School Health Services

Procedures for Student

Form Approved

OMB No: 0920-0445

Expiration Date: xx/xx/xxxx

Health Services
School Questionnaire

§

Public reporting burden for this collection of information is estimated to average 55 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, Mailstop D-74, Atlanta, GA 30333; Attention PRA (0920-0445).

Health Services
School Questionnaire

Questions

Module 1

Job Title 1

Student Health Records 2–5

Required Immunizations 6–11

Tuberculosis Testing 12–16

Procedures for Student Medications 17–25

Funding/Medicaid 26–27

School-Based Health Centers 28–29

Communication 30–32

Module 2

Screening 33–34

School Nurse Staffing 35–42

Collaboration 43–46

Educational Requirements 47–50

Other Staffing 51–59

Module 3

Facilities and Equipment 60–66

Health Services Records and Reports 67–73

Injury Reports 74–76

Illness Reports 77–84

Provision of Health Services 85–93

Provision of Other Services 94–97

Services Provided at Other Sites 98–101

Health Services Coordinator 102–119

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. COMMENTS APPEARING IN THE MARGIN REPRESENT ASSISTANCE AVAILABLE TO THE RESPONDENT IF ADDITIONAL CLARIFICATION IS REQUIRED ON THE QUESTION OR THE SPECIFIC TERMINOLOGY USED. WHEN ASKED, THE INTERVIEWER WILL READ THESE STATEMENTS ALOUD TO THE RESPONDENT. THE PROGRAMMING SPECIFICATIONS FOR THE INTERVIEW ARE NOT INCLUDED IN THIS PRINTED VERSION OF THE QUESTIONNAIRE.

1. What is your job title at the school? (In which role do you spend more time?)

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

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

SHOW CARD 1

The first questions ask about student records.

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

2. Does your school obtain and keep…

Yes No

1. A physical health history? 1 2

2. An emotional or mental health history? 1 2

3. Tuberculosis screening results? 1 2

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

5. Medication needs? 1 2

6. Dietary needs or restrictions? 1 2

7. Information on severe food or other allergies? 1 2

8. Physical activity restrictions? 1 2

9. Asthma action plans? 1 2

10. Emergency contact information? 1 2

11. An authorization for emergency treatment? 1 2

12. Insurance coverage information? 1 2

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

14. Reasons for student absences? 1 2

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

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q6

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

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q6

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

Yes 1

No 2

The next questions are about immunizations.

6. Does your school require students to receive an influenza (flu) vaccine annually?

Yes 1

No 2

IF THIS IS A MIDDLE OR HIGH SCHOOL, SKIP TO THE INSTRUCTIONS BEFORE Q8.

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

Yes No

1. A second measles vaccine 1 2

2. A polio vaccine 1 2

3. A pertussis vaccine 1 2

4. A tetanus vaccine 1 2

5. A hepatitis A vaccine 1 2

6. A hepatitis B vaccine 1 2

7. A chicken pox or varicella vaccine 1 2

ANSWER Q8 FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO Q9.

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

Yes No

1. A second measles vaccine 1 2

2. A hepatitis A vaccine 1 2

3. A hepatitis B vaccine 1 2

4. A chicken pox or varicella vaccine 1 2

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

6. A meningococcal conjugate vaccine 1 2

7. A human papillomavirus, or HPV, vaccine, for girls only 1 2

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

Students who have not received the required
immunizations for school entry are
immediately excluded from attending classes 1 SKIP TO Q11

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

This school does not exclude students from
attending classes if they have not received
the required immunizations for school entry 3 SKIP TO Q11

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

Days

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

Yes No

1. Medical reasons? 1 2

2. Religious reasons? 1 2

3. Personal beliefs? 1 2

The next questions ask about tuberculosis (TB) screening and TB testing for students prior to school entry. For the purposes of these questions, “screening” means the identification of students meeting certain risk criteria, for example those born or recently living in other countries. Students meeting these criteria would then be referred for TB testing or required to provide evidence of medical clearance. TB “testing” refers to giving a clinical test for TB,
such as a skin test.

We will first be asking about TB screening. Do not consider TB testing when answering this question.

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

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

TB screening is required prior to school
entry for certain students, such as those
transferring into the school 2

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

The next question asks about your school’s requirements for tuberculosis (TB) testing for students. For the purposes of this question, “testing” refers to a clinical test for TB,
such as a skin test.

