Healthy and Safe School Environment

School Health Coordination

Form Approved
OMB No: 0920-0445
Expiration Date: xx/xx/xxxx

Healthy and Safe School Environment
School Questionnaire

Public reporting burden for this collection of information is estimated to average 75 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, Mailstop D-74, Atlanta, GA 30333; Attention PRA (0920-0445).

Healthy and Safe School Environment
School Questionnaire

Questions

MODULE 1

Job Title 1

General School Environment 2–20

Transportation 21–30

Joint Use Agreements 31–33

Violence Prevention 34–57

Tobacco Use Prevention 58–85

Alcohol Use Prevention 86–90

Illegal Drug Use Prevention 91–100

Injury Prevention and Safety 101–118

MODULE 2

Physical School Environment 119–140

MODULE 3

Crisis Preparedness, Response, and Recovery 141–151

Family Involvement 152–153

Community Service and Service Learning 154–158

Physical Activity 159–171

Foods and Beverages Available Outside of the School Meal Programs 172–208

School Health Coordination 209–227

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) 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 21) Facilities or Maintenance Director 22) Other Facilities or Maintenance Staff 50) Other Staff

During this interview, I will ask about policies and practices that affect the health, safety and security of the school environment at this school, such as measures taken to reduce violence, and to reduce alcohol or other drug use at school. When I ask about “policies,” I mean any mandate issued by the state, the local school board, or any other agency that affects your school environment. Please consider any policies officially adopted by your school or district, including policies developed by your school or (district/diocese), as well as policies built on model federal or state policies. When I ask whether the school has “adopted a policy,” I mean either that the school has its own policy or that the school follows a policy established at the district or state level, including any law, rule, regulation, administrative order, or similar kind of mandate. In addition, I will ask about practices that you might follow to promote the health and well-being of students. Please keep in mind that I will be asking only about policies and practices, not about standard classroom instruction on these topics. If I ask about things that do not apply to this school or that your school does not do, please bear with me.

2. How many students are currently enrolled in…

Kindergarten? Students

1^st grade? Students

2^nd grade? Students

3^rd grade? Students

4^th grade? Students

5^th grade? Students

6^th grade? Students

7^th grade? Students

8^th grade? Students

9^th grade? Students

10^th grade? Students

11^th grade? Students

12^th grade? Students

The next questions ask about physical features in and around your school.

3. Other than restroom sinks, does your school have hand washing facilities or hand sanitizers available for students to use?

Yes 1

No 2

4. Are students permitted to have a drinking water bottle with them during the school day?

Yes, in all locations 1

Yes, in certain locations 2

No 3

5. Does your school have a school food garden?

Yes 1

No 2

6. In what year was this school’s main instructional building constructed?

The next question asks about major renovation of your school building. By “major renovation,” I mean a significant rehabilitation of the interior of the building; of major systems in the building such as the heating, ventilation, and air conditioning system; or of the building envelope, that is, the outer shell of the building such as the foundation, roof, walls, doors and windows. Major renovations would also include building new attached and/or detached permanent additions to original buildings such as a new classroom wing or gymnasium. A major renovation does not include general maintenance, repair, and upkeep such as painting walls or replacing floor coverings with carpet or tile.

7. In what year was the last major renovation of your school’s main instructional building?

OR

This school has had no major renovation 1

My next questions focus on safety and security measures.

8. Is this school a “closed campus,” meaning that students are not allowed to leave school during the school day, including during lunchtime?

Yes 1

No 2

9. During the school day, are staff or adult volunteers assigned to monitor…

Yes No

1. School halls during classes? 1 2

2. School halls between classes? 1 2

3. Restrooms? 1 2

4. School grounds? 1 2

ANSWER Q10 FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO Q11.

10. Does this school routinely conduct locker searches?

Yes 1

No 2

School does not have lockers 3

11. Are students at this school required to wear school uniforms?

Yes 1 SKIP TO Q13A

No 2

12. Is there a dress code at your school?

Yes 1

No 2

13a. Are students at your school required to wear identification badges?

Yes 1

No 2

13b. What about school faculty and staff?

Yes 1

No 2

13c. What about visitors to your school? These identification badges can include adhesive stickers with hand-written names.

Yes 1

No 2

14. During the school day, does your school use…

Yes No

1. Security or surveillance cameras, either inside
   or outside the building? 1 2

2. Metal detectors, including wands? 1 2

3. Communication devices, such as cell phones, 2-way radios,
   walkie-talkies, or intercoms for security purposes? 1 2

13. At your school, are students required to refrain from using personal communication devices, such as cell phones, during the school day?

Yes 1

No 2

14. I’m going to ask about different types of security staff that this school might use. During the regular school day, does your school use…

Yes No

a. Police or school resource officers? 1 2

b. Security guards? 1 2

IF THIS SCHOOL USES SECURITY STAFF (Q16A OR B IS “YES”) CONTINUE WITH Q17. OTHERWISE, SKIP TO Q18.

15. Are any of the security staff at your school armed?

Yes 1

No 2

16. At your school, do students receive a student handbook, code of conduct, or other document that outlines school policies, rules, regulations and standards for behavior that students are expected to follow?

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q21

17. Are students required to acknowledge receipt of the student handbook, code of conduct, or other document?

Yes 1

No 2

18. Does the student handbook, code of conduct, or other document inform students about rules related to…

Yes No

1. The use of personal communication devices, such as
   cell phones? 1 2

2. Physical fighting? 1 2

3. Weapon possession or use? 1 2

4. Gang activity? 1 2

5. Bullying? 1 2

6. Electronic aggression or cyber-bullying? 1 2

7. Cigarette smoking? 1 2

8. Smokeless tobacco use? 1 2

9. Alcohol use? 1 2

10. Illegal drug possession or use? 1 2

ANSWER K FOR ELEMENTARY SCHOOLS ONLY. OTHERWISE, SKIP TO THE INTRODUCTION TO Q21.

11. Playground safety? 1 2

The next questions are related to transportation.

19. During peak school travel times, what is the speed limit on the streets that abut or are adjacent to the school grounds?

15 mph or lower 1

20 mph 2

25 mph 3

30 mph 4

35 mph or higher 5

20. Hazard busing occurs when students are bused relatively short distances to school (about one mile or less) because their walk route is deemed to be hazardous. These hazards might include lack of sidewalks, high traffic volume, unmarked crossings, railroad crossings, or major arterial roads. Does your school use hazard busing for any students?

Yes 1

No 2

School does not have school buses 3

21. Does your school support or promote the use of public transportation for its students to travel to and from school?

Yes 1

No 2

No public transportation available 3

22. Does your school support or promote the use of public transportation for its faculty and staff to travel to and from school?

Yes 1

No 2

No public transportation available 3

23. Has your school implemented an engine idling reduction program for…

School does
not have
Yes No school buses

1. School buses? 1 2 3

2. Commercial vehicles, such as
   delivery trucks? 1 2

3. Personal vehicles, such as cars? 1 2

The next questions ask about walking or biking to and from school.

24. Does your school have any of the following?

Yes No

1. Paid or volunteer crossing guards 1 2

2. A walking school bus 1 2

3. Law enforcement officials to promote traffic safety
   near the school 1 2

4. Law enforcement officials to prevent crime
   near the school 1 2

5. Bicycle racks 1 2

6. Traffic calming devices to slow driving speeds on the
   streets that abut or are adjacent to the school grounds 1 2

7. Reduced speed limits during peak school travel times on
   the streets that abut or are adjacent to the school grounds 1 2

25. Does your school provide promotional materials to students or families on walking or biking to school, such as safety tips or maps of bicycle or walking routes?

Yes 1

No 2

26. On an average school day, what percentage of students walk or bike to your school in the morning?

10% or less 1

11–25% 2

26–50% 3

51–75% 4

76–90% 5

More than 90% 6

27. On an average school day, what percentage of students walk or bike home or to some other destination from your school in the afternoon?

10% or less 1

11–25% 2

26–50% 3

51–75% 4

76–90% 5

More than 90% 6

28. Does your school prohibit students from walking or biking to or from school?

Yes 1

No 2

The next questions ask about joint use agreements.

