspensions/expulsions for possessing weapons other than a firearm at school.
7.1.9) Suspensions/expulsions for theft at school.
7.1.10) Referrals to legal authorities for a crime committed at school.

*Suspensions or expulsions are defined as any disciplinary act that removes a student from the regular classroom for one school day or more.

8. Violent Deaths

   1. Please provide the number of violent deaths in the past two school years (2010-2011 and 2011-2012) of your school’s students, faculty, staff, or other adults or youth who are not affiliated with the school campus.

	Students	Faculty	Staff	Other Adults	Other Children/ Youth
8.1.1) Homicides at school, on school grounds, or at a school-sponsored event					
8.1.2) Homicides outside of school					
8.1.3) Suicides at school, on school grounds, or at a school-sponsored event					
8.1.4) Suicides outside of school					

8. Other Threats to Safety at School

   1. In the past two school years (2010-2011 and 2011-2012), did your school experience any:

      	YES	NO
      9.1.1) Shooting incidents on school grounds in which students used firearms with intent to do harm.		
      9.1.2) Shooting incidents on school grounds in which non-students used firearms with intent to harm		

   2. Please indicate whether incidents in the categories below occurred at your school during the past two school years (2010-2011 and 2011-2012). If an incident occurred, please indicate the number of incidents that occurred during that time period.

[Count all incidents that happened at school:

• regardless of whether students or non-students were involved;

• regardless of whether they happened during normal school hours;

• record “0” if no incidents in a category;

• count only the most serious offense when an incident involved multiple offenses (for example, if an incident included rape and robbery, include the incident only under rape but note in the final column that more than one offense occurred).]

OFFENSE TYPE (in order of seriousness)	YES	NO	If Yes, Number of Incidents	Number of Multiple Offenses Same Incident?
9.2.1) Rape or attempted rape			_______	_______
9.2.2) Sexual battery other than rape (including threatened rape)			_______	_______
9.2.3) Physical attack or fight between two students
(a) With weapon			_______	_______
(b) Without weapon			_______	_______
9.2.4) Physical attack or fight involving several students/individuals
(a) With weapon			_______	_______
(b) Without weapon			_______	_______
9.2.5) Threats of physical attack
(a) With weapon			_______	_______
(b) Without weapon			_______	_______
9.2.6) Robbery (taking things by force)
(a) With weapon			_______	_______
(b) Without weapon			_______	_______
9.2.7) Theft/larceny (taking things over $10/no personal confrontation)			_______	_______
9.2.8) Possession of firearm/ explosive device			_______	_______
9.2.9) Possession of knife or sharp object			_______	_______
9.2.10) Distribution of illegal drugs			_______	_______
9.2.11) Possession or use of alcohol			_______	_______
9.2.12) Possession or use of illegal drugs			_______	_______
9.2.13) Possession or use of prescription drugs without a doctor’s permission			_______	_______
9.2.14) Sexual harassment other student			_______	_______
9.2.15) Sexual harassment faculty or staff			_______	_______
9.2.16) Intimidation (bullying)			_______	_______
9.2.17) Vandalism			_______	_______
9.2.18) Trespassing			_______	_______
9.2.19) Other (specify)			_______	_______

9. Security and Prevention Practices

Use of Security Personnel

10.1) During the 2011-2012 school year at what times does your school regularly use paid law enforcement or security services at school? [Select one response on each line.]

	YES	NO
10.1.1) At any time during school hours		
10.1.2) While students were arriving and/or leaving		
10.1.3) At selected school activities (e.g., athletic and social events, open houses, science fairs)		
10.1.4) When school/school activities not occurring		
10.1.5) Other (please specify)		

10.2) During the 2011-2012 school year, does your school use full-time security personnel?

1. Yes

2. No [SKIP TO Q10.3]

10.2.1) ______ Number of School Resource Officers/Sworn Law Enforcement Officers

10.2.2) ______ Number of Private Security Officers

10.2.3) ______ Number of School system Police Officers

Architectural/Environmental Modifications

10.3) In the last three years, did your school complete any architectural or environmental modifications to reduce opportunities for crime and violence?

1. Yes

2. No

10.4) Does your school currently have any of the following security equipment?

	YES	NO	NUMBER
Communication Devices
10.4.1) 2-way radios			_______
10.4.2) 2-way intercom in most classrooms			_______
10.4.3) Other (specify)			_______
Access Restrictions
10.4.4) Proximity or card swipe access for staff			_______
10.4.5) Intrusion Alarm Systems			_______
If yes, where?			_______
10.4.6) Main building(s)			_______
10.4.7) Other (specify)			_______
Surveillance Cameras
If yes, where?			_______
10.4.8) Entry/exit areas – exterior			_______
10.4.9) Athletic areas			_______
10.4.10) Other (specify)			_______
10.4.11) Entry/exit areas – interior			_______
10.4.12) Corridors			_______
10.4.13) Other (specify)			_______
Metal Detectors
If yes, where?			_______
10.4.14) Main entry			_______
10.4.15) Secondary entries			_______
10.4.16) Other (specify)			_______

Prevention Training

10.5) Does your school require violence prevention and awareness training for students each year?

(a) Yes

(b) No [SKIP TO Q10.6]

10.5.1) What violence prevention program did you use: ______________________

10.5.2) How was the prevention program used (e.g., in a stand-alone class, in a group with multiple classes; gender specific)? ___________________________________________________________________

10.5.3) How many hours of prevention education does the program require? _____________

10.5.4) For how many years has this training been required? _____________

10.6) Does your school require violence prevention and awareness training for faculty and staff each year?

(a) Yes

(b) No [SKIP TO END]

10.6.1) What violence prevention program did you use: ______________________

10.6.2) How was the prevention program used (e.g., classroom instruction, individualized)? __________________________________________________________________________

10.6.3) How many hours of prevention education does the program require? _____________

10.6.4) For how many years has this training been required? _____________

END: Thank you for collecting the information for this school profile.

It will help us interpret other data we are collecting for this study.