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

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

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

TB testing is required prior to school entry
for certain students, such as those
transferring into the school 3

TB testing is not required prior to
school entry for any students 4

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

Periodic TB testing is required
for all students 1

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

Periodic TB testing is not required
for any students 3

IF Q13 IS 4 AND Q14 IS 3, SKIP TO THE INTRODUCTION TO Q17.

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

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

(These) students are tested in one
particular grade 1

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

(These) students are tested every year 3

SHOW CARD 2

16. Which method does your school accept as evidence of a negative TB test?

PPD skin test done by Mantoux method 1

Skin test not otherwise specified 2

Chest x-ray 3

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

More than one testing method is acceptable 5

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

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

Yes No

1. A prescription quick-relief inhaler? 1 2

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

3. Insulin or other injected medications? 1 2

4. Any other prescribed medications? 1 2

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

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

School nurse 1

School physician 2

School health aide 3

Teachers 4

Other school staff, such as principals
or secretaries 5

No teachers or staff are allowed
to administer prescription medications 6

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

School nurse 1

School physician 2

School health aide 3

Teachers 4

Other school staff, such as principals
or secretaries 5

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

IF Q18 OR Q19 IS 3, 4, OR 5 CONTINUE TO Q20. OTHERWISE, SKIP TO Q24.

20. When someone who is not a licensed healthcare professional administers prescription medications to students, are they required to be licensed or certified to administer medications?

Yes 1

No 2

21. When someone who is not a licensed healthcare professional administers over-the-counter medications to students, are they required to be licensed or certified to administer medications?

Yes 1

No 2

22. When someone who is not a licensed healthcare professional administers prescription medications to students, are they required to be trained to administer medications?

Yes 1

No 2

23. When someone who is not a licensed healthcare professional administers over-the-counter medications to students, are they required to be trained to administer medications?

Yes 1

No 2

IF Q18 IS 6, SKIP TO THE INSTRUCTIONS BEFORE Q25.

SHOW CARD 3

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

Written instructions from the physician
or prescriber 1

Written request from the parent or guardian 2

Written information on possible side-effects 3

None of these 4

IF Q18 IS 6, SKIP TO THE INSTRUCTIONS BEFORE Q25.

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

Written instructions from the physician 1

Written request from the parent or guardian 2

Written information on possible side-effects 3

None of these 4

SHOW CARD 4

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

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

School district budget 1

Medicaid 2

State Children’s Health Insurance Program,
or SCHIP 3

Private insurance 4

Public grants 5

Private grants 6

Other 7

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

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

Yes 1

No 2

The following questions ask about health services offered at school-based health centers—that is, health centers on school property where enrolled students can receive primary care, including diagnostic and treatment services. These services are usually provided by a nurse practitioner or physician’s assistant. Some school-based health centers offer mental health and social services, which are usually provided by a psychologist, social worker, or other mental health or social services professional. In answering these questions, please do not include traveling or mobile health centers.

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

Yes 1

No 2

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

Yes 1

No 2

The next questions ask about communication with families related to standard health services. By “standard,” I mean services offered to all students in your school.

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

Yes No

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

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

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

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

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

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

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

Yes No N/A

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

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

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

Yes No N/A

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

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

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

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

Yes No

1. Hearing problems? 1 2

2. Vision problems? 1 2

3. Oral health problems? 1 2

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

5. Mental health problems? 1 2

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

SHOW CARD 5

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

Notify the student’s parents or guardians 1

Notify the student’s teachers 2

Provide referrals to community
healthcare providers 3

None of the above 4

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

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

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q46

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

RNs

IF Q36 IS 0, SKIP TO Q38.

I would like to find out about the time each RN spends at your school.

37. During the past 30 days, how many hours per week on average has/have the RN(s) spent at your school?

RN 1 Hours/week

RN 2 Hours/week

RN 3 Hours/week

RN 4 Hours/week

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

LPNs

IF Q38 IS 0, SKIP TO THE INSTRUCTIONS BEFORE Q40.

I would like to find out about the time each LPN spends at your school.

39. During the past 30 days, how many hours per week on average has/have the LPN(s) spent at your school?

LPN 1 Hours/week

LPN 2 Hours/week

LPN 3 Hours/week

LPN 4 Hours/week

IF THIS IS A PRIVATE OR CATHOLIC SCHOOOL, SKIP TO THE INTRODUCTION TO Q43.