A joint use agreement is a formal agreement, such as a memorandum of agreement or understanding, between the school or school district and another public or private entity to jointly use or share either school facilities or community facilities to share costs and responsibilities. For example, joint use agreements might be designed to increase access to spaces for recreation and physical activity, library services, school health centers, preschool programs, child care centers, before- or after-school programs, adult education, or other programs that benefit students and the community. These could be indoor or outdoor education or recreational facilities.

29. Does your school, either directly or through the school district, have such an agreement for shared use of school or community property? Do not include situations where the community can use school property but no formal agreement with another entity exists.

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q34

30. Does this formal agreement apply to the use of facilities for…

Yes No

1. Indoor recreation or physical activity? 1 2

2. Outdoor recreation or physical activity? 1 2

3. Library services? 1 2

4. Preschool or infant child care programs? 1 2

5. Before- or after-school programs for school-aged children? 1 2

6. Adult education programs? 1 2

7. Healthcare services? 1 2

8. Other activities or programs? 1 2

31. Does your school, either directly or through the school district, have a formal joint use agreement with…

Yes No

1. A local parks or recreation department? 1 2

2. A local youth organization, such as the YMCA,
   Boys and Girls Clubs, or the Boy Scouts or Girl Scouts? 1 2

3. A local faith-based organization? 1 2

4. A local health club? 1 2

5. A local healthcare facility? 1 2

6. A local library system? 1 2

7. Any other public or private entity? (Specify) 1 2

Now I would like to ask about your school’s policies regarding violence.

32. During the 2012–13 school year, were there four or more times that students at your school were caught physically fighting?

Yes 1

No 2 SKIP TO Q37

SHOW CARD 1

33. Which of the things listed on this card helped determine what actions the school took when students were caught physically fighting?
    MARK ALL THAT APPLY

Zero-tolerance 1

Effect or severity of the violation 2

Grade level of student 3

Victim versus perpetrator status 4

Repeat offender status 5

None 6

SHOW CARD 2

34. When students were caught physically fighting, how often were they…

Almost
Some- Always or
Never Rarely times Always N/A

1. Referred to a school counselor? 1 2 3 4 5

2. Referred to a school administrator? 1 2 3 4

3. Referred to peer mediation? 1 2 3 4 5

4. Encouraged, but not required,
   to participate in an assistance
   or education program? 1 2 3 4 5

5. Required to participate in an assistance
   or education program? 1 2 3 4 5

6. Referred to legal authorities? 1 2 3 4

7. Placed in detention? 1 2 3 4 5

8. Given in-school suspension? 1 2 3 4 5

9. Not allowed to participate in
   extracurricular activities or
   interscholastic sports? 1 2 3 4 5

10. Suspended from school? 1 2 3 4

11. Expelled from school? 1 2 3 4

12. Reassigned to an alternative school? 1 2 3 4 5

35. During the 2012–13 school year, were there four or more times that students at your school were caught using or possessing a weapon?

Yes 1

No 2 SKIP TO Q40

SHOW CARD 3

36. Which of the things listed on this card helped determine what actions the school took
    when students were caught using or possessing a weapon?
    MARK ALL THAT APPLY

Zero-tolerance 1

Effect or severity of the violation 2

Grade level of student 3

Repeat offender status 4

Type of weapon 5

Use versus possession 6

None 7

SHOW CARD 4

37. When students were caught using or possessing a weapon, how often were they…

Almost
Some- Always or
Never Rarely times Always N/A

1. Referred to a school counselor? 1 2 3 4 5

2. Referred to a school administrator? 1 2 3 4

3. Encouraged, but not required,
   to participate in an assistance
   or education program? 1 2 3 4 5

4. Required to participate in an assistance
   or education program? 1 2 3 4 5

5. Referred to legal authorities? 1 2 3 4

6. Placed in detention? 1 2 3 4 5

7. Given in-school suspension? 1 2 3 4 5

8. Not allowed to participate in
   extracurricular activities or
   interscholastic sports? 1 2 3 4 5

9. Suspended from school? 1 2 3 4

10. Expelled from school? 1 2 3 4

11. Reassigned to an alternative school? 1 2 3 4 5

38. Has this school adopted a policy prohibiting gang activity, such as recruiting or wearing gang colors, symbols, or other gang attire?

Yes 1

No 2

The next question asks whether certain groups have helped develop, communicate, or implement violence prevention policies or activities. Examples of this might include sitting on a committee, presenting to the school board, organizing an event related to violence prevention, or soliciting or providing donations for violence prevention programs.

39. During the past two years, have any of the following groups helped develop, communicate, or implement violence prevention policies or activities?

Yes No

1. Students 1 2

2. Students’ families 1 2

3. Community members 1 2

40. Does your school post signs marking a weapons-free school zone, that is, a specified distance from school grounds where weapons are not allowed?

Yes 1

No 2

The next questions ask about bullying. By “bullying,” I mean when one or more students tease, threaten, spread rumors about, hit, shove, or hurt another student repeatedly. It is not bullying when two students of about the same strength or power argue or fight or tease each other in a friendly way.

41. Has this school adopted a policy prohibiting bullying on school property?

Yes 1

No 2

42. Has this school adopted a policy prohibiting bullying at off-campus, school‑sponsored events?

Yes 1

No 2

43. During the 2012–13 school year, were there four or more times that students at your school were caught bullying?

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q48

SHOW CARD 5

44. Which of the things listed on this card helped determine what actions the school took when students were caught bullying?
    MARK ALL THAT APPLY

Zero-tolerance 1

Effect or severity of the violation 2

Grade level of student 3

Repeat offender status 4

Type of bullying
(for example, physical or verbal) 5

None 6

45. When students were caught bullying, how often were they…

Almost
Some- Always or
Never Rarely times Always N/A

1. Referred to a school counselor? 1 2 3 4 5

2. Referred to a school administrator? 1 2 3 4

3. Encouraged, but not required,
   to participate in an assistance
   or education program? 1 2 3 4 5

4. Required to participate in an assistance
   or education program? 1 2 3 4 5

5. Referred to legal authorities? 1 2 3 4

6. Placed in detention? 1 2 3 4 5

7. Given in-school suspension? 1 2 3 4 5

8. Not allowed to participate in
   extracurricular activities or
   interscholastic sports? 1 2 3 4 5

9. Suspended from school? 1 2 3 4

10. Expelled from school? 1 2 3 4

11. Reassigned to an alternative school? 1 2 3 4 5

The next questions ask about electronic aggression, sometimes called cyber-bullying. By “electronic aggression,” I mean when students use a cell phone, the Internet, or other communication devices to send or post text, pictures, or videos intended to threaten, harass, humiliate, or intimidate other students or staff.

46. Has your school adopted a policy prohibiting electronic aggression or cyber-bullying on school property?

Yes 1

No 2

47. Has your school adopted a policy prohibiting electronic aggression or cyber-bullying at off‑campus, school-sponsored events?

Yes 1

No 2

48. Has your school adopted a policy prohibiting any electronic aggression or cyber-bullying that interferes with the educational environment, even if it does not occur on school property or at school-sponsored events?

Yes 1

No 2

49. During the 2012–13 school year, were there four or more times that students at your school were caught engaging in electronic aggression or cyber-bullying?

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q54

SHOW CARD 6

50. Which of the things listed on this card helped determine what actions the school took when students were caught engaging in electronic aggression or cyber-bullying?
    MARK ALL THAT APPLY

Zero-tolerance 1

Effect or severity of the violation 2

Grade level of student 3

Repeat offender status 4

None 5

SHOW CARD 7

51. When students were caught engaging in electronic aggression or cyber-bullying, how often were they…

Almost
Some- Always or
Never Rarely times Always N/A

1. Referred to a school counselor? 1 2 3 4 5

2. Referred to a school administrator? 1 2 3 4

3. Encouraged, but not required,
   to participate in an assistance
   or education program? 1 2 3 4 5

4. Required to participate in an assistance
   or education program? 1 2 3 4 5

5. Referred to legal authorities? 1 2 3 4

6. Placed in detention? 1 2 3 4 5

7. Given in-school suspension? 1 2 3 4 5

8. Not allowed to participate in
   extracurricular activities or
   interscholastic sports? 1 2 3 4 5

9. Suspended from school? 1 2 3 4

10. Expelled from school? 1 2 3 4

11. Reassigned to an alternative school? 1 2 3 4 5

The next questions ask about school-wide programs to prevent behaviors related to violence. When answering these questions, please do not include instruction on these topics that occurs only in health education classes or courses.