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

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

Yes 1

No 2

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

Yes 1

No 2

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

Yes 1

No 2

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

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

Yes No

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

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

2. A physical education class? 1 2

3. Any other class at your school? 1 2

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

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

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

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

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

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

Yes 1

No 2

School does not have health education staff 3

44b. What about with physical education staff?

Yes 1

No 2

School does not have physical education staff 3

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

Yes 1

No 2

School does not have nutrition
or food service staff 3

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

Yes 1

No 2

School does not have mental health
or social services staff 3

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

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

Yes 1

No 2

School does not have school-based
health center staff 3

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

Yes No

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

2. A local health department? 1 2

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

4. A local juvenile justice department? 1 2

5. A local college or university? 1 2

6. A local business? 1 2

7. A local child welfare agency? 1 2

8. A local hospital? 1 2

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

10. A community healthcare provider? 1 2

The next question asks whether certain groups have helped develop, communicate, or implement health services policies or activities. Examples of this might include sitting on a committee, presenting to the school board, organizing a school-located vaccination clinic, or soliciting or providing donations for school health services.

44. During the past two years, have any of the following groups helped develop, communicate, or implement health services policies or activities?

Yes No

1. Students 1 2

2. Students’ families 1 2

3. Teachers 1 2

4. Other community members 1 2

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

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

Associate’s degree in nursing 1

Undergraduate degree in nursing 2

Graduate degree in nursing 3

Other (Specify) 4

No specific education requirement 5

School does not have school nurses 6 SKIP TO THE INTRODUCTION TO Q51

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

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

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

No specific licensure requirement 3

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

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

State school nurse certification 2

No specific certification requirement 3

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

Yes 1

No 2

Now I’d like to ask about other health services staff available at your school to provide services to students.

49. Are each of the following types of staff available part-time or full-time at your school?

Yes No

1. Athletic trainer 1 2

2. Occupational therapist 1 2

3. Physical therapist 1 2

4. Respiratory therapist 1 2

5. Speech therapist 1 2

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

Yes 1

No 2

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

Yes 1

No 2

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

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

Physicians

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

I would like to find out about the time that each physician spends at your school.

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

Physician 1 Hours/week

Physician 2 Hours/week

Physician 3 Hours/week

Physician 4 Hours/week

The next questions ask about school health aides.

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

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q60

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

Yes 1

No 2

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

School health aides

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

I would like to find out about the time each school health aide spends at your school.

57. During the past 30 days, how many hours per week on average has/have the school health aide(s) spent at your school?

School health aide 1 Hours/week

School health aide 2 Hours/week

School health aide 3 Hours/week

School health aide 4 Hours/week

The next questions ask about the health services facilities and equipment that are available at your school.

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

Yes 1

No 2 SKIP TO Q64

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

Yes 1

No 2 SKIP TO Q64

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

Students

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

Yes No

1. A cot? 1 2

2. Disposable face masks for sick students? 1 2

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

4. A sink with soap and running water? 1 2

5. Hand sanitizer? 1 2

6. Gloves? 1 2

62. Where do students wait to receive health services if the nurse or other health services provider is not available?
    MARK ALL THAT APPLY

Main office 1

Designated health room waiting area 2

Hallway 3

Classroom 4

Some other location 5

IF Q60 OR Q61 IS “NO,” ASK Q65A-C. OTHERWISE, SKIP TO Q65D.

63. Does your school have…

Yes No

1. A cot? 1 2

2. Disposable face masks for sick students? 1 2

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

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

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

6. A computer with Internet access reserved for
   health services staff? 1 2

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

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

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

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

11. An electronic or beam balance scale? 1 2

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

13. A portable first aid kit? 1 2

14. A sharps container? 1 2

15. A stethoscope? 1 2

16. An audiometer? 1 2

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

18. A stadiometer? 1 2

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

20. A blood pressure gauge and cuff? 1 2

21. A pen light? 1 2

22. An otoscope or ophthalmoscope? 1 2

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

24. A scoliometer? 1 2

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

26. A tympanometer? 1 2

(Q65 continued)

Yes No

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

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

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

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

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

32. Suction equipment, not necessarily electric? 1 2

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

34. A pulse oximeter? 1 2

35. An automated external defibrillator, or AED? 1 2

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

Yes No

1. In all classrooms? 1 2

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

3. In the cafeteria? 1 2

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

65. At your school, is there a system to document why students are absent?

Yes 1

No 2

66. At your school, is there a system to document student visits to the school nurse?

Yes 1

No 2 SKIP TO Q71

67. Is this system electronic or computerized?

Yes 1

No 2

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

Yes 1

No 2

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

Yes 1

No 2

School does not keep health services records 3

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

Yes 1

No 2

71. At your school, is there a system to document medication errors or omissions that occur at school?

Yes 1

No 2

The next questions ask about your school’s reports for students who are seriously injured on school property. By “seriously injured,” I mean an injury requiring emergency medical services or EMS response or immediate care by a physician or other healthcare professional.

72. After a student is seriously injured on school property, does a school staff member complete a report?

Yes 1

No 2 SKIP TO Q77

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

Yes 1

No 2

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

Yes 1

No 2

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

Yes 1

No 2

The next question asks about students who experience a serious illness at school. By “serious illness,” I mean one requiring EMS response, or immediate care by a physician or other healthcare professional.

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

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q80

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

Yes 1

No 2

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

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

Yes 1

No 2 SKIP TO Q82

79. What is that temperature?

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

Yes 1

No 2

The next questions ask about your school’s response to head lice.

81. At your school, are students found to have head lice sent home?

Yes 1

No 2

82. Does your school have rules regarding how long students must stay home when they have head lice?

Yes 1

No 2

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

SHOW CARD 6

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

Yes No

1. First aid? 1 2

2. CPR? 1 2

3. Administration of medications? 1 2

4. Seasonal influenza (flu) vaccine? 1 2

5. Immunizations other than seasonal influenza (flu)? 1 2

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

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

8. Tracking students with chronic health conditions? 1 2

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

10. Case management for students with disabilities? 1 2

11. Administration of sports physicals? 1 2

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

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

14. Application of dental sealants? 1 2

ANSWER O–Q FOR MIDDLE AND HIGH SCHOOL ONLY.
OTHERWISE, SKIP TO INSTRUCTIONS BEFORE Q86.

15. Prenatal care referrals? 1 2

16. Identification, treatment of, or referral for STDs? 1 2

17. Contraceptives? 1 2

IF Q85A–Q ARE ALL “NO,” SKIP TO THE INSTRUCTIONS BEFORE Q87.

84. Who provides [the services listed in Q85A–Q]?
    MARK ALL THAT APPLY

School nurse 1

School physician 2

School health aide 3

School counselor 4

School psychologist 5

School social worker 6

Other (Specify) 7

IF THIS IS AN ELEMENTARY SCHOOL, SKIP TO THE INSTRUCTIONS BEFORE Q88.

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

Yes 1

No 2

ANSWER Q88 IF IMMUNIZATIONS ARE PROVIDED AT THIS SCHOOL (Q85E IS YES). OTHERWISE, SKIP TO Q89.

SHOW CARD 7

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

86. Does your school provide…

Yes No

1. A measles vaccine? 1 2

2. A polio vaccine? 1 2

3. An influenza (flu) vaccine? 1 2

4. A hepatitis A vaccine? 1 2

5. A hepatitis B vaccine? 1 2

6. A chicken pox or varicella vaccine? 1 2

IF THIS IS AN ELEMENTARY SCHOOL, ASK Q88G AND Q88H, THEN SKIP TO Q89. IF THIS IS A MIDDLE OR HIGH SCHOOL, SKIP TO Q88H.

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

8. A tetanus-diptheria-pertussis, or Tdap, vaccine
   for children over the age of 7? 1 2

9. A meningococcal conjugate vaccine? 1 2

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

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

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q91

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

Yes No

1. Students 1 2

2. Faculty and staff 1 2

3. Students’ families 1 2

4. Other community members 1 2

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

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

Medically fragile students

IF THERE ARE NO MEDICALLY FRAGILE STUDENTS AT THIS SCHOOL
(Q91 IS ZERO), SKIP TO THE INTRODUCTION TO Q94.

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

Service was
Yes No not needed

1. Catheterizations 1 2 3

2. Stoma care 1 2 3

3. Tube feedings 1 2 3

4. Ventilator care 1 2 3

5. Suctioning 1 2 3

6. Tracheostomy care 1 2 3

7. IV medications 1 2 3

IF ANY Q92A–Q92G IS “YES,” ASK Q93. OTHERWISE, SKIP TO THE INTRODUCTION TO Q94.