52. Does your school have or participate in…

Yes No

1. A program to prevent dating violence? 1 2

2. A program to prevent gang violence? 1 2

3. A program to prevent bullying? 1 2

4. A program to prevent suicide? 1 2

53. Does this school have a plan for the actions to be taken when a student at risk for suicide is identified?

Yes 1

No 2 SKIP TO Q57

54. Does this plan require that…

Yes No

1. The student’s family be informed? 1 2

2. The student be referred to a mental health provider? 1 2

3. A visit with a mental health provider be documented
   before the student returns to school? 1 2

55. Does this school have a student-led club that aims to create a safe, welcoming, and accepting school environment for all youth, regardless of sexual orientation or gender identity? These clubs are sometimes called gay/straight alliances.

Yes 1

No 2

The next questions ask about your school’s policies regarding tobacco use.

56. Has this school adopted a policy prohibiting cigarette smoking by students?

Yes 1

No 2 SKIP TO Q60

57. Does your school’s policy specifically prohibit cigarette smoking by students…

Yes No

1. In school buildings? 1 2

2. Outside on school grounds, including parking lots
   and playing fields? 1 2

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

4. At off-campus, school-sponsored events? 1 2

58. During the 2012–13 school year, were there four or more times that students at your school were caught smoking cigarettes?

Yes 1

No 2 SKIP TO Q63

SHOW CARD 6

59. Which of the things listed on this card helped determine what actions the school took when students were caught smoking cigarettes?
    MARK ALL THAT APPLY

Zero-tolerance 1

Effect or severity of the violation 2

Grade level of student 3

Repeat offender status 4

None 5

SHOW CARD 4

60. When students were caught smoking cigarettes, how often were they…

Almost
Some- Always or
Never Rarely times Always N/A

1. Referred to a school counselor? 1 2 3 4 5

2. Referred to a school administrator? 1 2 3 4

3. Encouraged, but not required,
   to participate in an assistance,
   education, or cessation program? 1 2 3 4 5

4. Required to participate in an assistance
   education, or cessation program? 1 2 3 4 5

5. Referred to legal authorities? 1 2 3 4

6. Placed in detention? 1 2 3 4 5

7. Given in-school suspension? 1 2 3 4 5

8. Not allowed to participate in
   extracurricular activities or
   interscholastic sports? 1 2 3 4 5

9. Suspended from school? 1 2 3 4

10. Expelled from school? 1 2 3 4

11. Reassigned to an alternative school? 1 2 3 4 5

61. Has this school adopted a policy prohibiting cigar or pipe smoking by students?

Yes 1

No 2

62. Has this school adopted a policy prohibiting smokeless tobacco use by students?

Yes 1

No 2 SKIP TO Q66

63. Does your school’s policy specifically prohibit smokeless tobacco use by students…

Yes No

1. In school buildings? 1 2

2. Outside on school grounds, including parking lots
   and playing fields? 1 2

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

4. At off-campus, school-sponsored events? 1 2

64. During the 2012–13 school year, were there four or more times that students at your school were caught using smokeless tobacco?

Yes 1

No 2 SKIP TO Q69

SHOW CARD 6

65. Which of the things listed on this card helped determine what actions the school took when students were caught using smokeless tobacco?
    MARK ALL THAT APPLY

Zero-tolerance 1

Effect or severity of the violation 2

Grade level of student 3

Repeat offender status 4

None 5

SHOW CARD 4

66. When students were caught using smokeless tobacco, how often were they…

Almost
Some- Always or
Never Rarely times Always N/A

1. Referred to a school counselor? 1 2 3 4 5

2. Referred to a school administrator? 1 2 3 4

3. Encouraged, but not required,
   to participate in an assistance,
   education, or cessation program? 1 2 3 4 5

4. Required to participate in an assistance,
   education, or cessation program? 1 2 3 4 5

5. Referred to legal authorities? 1 2 3 4

6. Placed in detention? 1 2 3 4 5

7. Given in-school suspension? 1 2 3 4 5

8. Not allowed to participate in
   extracurricular activities or
   interscholastic sports? 1 2 3 4 5

9. Suspended from school? 1 2 3 4

10. Expelled from school? 1 2 3 4

11. Reassigned to an alternative school? 1 2 3 4 5

67. Is tobacco advertising prohibited…

Yes No

1. In school buildings? 1 2

2. Outside on school grounds, including parking lots
   and playing fields? 1 2

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

4. At off-campus, school-sponsored events? 1 2

5. Through sponsorship of school events? 1 2

68. Are students at your school prohibited from wearing tobacco brand-name apparel or carrying merchandise with tobacco company names, logos, or cartoon characters on it?

Yes 1

No 2

The next question asks whether certain groups have helped develop, communicate, or implement tobacco-use prevention policies or activities. Examples of this might include sitting on a committee, presenting to the school board, organizing an event such as a health and safety fair, or soliciting or providing donations for tobacco-use prevention programs.

69. During the past two years, have any of the following groups helped develop, communicate, or implement tobacco-use prevention policies or activities?

Yes No

1. Students 1 2

2. Students’ families 1 2

3. Community members 1 2

70. Does your school post signs marking a tobacco-free school zone, that is, a specified distance from school grounds where tobacco use is not allowed?

Yes 1

No 2

ANSWER Q73 FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO THE INTRODUCTION TO Q74.

71. Does your school have or participate in a youth empowerment or advocacy program related to tobacco use prevention?

Yes 1

No 2

These next questions are about tobacco use by faculty and staff.

72. Has this school adopted a policy prohibiting cigarette smoking by faculty and staff during any school-related activity?

Yes 1

No 2 SKIP TO Q76

73. Does your school’s policy specifically prohibit cigarette smoking by faculty and staff…

Yes No

1. In school buildings? 1 2

2. Outside on school grounds, including parking lots
   and playing fields? 1 2

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

4. At off-campus, school-sponsored events? 1 2

74. Has this school adopted a policy prohibiting cigar or pipe smoking by faculty and staff during any school-related activity?

Yes 1

No 2

75. Has this school adopted a policy prohibiting smokeless tobacco use by faculty and staff during any school-related activity?

Yes 1

No 2 SKIP TO THE INSTRUCTIONS BEFORE Q79

76. Does your school’s policy specifically prohibit smokeless tobacco use by faculty and staff…

Yes No

1. In school buildings? 1 2

2. Outside on school grounds, including parking lots
   and playing fields? 1 2

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

4. At off-campus, school-sponsored events? 1 2

IF Q74, Q76, AND Q77 ARE ALL “NO,” SKIP TO THE INTRODUCTION TO Q80. OTHERWISE, CONTINUE.

77. Does your school have procedures to inform faculty and staff…

Yes No

1. About rules related to tobacco use by faculty and staff? 1 2

2. About what happens if they break the rules? 1 2

These next questions are about tobacco use by school visitors. By “visitors,” I mean anyone other than students or faculty and staff, including family members, community members, contractors, and repair workers. These people might visit school during or outside of school hours.

78. Has this school adopted a policy prohibiting cigarette smoking by school visitors?

Yes 1

No 2 SKIP TO Q82

79. Does your school’s policy specifically prohibit cigarette smoking by school visitors…

Yes No

1. In school buildings? 1 2

2. Outside on school grounds, including parking lots
   and playing fields? 1 2

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

4. At off-campus, school-sponsored events? 1 2

80. Has this school adopted a policy prohibiting cigar or pipe smoking by school visitors?

Yes 1

No 2

81. Has this school adopted a policy prohibiting smokeless tobacco use by school visitors?

Yes 1

No 2 SKIP TO THE INSTRUCTIONS BEFORE Q85

82. Does your school’s policy specifically prohibit smokeless tobacco use by school visitors…

Yes No

1. In school buildings? 1 2

2. Outside on school grounds, including parking lots
   and playing fields? 1 2

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

4. At off-campus, school-sponsored events? 1 2

IF THIS SCHOOL HAS ADOPTED ANY POLICIES PROHIBITING TOBACCO USE BY SCHOOL VISITORS (Q80, Q82 OR Q83 IS “YES”), ANSWER Q85. OTHERWISE, SKIP TO THE INTRODUCTION TO Q86.