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

School nurse 1

School physician 2

School health aide 3

Other (Specify) 4

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

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

Yes No

1. Nutrition and dietary behavior counseling 1 2

2. Physical activity and fitness counseling 1 2

ANSWER C–E FOR MIDDLE AND HIGH SCHOOL ONLY.
OTHERWISE, SKIP TO Q94F.

3. Pregnancy prevention 1 2

4. HIV prevention 1 2

5. STD prevention 1 2

6. Suicide prevention 1 2

7. Tobacco use prevention 1 2

8. Alcohol or other drug use prevention 1 2

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

10. Injury prevention and safety counseling 1 2

IF Q94A–Q94J ARE ALL “NO,” SKIP TO THE INTRODUCTION TO Q96. OTHERWISE, CONTINUE TO Q95.

93. Who provides [the services listed in Q94A–J] in one-on-one or small-group sessions?
    MARK ALL THAT APPLY

School nurse 1

School physician 2

School health aide 3

School counselor 4

School psychologist 5

School social worker 6

Other (Specify) 7

SHOW CARD 8

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

94. Does the school provide…

Yes No

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

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

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

3. Tobacco use cessation? 1 2

4. Alcohol or other drug use treatment? 1 2

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

6. Crisis intervention for personal problems? 1 2

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

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

9. Stress management? 1 2

10. Weight management? 1 2

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

11. Identification of or referral for eating disorders? 1 2

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

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

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

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

(Q96 continued)

Yes No

ANSWER P–R FOR MIDDLE AND HIGH SCHOOL ONLY.
OTHERWISE, SKIP TO S.

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

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

18. Job readiness skills programs? 1 2

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

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

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

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

IF Q96A–V ARE ALL “NO,” SKIP TO THE INTRODUCTION TO Q98. OTHERWISE, CONTINUE TO Q97.

95. Who provides [the services listed in Q96A–V]?
    MARK ALL THAT APPLY

School nurse 1

School physician 2

School health aide 3

School counselor 4

School psychologist 5

School social worker 6

Other (Specify) 7

This next set of questions asks about health services delivered to students from your school at other sites not on school property, regardless of whether the services are paid for by the school system. These services may be provided by healthcare professionals who work at school-linked health centers or who have a contract, memorandum of agreement, or other similar arrangement with the district or school to provide health services to students.

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

Yes 1

No 2 SKIP TO Q102

SHOW CARD 9

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

A school-linked health center 1

A community health clinic
or health center 2

A local health department 3

A local hospital 4

A local mental health or social
services agency 5

A university, medical school, or nursing school 6

A dental or dental hygiene school 7

A managed care organization 8

A private physician 9

A private dentist 10

SHOW CARD 10

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

98. Are there arrangements to provide…

Yes No

1. Primary care? 1 2

2. Prescriptions for medications? 1 2

3. Seasonal influenza (flu) vaccine? 1 2

4. Immunizations other than seasonal influenza (flu)? 1 2

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

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

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

8. Case management for students with disabilities? 1 2

9. Administration of sports physicals? 1 2

10. Oral healthcare or oral healthcare referrals? 1 2

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

12. Application of dental sealants? 1 2

13. Lab tests? 1 2

ANSWER N–P FOR MIDDLE AND HIGH SCHOOL ONLY.
OTHERWISE, SKIP TO THE INTRODUCTION TO Q101.

14. Prenatal care or prenatal care referrals? 1 2

15. Identification, treatment of, or referral for STDs? 1 2

16. Contraceptives? 1 2

SHOW CARD 11

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

99. Are there arrangements to provide…

Yes No

1. Nutrition and dietary behavior counseling? 1 2

2. Physical activity and fitness counseling? 1 2

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

3. Pregnancy prevention? 1 2

4. HIV prevention? 1 2

5. STD prevention? 1 2

6. Suicide prevention? 1 2

7. Tobacco use prevention? 1 2

8. Alcohol or other drug use prevention? 1 2

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

10. Injury prevention and safety counseling? 1 2

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

Yes 1

No 2 SKIP TO Q119

101. Are you this person?

Yes 1

No 2 SKIP TO Q119

IF Q1 IS 15, CONTINUE. OTHERWISE, SKIP TO Q105.

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

Years

SHOW CARD 12

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

School district 1

This school 2

A local health department 3

A local hospital 4

Other 5

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

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

High school or GED 1 SKIP TO Q111

Associate’s degree 2

Undergraduate degree 3

Master’s degree 4

Doctoral degree 5

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

Nursing 1

Biology or other science 2

Counseling, psychology, or social work 3

Education 4

Other (Specify) 5

IF Q106 IS 2, SKIP TO Q111.

106. Did you have an undergraduate minor?

Yes 1

No 2 SKIP TO THE INSTUCTIONS BEFORE Q110

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

Nursing 1

Biology or other science 2

Counseling, psychology, or social work 3

Education 4

Other (Specify) 5

IF Q106 IS 4 OR 5, ANSWER Q110. OTHERWISE, SKIP TO Q111.

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

Nursing 1

Public health 2

Biology or other science 3

Healthcare administration or business 4

Counseling, psychology, or social work 5

Education 6

Other 7

109. Do you have…

Yes No

1. An LPN’s license? 1 2

2. An RN’s license? 1 2

3. A CNP’s license? 1 2

110. Do you have…

State does not
offer school nurse
Yes No certification

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

b. A state school nurse certification? 1 2 3

c. An ANCC certification? 1 2

d. Any other certifications? (Specify) 1 2

The next questions ask about professional development.

SHOW CARD 13

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

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

Yes No

1. First aid? 1 2

2. CPR or use of AED equipment? 1 2

3. Administration of medications? 1 2

4. Seasonal influenza (flu) vaccine? 1 2

5. Immunizations other than seasonal influenza (flu)? 1 2

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

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

8. Tracking students with chronic health conditions? 1 2

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

10. Case management for students with disabilities? 1 2

11. Sports physicals? 1 2

12. Oral health problems? 1 2

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

14. Dental sealants? 1 2

15. Prenatal care? 1 2

16. Identification, treatment of, or referral for STDs? 1 2

17. Contraceptives? 1 2

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

SHOW CARD 14

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

First aid 1

CPR or use of AED equipment? 2

Administration of medications 3

Seasonal influenza (flu) vaccine 4

Immunizations other than seasonal influenza
(flu) 5

Identification or school-based management
of acute illnesses 6

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

Tracking students with chronic
health conditions 8

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

Case management for students
with disabilities 10

Sports physicals 11

Oral health problems 12

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

Dental sealants 14

Prenatal care 15

Identification, treatment of, or referral
for STDs 16

Contraceptives 17

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

None of these 19

SHOW CARD 15

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

113. 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

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

Nutrition and dietary behavior counseling 1

Physical activity and fitness counseling 2

Pregnancy prevention 3

HIV prevention 4

STD prevention 5

Suicide prevention 6

Tobacco use prevention 7

Alcohol or other drug use prevention 8

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

Injury prevention and safety counseling 10

None of these 11

SHOW CARD 16

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

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

Yes No

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

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

3. Tobacco use cessation? 1 2

4. Alcohol or other drug use treatment? 1 2

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

6. Crisis intervention for personal problems? 1 2

7. Emergency preparedness? 1 2

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

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

10. Stress management? 1 2

11. Weight management? 1 2

12. Identification of or referral for eating disorders? 1 2

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

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

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

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

17. Child care options for teen mothers? 1 2

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

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

(Q117 continued)

Yes No

20. Securing temporary or permanent housing? 1 2

21. Enrolling in Medicaid or SCHIP? 1 2

22. Accessing benefits for students with disabilities? 1 2

23. Job readiness skills programs? 1 2

24. Infectious disease outbreak detection and response? 1 2

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

26. Accurately measuring student height and weight? 1 2

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

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

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

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

Tobacco use cessation 3

Alcohol or other drug use treatment 4

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

Crisis intervention for personal problems 6

Emergency preparedness 7

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

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

Stress management 10

Weight management 11

Identification of or referral for eating
disorders 12

HIV counseling, testing, and referral 13

(Q118 continued)

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

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

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

Child care options for teen mothers 17

Services specifically for gay, lesbian,
or bisexual students 18

Enrolling in WIC
or accessing food stamps or food banks 19

Securing temporary or permenant housing 20

Enrolling in Medicaid
or SCHIP 21

Accessing benefits
for students with disabilities 22

Job readiness skills programs 23

Infectious disease outbreak detection
and response 24

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

Accurately measuring student height
and weight 26

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

None of these 28

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

( ) -

1) Daytime or

2) Evening/Weekend

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

Health Services School Questionnaire—Public Use Version 0