83. Does your school have procedures to inform school visitors…

Yes No

1. About rules related to tobacco use by visitors? 1 2

2. About what happens if they break the rules? 1 2

Now I would like to ask about alcohol use among students at your school.

84. During the 2012–13 school year, were there four or more times that students at your school were caught drinking alcohol?

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q89

SHOW CARD 6

85. Which of the things listed on this card helped determine what actions the school took when students were caught drinking alcohol?
    MARK ALL THAT APPLY

Zero-tolerance 1

Effect or severity of the violation 2

Grade level of student 3

Repeat offender status 4

None 5

SHOW CARD 4

86. When students were caught drinking alcohol, how often were they…

Almost
Some- Always or
Never Rarely times Always N/A

1. Referred to a school counselor? 1 2 3 4 5

2. Referred to a school administrator? 1 2 3 4

3. Encouraged, but not required,
   to participate in an assistance,
   education, or cessation program? 1 2 3 4 5

4. Required to participate in an assistance,
   education, or cessation program? 1 2 3 4 5

5. Referred to legal authorities? 1 2 3 4

6. Placed in detention? 1 2 3 4 5

7. Given in-school suspension? 1 2 3 4 5

8. Not allowed to participate in
   extracurricular activities or
   interscholastic sports? 1 2 3 4 5

9. Suspended from school? 1 2 3 4

10. Expelled from school? 1 2 3 4

11. Reassigned to an alternative school? 1 2 3 4 5

The next question asks whether certain groups have helped develop, communicate, or implement alcohol-use prevention policies or activities. Examples of this might include sitting on a committee, presenting to the school board, organizing an event such as a health and safety fair, or soliciting or providing donations for alcohol-use prevention programs.

87. During the past two years, have any of the following groups helped develop, communicate, or implement alcohol-use prevention policies or activities?

Yes No

1. Students 1 2

2. Students’ families 1 2

3. Community members 1 2

88. Does your school have or participate in a community-based alcohol use prevention program?

Yes 1

No 2

The next questions ask about illegal drug use among students at your school.

89. During the 2012–13 school year, were there four or more times that students at your school were caught possessing or using illegal drugs? Please do not include positive drug tests.

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q94

SHOW CARD 8

90. Which of the things listed on this card helped determine what actions the school took when students were caught possessing or using illegal drugs?
    MARK ALL THAT APPLY

Zero-tolerance 1

Effect or severity of the violation 2

Grade level of student 3

Repeat offender status 4

Type of drug 5

None 6

SHOW CARD 4

91. When students were caught possessing or using illegal drugs, how often were they…

Almost
Some- Always or
Never Rarely times Always N/A

1. Referred to a school counselor? 1 2 3 4 5

2. Referred to a school administrator? 1 2 3 4

3. Encouraged, but not required,
   to participate in an assistance,
   education, or cessation program? 1 2 3 4 5

4. Required to participate in an assistance,
   education, or cessation program? 1 2 3 4 5

5. Referred to legal authorities? 1 2 3 4

6. Placed in detention? 1 2 3 4 5

7. Given in-school suspension? 1 2 3 4 5

8. Not allowed to participate in
   extracurricular activities or
   interscholastic sports? 1 2 3 4 5

9. Suspended from school? 1 2 3 4

10. Expelled from school? 1 2 3 4

11. Reassigned to an alternative school? 1 2 3 4 5

The next question asks whether certain groups have helped develop, communicate, or implement illegal drug-use prevention policies or activities. Examples of this might include sitting on a committee, presenting to the school board, organizing an event such as a health and safety fair, or soliciting or providing donations for illegal drug-use prevention programs.

92. During the past two years, have any of the following groups helped develop, communicate, or implement illegal drug-use prevention policies or activities?

Yes No

1. Students 1 2

2. Students’ families 1 2

3. Community members 1 2

93. Does your school post signs marking a drug-free school zone, that is, a specified distance from school grounds where illegal drugs are not allowed?

Yes 1

No 2

94. Does your school have or participate in a community-based illegal drug use prevention program?

Yes 1

No 2

ANSWER Q97 FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO THE INTRODUCTION TO Q101.

The next questions ask about student drug testing.

95. Does your school conduct any drug testing on students?

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q101

96. The next questions ask about how students are chosen for drug testing at your school.

Yes No

ANSWER A FOR PRIVATE AND CATHOLIC SCHOOLS ONLY.
OTHERWISE, SKIP TO B.

1. Is student drug testing conducted randomly, with the
   entire student population subject to testing? 1 2

2. Is student drug testing conducted randomly
   among members of specific groups of students,
   such as athletes, students who participate in other
   extracurricular activities, or student drivers? 1 2

3. Is student drug testing conducted when it is suspected
   that a student is using drugs at school, that is, for cause? 1 2

4. Is student drug testing voluntary for all students
   or for specific groups of students? 1 2

5. Are students chosen for drug testing using criteria
   other than the ones we just discussed? 1 2

97. Does your school test for…

Yes No

1. Alcohol? 1 2

2. Nicotine? 1 2

3. Cocaine? 1 2

4. Marijuana? 1 2

5. Opiates, for example, heroin or morphine? 1 2

6. Amphetamines, for example, methamphetamine or ecstasy? 1 2

7. Phencyclidine, that is, PCP? 1 2

8. Steroids? 1 2

SHOW CARD 9

98. Which of the methods on this card does your school use to conduct drug testing?
    MARK ALL THAT APPLY

Breathalyzer (breath alcohol test) 1

Urine 2

Hair 3

Saliva 4

Sweat 5

Other 6

The next questions ask about injury prevention and safety procedures related to sports or playground activities, school lab or workshop activities, the use of school vehicles, and fire safety.

99. During the past 12 months, have the following been inspected and provided with the appropriate maintenance?

Yes No N/A

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

1. Playground facilities and equipment,
   such as playing surfaces, benches,
   monkey bars, and swings 1 2 3

2. Indoor athletic facilities and equipment,
   such as playing surfaces, benches, tumbling
   mats, and weight lifting equipment 1 2 3

3. Outdoor athletic equipment, such as
   playing fields and bleachers 1 2 3

4. Special classroom areas, such as
   chemistry labs, workshops, and art rooms 1 2 3

5. Other areas of the school, such as halls,
   stairs, and regular classrooms 1 2

6. Smoke alarms 1 2

7. Fire extinguishers 1 2

8. Sprinkler systems 1 2

9. Lighting inside school buildings 1 2

10. Lighting outside school buildings 1 2

11. Automated external defibrillators (AEDs) 1 2 3

100. Are students required to wear appropriate protective gear when engaged in…

Yes No N/A

1. Classes such as wood shop or metal shop? 1 2 3

2. Lab activities for photography, chemistry,
   biology, or other science classes? 1 2 3

101. Are students required to use hearing protection devices during classes or activities where they are exposed to potentially unsafe noise levels, such as industrial arts classes or marching band? By “hearing protection devices,” I mean any piece of equipment or apparatus that is made to reduce the loudness of sound, such as earplugs or earmuffs.

Yes 1

No 2

School does not have these classes
or activities 3

ANSWER Q104–106 FOR ELEMENTARY SCHOOL ONLY. OTHERWISE, SKIP TO THE INSTRUCTIONS BEFORE Q107.

102. Does your school use the safety checklist and equipment guidelines published in the Handbook for Public Playground Safety by the U.S. Consumer Product Safety Commission?

Yes 1

No 2

103. Does your school post rules for the safe use of specific types of playground equipment, such as swings, slides, or climbing structures?

Yes 1

No 2

104. During the 2012–13 school year, when students were caught breaking playground safety rules, how often were they…

Almost
Some- Always or
Never Rarely times Always

1. Provided verbal redirection by a
   playground monitor? 1 2 3 4

2. Required to refrain from playing for a
   designated time period? 1 2 3 4

3. Not allowed to participate in the
   next scheduled recess period?
   (e.g., the next day) 1 2 3 4

4. Placed in detention? 1 2 3 4

5. Suspended from school? 1 2 3 4

ASK Q107 IF HIGH SCHOOL, OTHERWISE, SKIP TO Q108.

105. Schools often establish rules that students must follow to use a school’s parking facilities. These rules are sometimes outlined in a parking permit agreement. Does your school’s parking permit agreement specifically require seat belt use?

Yes 1

No 2

School does not have
parking permit agreement 3

106. Does your school have a procedure to monitor seat belt use on school property?

Yes 1

No 2

The next question asks whether certain groups have helped develop, communicate, or implement injury prevention and safety policies or activities. Examples of this might include sitting on a committee, presenting to the school board, organizing an event such as a health and safety fair, or soliciting or providing donations for injury prevention and safety programs.

107. During the past two years, have any of the following groups helped develop, communicate, or implement injury prevention and safety policies or activities?

Yes No

1. Students 1 2

2. Students’ families 1 2

3. Community members 1 2

108. Has your school ever been sued because of an injury that occurred on school property or at an off-campus, school-sponsored event? Please include any claim filed with a court, regardless of the outcome.

Yes 1

No 2

The next questions ask about sun safety.

109. During the past 12 months, how often were outdoor activities during the school day scheduled to avoid times when the sun was at peak intensity?

Never 1

Rarely 2

Sometimes 3

Almost always or always 4

The next questions ask about sunscreen use during a typical school day. Do not include field trips or after-school activities.

110. At your school,…

Yes No

1. Are parents asked to ensure students apply sunscreen
   before school? 1 2

2. Do teachers allow time for students to apply sunscreen
   at school? 1 2

3. Do teachers remind students to apply sunscreen before
   going outside at school? 1 2

111. Does your school make sunscreen available for students to use?

Yes 1

No 2

112. Does your school encourage students to wear protective clothing, such as long sleeve shirts or long pants, when in the sun during the school day?

Yes 1

No 2

113. Does your school encourage students to wear hats or visors when in the sun during the school day?

Yes 1 SKIP TO Q117

No 2

114. Are students prohibited from wearing hats or visors when in the sun during the school day?

Yes 1

No 2

115. Does your school encourage students to wear sunglasses when in the sun during the school day?

Yes 1 SKIP TO THE INTRODUCTION TO Q119

No 2

116. Are students prohibited from wearing sunglasses when in the sun during the school day?

Yes 1

No 2

The next section asks about the physical school environment, such as building maintenance, indoor air quality, pest control, chemicals, siting, and campus design.

117. Does your school conduct periodic inspections…

Yes No

1. For condensation in and around the school facilities? 1 2

2. Of the building foundation, walls, and roof for cracks,
   leaks, or past water damage? 1 2

3. For mold? 1 2

4. Of the plumbing system? 1 2

5. Of the heating, ventilation, and air conditioning,
   or HVAC, system? 1 2

6. That test drinking water outlets for lead? 1 2

7. For clutter that prevents effective cleaning and
   maintenance? 1 2

118. During the past 12 months, has your school inspected for lead in cracked or peeling paint?

Yes 1

No 2

Lead paint previously identified
and remediated 3

The next questions ask about inspection for PCBs. PCBs, or polychlorinated biphenals, are man-made chemicals that are harmful to humans. They were commonly used in light ballasts, caulking, and a variety of other products before being banned in 1979.

119. During the past 12 months, has your school inspected for PCBs in caulking around windows and doors?

Yes 1

No 2

PCBs in caulking previously identified
and remediated 3

120. During the past 12 months, has your school inspected for PCBs in fluorescent
     light ballasts?

Yes 1

No 2

PCBs in fluorescent light ballasts previously
identified and remediated 3

121. How often does your school conduct a campus wide inspection for pests such as ants, roaches, bees, mice, or rats? By “campus wide,” I mean inside the buildings and on the school grounds.

Weekly 1

Monthly 2

Quarterly 3

Every 6 months 4

Once per year 5

Only as needed 6

Other time frame 7

122. How often does your school notify staff, students, and families prior to the application of pesticides?

Never 1

Each time 2

Once per year 3

Other time frame 4

School does not apply pesticides 5

123. During the past 12 months, how often…

Almost
Some- Always or
Never Rarely times Always N/A

1. Were ASHRAE standards for
   ventilation maintained? 1 2 3 4

2. Were openings in walls, floors, doors,
   and windows sealed with caulk or
   weather stripping? 1 2 3 4 5

3. Were vegetation, shrubs, and wood
   mulch kept at least one foot away from
   buildings to control pests? 1 2 3 4 5

4. Was eating allowed only in designated
   areas to control pests? 1 2 3 4

5. Was food waste stored in plastic, glass,
   or metal containers with tight lids
   so that it was inaccessible to pests? 1 2 3 4

6. Were cracks in the pavement
   and sidewalks repaired? 1 2 3 4 5

7. Were infested or diseased plants
   removed? 1 2 3 4 5

8. Were spot treatments and baiting used
   rather than widespread applications of
   pesticides? 1 2 3 4 5

9. Were indoor and outdoor areas that had
   been treated with pesticides marked? 1 2 3 4 5

For the next questions, please answer based on what your school does in those months when school is in session.

ASK Q126 ONLY FOR MIDDLE AND HIGH SCHOOLS. ELEMENTARY SCHOOLS SKIP TO Q127.

124. How often does your school require students to clean their lockers? Do not include gym lockers.

Daily 1

Weekly 2

Monthly 3

Quarterly 4

Every 6 months 5

Once per year 6

Only as needed 7

Other time frame 8

School does not have lockers 9

ASK Q127 AND Q128 ONLY FOR ELEMENTARY SCHOOLS. MIDDLE AND HIGH SCHOOLS SKIP TO Q129.

125. How often does your school require students to clean the inside of their desks?

Daily 1

Weekly 2

Monthly 3

Quarterly 4

Every 6 months 5

Once per year 6

Only as needed 7

Other time frame 8

School does not have this type of desk 9

126. How often does your school require students to clean the inside of their cubbies?

Daily 1

Weekly 2

Monthly 3

Quarterly 4

Every 6 months 5

Once per year 6

Only as needed 7

Other time frame 8

School does not have cubbies 9

127. How often does your school clean desk tops?

Daily 1

Weekly 2

Monthly 3

Quarterly 4

Every 6 months 5

Once per year 6

Only as needed 7

Other time frame 8

128. Does your school have a plan for how to address mold problems?

Yes 1

No 2

129. During the past 12 months, did your school respond to moisture-related issues, such as floods, leaks, or condensation within 48 hours or less?

Yes 1

No 2

No moisture-related issues during the past
12 months 3

130. Does your school have an indoor air quality management program?

Yes 1

No 2 SKIP TO Q134

131. Is your program based on EPA’s Indoor Air Quality Tools for Schools?

Yes 1

No 2

132. Has your school ever been tested for radon?

Yes 1

No 2

133. Does your school operate its own water system, that is, the school obtains drinking water from its own well, spring, or small reservoir?

Yes 1 SKIP TO Q138

No 2

134. During the past 12 months, was your school’s drinking water tested for…

Yes No

1. Bacteria? 1 2

2. Coliforms? 1 2

3. Other contaminants? 1 2

Q136A, Q136B, OR Q136C IS “YES,” ANSWER Q137. OTHERWISE, SKIP TO Q138.

135. Were the results of this/these test(s) provided to…

Yes No

1. School faculty and staff? 1 2

2. Students’ families? 1 2

3. Students? 1 2

136. Does your school flush drinking water outlets after periods of non-use, such as after weekends or school vacations?

Yes 1

No 2

The next question asks about low-emitting products, which are products designed to give off low levels of fumes or vapors. These products might include floor covering, furniture, paint, cleaners, markers, textiles, or adhesives.

137. Has your school adopted a policy to purchase low-emitting products for use in and around the school and school grounds, including in art classes, industrial art classes, and science laboratories?

Yes 1

No 2

138. Are custodial or maintenance staff at this school required to receive training on…

Yes No

1. Use of hazardous materials? 1 2

2. Labeling of hazardous materials? 1 2

3. Storage of hazardous materials? 1 2

4. Disposal of hazardous materials? 1 2

5. How to reduce the use of hazardous materials? 1 2

6. How to address mold problems? 1 2

7. Indoor air quality? 1 2

8. School drinking water quality? 1 2

9. Pest management practices that limit the use of pesticides? 1 2

10. Green cleaning products and practices? 1 2

The next questions ask about crisis preparedness, response, and recovery in the event of a natural disaster or other emergency situation.

SHOW CARD 10

139. Which of the following best describes your school’s plan to address crisis preparedness, response, and recovery in the event of a natural disaster or other emergency or crisis situation?

This school does not have such a plan 1 SKIP TO Q147

This school uses a plan provided
by the district 2 SKIP TO Q145

This school uses a district-level plan that has
been adapted to meet our school’s needs 3

This school has its own plan 4

140. Did your school use any materials from the U.S. Department of Education, such as Practical Information on Crisis Planning: A Guide for Schools and Communities, to develop the plan?

Yes 1

No 2

141. In developing the crisis preparedness, response, and recovery plan, did your school work with staff or members from…

Yes No

1. A local fire department? 1 2

2. A local law enforcement agency? 1 2

3. Local emergency medical services? 1 2

4. The local public transportation department? 1 2

5. A local health department? 1 2

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

7. A local hospital? 1 2

8. A local homeland security office or
   emergency management office? 1 2

142. Did your school work with students, families, or other community members to develop the crisis preparedness, response, and recovery plan?

Yes 1

No 2

143. Does the crisis preparedness, response, and recovery plan used by your school include…

Yes No

1. Evacuation plans? 1 2

2. Procedures to stop people from leaving or entering
   school buildings, that is, lock down plans? 1 2

3. Procedures to control the exterior of the building and
   school grounds? 1 2

4. Plans to seek immediate shelter and remain in that area
   during a chemical, biological, or radiological emergency
   rather than evacuating, or shelter-in-place plans? 1 2

5. Requirements to conduct regular emergency drills,
   other than fire drills? 1 2

6. Family reunification procedures? 1 2

7. Provisions for students and staff with special needs? 1 2

8. Plans to resume normal activities after buildings or
   facilities have been damaged? 1 2

9. Provision of mental health services for students, faculty,
   and staff after a crisis has occurred, for example to treat
   post-traumatic stress disorder? 1 2

10. Mechanisms for communicating with school personnel? 1 2

11. Establishment of an incident command system? 1 2

12. Procedures for responding to media inquiries? 1 2

13. Mechanisms for communicating the plan to
    students’ families? 1 2

14. Requirements to periodically review and revise
    emergency response plans? 1 2

15. Procedures for responding to pandemic flu or other
    infectious disease outbreaks? 1 2

16. Procedures for implementing unplanned school dismissal
    or school closure? 1 2

144. During the past two years, has your school provided training on the crisis preparedness, response, and recovery plan to…

Yes No

1. School faculty and staff? 1 2

2. Students? 1 2

3. Students’ families? 1 2

145. During the past two years, has your school provided training on crisis preparedness, response, and recovery to students’ families?

Yes 1

No 2

IF Q141 IS 1 OR 2, SKIP TO Q149.

146. During the past 12 months, has your school’s crisis preparedness, response, and recovery plan been evaluated or assessed?

Yes 1

No 2

147. Some communities have a group of local agencies that coordinates crisis preparedness, response, and recovery efforts. Such a group might be called a local emergency planning committee, an emergency management team, or something else. Is your school a member of such a group?

Yes 1

No 2

No such group 3

148. Is your school designated to serve as a staging area or a community shelter during local emergencies?

Yes 1

No 2

149. Does your school have a National Oceanic and Atmospheric Administration, or NOAA, weather radio?

Yes 1

No 2

SHOW CARD 11

The next questions ask about family involvement in school. This card lists some ways faculty might promote family involvement in school.

150. During the past 12 months, how many of your school’s faculty…

None Some Most All N/A

1. Provided students’ families with
   a way to communicate directly with
   teachers, such as voicemail or an
   e-mail address? Would you say none,
   some, most, or all? 1 2 3 4

2. Provided families with the opportunity
   to review curricula? 1 2 3 4

3. Provided families with copies
   of assignments? 1 2 3 4

4. Contacted families to communicate
   about problems with their child? 1 2 3 4 5

5. Contacted families to communicate
   praise about their child? 1 2 3 4

6. Encouraged families to volunteer
   at the school, for example by asking
   parents for assistance with fundraising
   efforts or to serve as a chaperone
   for school trips? 1 2 3 4

7. Discussed with families ways
   to reinforce learning at home? 1 2 3 4

8. Requested that families regularly review
   and sign homework assignments? 1 2 3 4 5

9. Encouraged families to attend
   parent-teacher conferences? 1 2 3 4 5

10. Encouraged family participation in
    PTA meetings? 1 2 3 4 5

151. Are students at this school involved in developing school or classroom rules?

Yes 1

No 2

The next questions ask about community service and service-learning. By “community service,” I mean unpaid work that helps the community. By “service-learning,” I mean a particular type of community service that is designed to meet specific learning objectives for a course.

152. Does your school provide community service opportunities for students?

Yes 1

No 2 SKIP TO Q156

153. At your school, is community service…

Yes No

1. Required for all students? 1 2

IF Q155A IS “YES,” THEN SKIP TO Q156.

2. Required for students in specific grades? 1 2

3. Required for students who meet specific criteria,
   for example honor students? 1 2

4. Voluntary for all students? 1 2

154. Does your school provide service-learning opportunities for students?

Yes 1

No 2 SKIP TO Q158

155. At your school, is service-learning…

Yes No

1. Required for all students? 1 2

IF Q157A IS “YES,” THEN SKIP TO Q158.

2. Required for students in specific grades? 1 2

3. Required for students in specific courses? 1 2

156. Does your school participate in a program in which family or community members serve as role models to students or mentor students, such as the Big Brothers Big Sisters program?

Yes 1

No 2

The next questions ask about physical activity.

ANSWER Q159–Q169 FOR ELEMENTARY SCHOOL ONLY. OTHERWISE, SKIP TO THE INSTRUCTIONS BEFORE Q170.

I would like to ask about times when students participate in regularly scheduled recess at this school. Please do not include activities that students engage in during physical education class.

157. In what grade or grades do students participate in regularly scheduled recess during the school day?
     MARK ALL THAT APPLY

Kindergarten 0

1^st Grade 1

2^nd Grade 2

3^rd Grade 3

4^th Grade 4

5^th Grade 5

6^th Grade 6

None 7 SKIP TO THE INSTRUCTIONS BEFORE Q170

158. On average, how many days per week are the students scheduled to have recess?

Days/Week

159. On average, how many minutes each day do students spend in recess?

Minutes

160. About how many classes have regularly scheduled recess immediately before lunch?

None 1

Less than half 2

Half 3

More than half 4

All 5

161. About how many classes have regularly scheduled recess immediately after lunch?

None 1

Less than half 2

Half 3

More than half 4

All 5

162. Are staff at this school prohibited or actively discouraged from excluding students from all or part of recess as punishment for bad behavior or failure to complete class work?

Yes 1

No 2

163. Which of the following statements best describes how recess is structured at your school?

Students engage in free play or
physical activity 1

Students are required or encouraged to use
physical activity or fitness stations 2

Other (Specify) 3

164. Is recess held outdoors, weather permitting?

Yes 1

No 2

165. (When students cannot go outside for recess,) which of the following statements best describes what happens during recess time?

Students participate in physical activity
in the gymnasium, multi-purpose room,
or cafeteria 1

Students participate in physical activity
in regular classrooms 2

Students watch a DVD/video (do not include
physical activity DVDs/videos) 3

Students engage in other sedentary activities,
such as board games 4

Other (Specify) 5

166. Do students participate in regular physical activity breaks, outside of physical education class and recess, during the school day?

Yes 1

No 2

167. Does your school have a specified time or event for school-wide physical activity outside of physical education classes and recess, for example during morning announcements?

Yes 1

No 2

ANSWER Q170 FOR MIDDLE AND HIGH SCHOOL ONLY. OTHERWISE, SKIP TO THE INTRODUCTION TO Q172.

168. Do students participate in regular physical activity breaks, outside of physical education class, during the school day?

Yes 1

No 2

169. Does your school have a specified time or event for school-wide physical activity outside of physical education classes, for example during morning announcements?

Yes 1

No 2

The next questions ask about influences on students’ dietary behavior while at school.

170. Are staff at your school prohibited or actively discouraged from using food or food coupons as a reward for good behavior or good academic performance?

Yes 1

No 2

171. Are staff at your school prohibited or actively discouraged from withholding food or restricting the types of foods available as a form of punishment for students’ behavior?

Yes 1

No 2

Next, I’ll ask about policies your school might have adopted on foods offered at specific events or venues. Do not include foods offered in the cafeteria, vending machines, or school store.

172. Has your school adopted a policy stating that, if food is served at student parties, fruits or vegetables will be among the foods offered?

Yes 1

No 2

School does not have student parties 3

173. Has your school adopted a policy stating that, if food is served in after-school or extended day programs, fruits or vegetables will be among the foods offered?

Yes 1

No 2

School does not have after-school
or extended day programs 3

174. Has your school adopted a policy stating that fruits or vegetables will be among the foods offered at concession stands?

Yes 1

No 2

School does not have concession stands 3

175. Has your school adopted a policy stating that, if food is served at student parties, whole grain foods will be among the foods offered?

Yes 1

No 2

School does not have student parties 3

176. Has your school adopted a policy stating that, if food is served in after-school or extended day programs, whole grain foods will be among the foods offered?

Yes 1

No 2

School does not have after-school or
extended day programs 3

177. Has your school adopted a policy stating that whole grain foods will be among the foods offered at concession stands?

Yes 1

No 2

School does not have concession stands 3

178. Has your school adopted a policy stating that, if beverages are served at student parties, healthful beverages such as plain water or low-fat milk will be among the beverages offered?

Yes 1

No 2

School does not have student parties 3

179. Has your school adopted a policy stating that, if beverages are served in after-school or extended day programs, healthful beverages such as plain water or low-fat milk will be among the beverages offered?

Yes 1

No 2

School does not have after-school or
extended day programs 3

180. Has your school adopted a policy stating that healthful beverages such as plain water or low-fat milk will be among the beverages offered at concession stands?

Yes 1

No 2

School does not have concession stands 3

The next questions ask about the availability of junk foods in schools. Junk foods are foods or beverages that have low nutrient density, that is, they provide calories primarily through fats or added sugars and have minimal amounts of vitamins and minerals.

181. Has your school adopted a policy prohibiting junk foods from being offered at student parties?

Yes 1

No 2

School does not have student parties 3

182. Has your school adopted a policy prohibiting junk foods from being offered in after-school or extended day programs?

Yes 1

No 2

School does not have after-school or
extended day programs 3

183. Has your school adopted a policy prohibiting junk foods from being offered at concession stands?

Yes 1

No 2

School does not have concession stands 3

The next questions ask about foods and beverages available in vending machines, school stores, canteens, or snack bars.

184. Can students purchase food or beverages from…

Yes No

1. One or more vending machines at the school? 1 2

2. A school store, canteen, or snack bar? 1 2

IF Q186A AND Q186B ARE “NO,” SKIP TO Q195. OTHERWISE, CONTINUE TO Q187.

185. Can students purchase the following from vending machines or school stores?

Yes No

1. Chocolate candy 1 2

2. Other kinds of candy 1 2

3. Cookies, crackers, cakes, pastries, or other baked goods
   that are not low in fat 1 2

4. Salty snacks that are not low in fat, such as
   regular potato chips 1 2

5. Ice cream or frozen yogurt that is not low in fat 1 2

6. 2% or whole milk (plain or flavored) 1 2

7. Water ices or frozen slushes that do not contain juice 1 2

IF Q187A–G ARE “NO,” SKIP TO Q189.

186. Can students purchase these items…

Yes No

1. Before classes begin in the morning? 1 2

2. During any school hours when meals are not
   being served? 1 2

3. During school lunch periods? 1 2

187. Can students purchase the following from vending machines or school stores?

Yes No

1. Low-fat cookies, crackers, cakes, pastries, or other
   low-fat baked goods 1 2

2. Salty snacks that are low in fat, such as pretzels,
   baked chips, or other low-fat chips 1 2

3. Snacks such as pretzels, crackers, or chips that are
   low in sodium 1 2

4. Whole grain bread products, such as bread sticks, rolls,
   or bagels 1 2

5. Bread sticks, rolls, bagels, pita bread, or other bread
   products that are not whole grain 1 2

6. Low-fat or fat-free ice cream, frozen yogurt, or sherbet 1 2

7. Low-fat or non-fat yogurt 1 2

8. Fruits or vegetables, not juice 1 2

9. 100% fruit juice 1 2

10. 100% vegetable juice 1 2

11. 1% or skim milk 1 2

12. Bottled water 1 2

IF Q189A–L ARE “NO,” SKIP TO Q191.

188. Can students purchase these items…

Yes No

1. Before classes begin in the morning? 1 2

2. During any school hours when meals are not
   being served? 1 2

3. During school lunch periods? 1 2

189. Can students purchase the following from vending machines or school stores?

Yes No

1. Soda pop or fruit drinks that are not 100% juice 1 2

2. Sports drinks, such as Gatorade™ 1 2

3. Coffee, coffee drinks, or any kind of tea 1 2

4. Sugar-sweetened beverages, such as lemonade, sweetened
   tea or coffee drinks, flavored milk, or Sunny Delight 1 2

5. Energy drinks, such as Red Bull or Jolt 1 2

IF Q191A–E ARE “NO,” SKIP TO Q193.

190. Can students purchase these items…

Yes No

1. Before classes begin in the morning? 1 2

2. During any school hours when meals are not being served? 1 2

3. During school lunch periods? 1 2

191. At your school, are healthful foods such as fruits, vegetables, and whole grain foods intentionally priced at a lower cost than junk food?

Yes 1

No 2

School does not sell junk food 3

192. At your school, are healthful beverages such as plain water or low-fat milk intentionally priced at a lower cost than sugar-sweetened beverages?

Yes 1

No 2

School does not sell sugar-sweetened
beverages 3

193. During the past 12 months, have any organizations at this school, such as student clubs, sports teams, or the PTA sold food at school or in the community to raise money?

Yes 1

No 2 SKIP TO Q200

194. During the past 12 months, have any of the following items been sold as part of fund­raising for any school organization?

Yes No

1. Chocolate candy 1 2

2. Other kinds of candy 1 2

3. Soda pop or fruit drinks that are not 100% juice 1 2

4. Sports drinks, such as Gatorade™ 1 2

5. Cookies, crackers, cakes, pastries, or other baked goods
   that are not low in fat 1 2

IF Q196A–E ARE “NO,” SKIP TO Q198.

195. Could students purchase these items…

Yes No

1. Before classes began in the morning? 1 2

2. During any school hours when meals were not
   being served? 1 2

3. During school lunch periods? 1 2

196. During the past 12 months, have any of the following items been sold as part of fundraising for any school organization?

Yes No

1. Fruits or vegetables 1 2

2. 100% fruit juice or vegetable juice 1 2

3. Low-fat cookies, crackers, cakes, pastries, or other
   low-fat baked goods 1 2

IF Q198A–C ARE “NO,” SKIP TO Q200.

197. Could students purchase these items…

Yes No

1. Before classes began in the morning? 1 2

2. During any school hours when meals were not
   being served? 1 2

3. During school lunch periods? 1 2

198. Does this school hold fundraiser nights at fast food restaurants where a portion of the sales made on a particular night benefit the school?

Yes 1

No 2

IF Q191A AND Q191B AND Q191D ARE “NO,” ANSWER Q201.
OTHERWISE, SKIP TO Q202.

199. Does this school sell soft drinks to students in any venue? Please include sports drinks, soda pop, or fruit drinks that are not 100% juice.

Yes 1

No 2 SKIP TO Q205

200. Does your school receive a specified percentage of soft drink sales receipts?

Yes 1

No 2 SKIP TO Q204

201. Does your school receive incentives, such as cash awards or donations of equipment, supplies, or other donations, once receipts total a specified amount?

Yes 1

No 2

202. Is your school prohibited from selling soft drinks produced by more than one company?

Yes 1

No 2

203. Are soft drink companies allowed to advertise soft drinks, such as sports drinks, soda pop, or fruit drinks…

School does not
have vending
Yes No machines

1. On vending machines? 1 2 3

2. Elsewhere in the school building? 1 2

3. On school grounds, including on the
   outside of the school building, on playing
   fields, or other areas of the campus? 1 2

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

204. Does your school allow advertisements for junk food or fast food restaurants on school property?

Yes 1

No 2

205. Does your school use any educational materials that promote junk food, fast food restaurants, or soft drinks?

Yes 1

No 2

206. At this school, are junk food, fast food restaurants, or soft drinks promoted through the distribution of products, such as t-shirts, hats, and book covers to students?

Yes 1

No 2

The next questions ask about school health coordination.

207. Is there one or more than one group—for example, a school health council, committee, or team—at this school that offers guidance on the development of policies or coordinates activities that are health-related?

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q215

208. Do any of these groups address…

Yes No

1. Tobacco use prevention? 1 2

2. Alcohol or other drug use prevention? 1 2

3. Food service or nutrition? 1 2

4. Physical education or physical activity? 1 2

ANSWER E–G FOR MIDDLE AND HIGH SCHOOL ONLY.
OTHERWISE, SKIP TO H.

5. Pregnancy prevention? 1 2

6. Human immunodeficiency virus, or HIV, prevention? 1 2

7. Other sexually transmitted disease, or STD, prevention? 1 2

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

9. Injury prevention and safety? 1 2

10. Health education? 1 2

11. Health services? 1 2

12. Mental health or social services? 1 2

13. The psychological and social environment,
    or school climate? 1 2

14. Faculty and staff health promotion? 1 2

15. Family and community involvement in school
    health programs? 1 2

16. Physical school environment? 1 2

17. Crisis preparedness, response, and recovery? 1 2

18. Management of chronic health conditions, such as
    asthma or diabetes? 1 2

(Q210 continued)

Yes No

19. Management of infectious diseases, such as influenza,
    or flu? 1 2

20. Management of foodborne illnesses? 1 2

21. Management of food allergies? 1 2

22. Local wellness policies? 1 2

SHOW CARD 12

209. Looking at this card, please tell me who is included on any school health council, committee, or team.
     MARK ALL THAT APPLY

FOR ELEMENTARY SCHOOLS ONLY

Elementary school classroom teachers 0

FOR ALL SCHOOLS

Health education teachers 1

Physical education teachers 2

Health services staff (e.g., school nurses) 3

Nutrition or food service staff 4

Mental health or social services staff 5

Maintenance staff 6

Transportation staff 7

Technology staff 8

Library or media center staff 9

District administrators 10

School-level administrators 11

Students 12

Students’ parents or families 13

SHOW CARD 13

210. Looking at this card, please tell me if these local agencies or organizations are represented on any school health council, committee, or team.
     MARK ALL THAT APPLY

Health department 1

Mental health or social service agencies 2

Healthcare providers, such as
pediatricians or dentists 3

Health organizations, such as
the local Red Cross chapter 4

Youth organizations, such as
the Boys and Girls Clubs 5

Businesses 6

Hospitals 7

Service clubs, such as the Rotary Club 8

Public safety agencies, such as
police, fire, or emergency services 9

Faith-based organizations 10

Other local government agencies 11

211. Do any of these groups…

Yes No

1. Identify student health needs based on a review of
   relevant data? 1 2

2. Recommend new or revised health and safety policies
   and activities to school administrators or the school
   improvement team? 1 2

3. Seek funding or leverage resources to support health
   and safety priorities for students and staff? 1 2

4. Review health-related curricula or instructional materials? 1 2

5. Communicate the importance of health and safety
   policies and activities to district administrators,
   school administrators, parent-teacher groups, or
   community members? 1 2

For the next question, please think about the school health council, committee, or team that met the most during the past 12 months.

212. During the past 12 months, how many times did this group meet?

0 times 1

1 or 2 times 2

3 or 4 times 3

5 or 6 times 4

More than 6 times 5

The next questions ask about materials your school might have used to assess your school’s health and safety policies and activities.

213. Has your school ever used the School Health Index, or SHI, or other self-assessment tool to assess your school’s health and safety policies and activities?

Yes 1

No 2

The next questions ask about a school improvement plan. The Elementary and Secondary Education Act requires certain schools to have a written School Improvement Plan, or SIP. Many states and school districts also require schools to have a written SIP. Such plans are developed to improve overall instructional and environmental policies and programs.

214. Does your school’s written SIP include health-related objectives on any of the following topics?

INTERVIEWER INSTRUCTIONS: IF THE SCHOOL DOES NOT HAVE A SIP,
MARK “NO SIP” FOR EACH QUESTION.

Yes No No SIP

1. Health education 1 2 3

2. Physical education and physical activity 1 2 3

3. Nutrition services and foods and beverages
   available at school 1 2 3

4. Health services 1 2 3

5. Mental health and social services 1 2 3

6. Healthy and safe school environment 1 2 3

7. Faculty and staff health promotion 1 2 3

8. Family and community involvement 1 2 3

The next questions ask about the person responsible for overseeing or coordinating all of the school’s health and safety policies and activities.

215. Currently, is there one person at your school who oversees or coordinates the school’s health and safety policies and activities, for example a school health coordinator?

Yes 1

No 2 SKIP TO Q227

216. Are you this person?

Yes 1

No 2 SKIP TO Q227

217. Are the following activities included in your responsibilities as coordinator of your school’s health and safety policies and activities?

Yes No N/A

1. Developing or assisting in the development
   of school health and safety policy language,
   policy guidance, or other policy materials 1 2

2. Securing funding or other resources to
   support health and safety policies and
   activities 1 2

3. Communicating health and safety priorities
   to school administrators, school staff,
   parent-teacher groups, or student groups.. 1 2

4. Linking community-based health-related
   resources to the school 1 2

5. Facilitating collaboration among school
   staff responsible for the health and safety
   of students and staff 1 2

6. Serving as a liaison between the school
   and those who oversee or implement health
   and safety policies and activities at the
   district level 1 2

7. Convening school health council,
   committee, or team meetings 1 2 3

218. Counting this year as a full year, how many years have you been responsible for coordinating school health and safety policies and activities?

Years

The last set of questions ask about your educational background.

219. Do you have an undergraduate degree?

Yes 1

No 2 SKIP TO Q227

220. What did you major in?

Health education 1

Physical education 2

Other education 3

Kinesiology, exercise physiology, or
exercise science 4

Nursing 5

Nutrition 6

Public health 7

Biology or other science 8

Home economics or family and
consumer science 9

Other 10

221. Did you have an undergraduate minor?

Yes 1

No 2 SKIP TO Q225

222. What did you minor in?

Health education 1

Physical education 2

Other education 3

Kinesiology, exercise physiology, or
exercise science 4

Nursing 5

Nutrition 6

Public health 7

Biology or other science 8

Home economics or family and
consumer science 9

Other 10

223. Do you have a graduate degree?

Yes 1

No 2 SKIP TO Q227

224. In what area or areas was your graduate work?

Health education 1

Physical education 2

Education administration 3

Other education 4

Kinesiology, exercise physiology, or
exercise science 5

Nursing 6

Nutrition 7

Public health 8

Biology or other science 9

Home economics or family and
consumer science 10

Other 11

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

( ) -

1) Daytime or

2) Evening/Weekend

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

Healthy and Safe School Environment School Questionnaire—Public Use Version 0