District Health Services

Health Services Coordinator

Form Approved

OMB No: 0920-0445

Expiration Date: xx/xx/xxxx

Health Services
District Questionnaire

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Public reporting burden for this collection of information is estimated to average 40 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
District Questionnaire

Questions

Student Health Records 1

Required Immunizations 2–9

Tuberculosis Screening and Testing 10–14

Procedures for Student Medications 15–24

Funding/Medicaid 25–26

Collaboration and Promotion 27–29

Evaluation 30

Injury and Illness Reports 31–41

Standard Precautions 42

Screening 43–53

Provision of Other Services 54–61

Staffing Characteristics 62–68

Professional Development 69–74

School-Based Health Center Services 75–77

Services at Other Sites 78–81

Health Services Coordinator 82–91

THIS QUESTIONNAIRE WILL BE ADMINISTERED USING WEB-BASED INTERVIEW TECHNOLOGY. AS THE RESPONDENT TYPES RESPONSES TO THE QUESTIONS INTO THE 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 ADDITIONAL CLARIFICATION ON THE QUESTION OR THE SPECIFIC TERMINOLOGY USED. THIS TEXT WILL APPEAR ON-SCREEN UNDER THE MAIN QUESTION TEXT. THE PROGRAMMING SPECIFICATIONS FOR THE INTERVIEW ARE NOT INCLUDED IN THIS PRINTED VERSION OF THE QUESTIONNAIRE.

1. This questionnaire focuses on your district’s policies and practices regarding health services.

2. For the purposes of this questionnaire, “policy” means any law, rule, regulation, administrative order, or similar kind of mandate issued by the local school board or other local agency with authority over schools in your district. SHPPS is most interested in what is required by the district, not what is recommended or contained in non-binding guidance documents, unless the question specifically asks about recommendations.

3. For the purposes of this questionnaire, “adopted a policy” means either that the district has its own policy or that the district follows a policy established at the state level, including any law, rule, regulation, administrative order, or similar kind of mandate.

4. If a district policy is worded in such a way that it requires schools to develop and adopt their own policies on a given topic, for the purposes of this questionnaire please consider it the same as a district-wide requirement.

5. Districts may sometimes grant policy exceptions or waivers, but please answer each question based on what is considered the general policy and standard practice in your district.

6. Please do not consider school practices or policies when answering the questions. This information is gathered during data collection from schools across the country.

7. For the purposes of this questionnaire, “elementary school” refers to a school that contains any of grades K–5. “Middle school” refers to a school that contains any of grades 6–8. Some jurisdictions may refer to these schools as “junior high schools.” “High school” refers to a school that contains any of grades 10–12. Some jurisdictions may refer to these schools as “senior high schools.”

The first question asks about information that might be found in student records.

1. Has your district adopted a policy stating that schools will obtain and keep the following information in any type of student record?

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. 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 (BMI) 1 2

14. Reasons for student absences 1 2

The next questions ask about your district’s policies regarding student immunizations.

2. Has your district adopted a policy stating that students must receive an influenza vaccine annually?

Yes 1

No 2

IF DISTRICT DOES NOT CONTAIN ELEMENTARY SCHOOLS, SKIP TO THE INSTRUCTIONS BEFORE Q5.

3. Has your district adopted a policy stating that students entering kindergarten or first grade will have…

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

4. Which of the following statements best describes your district’s policies related to whether students are excluded from attending classes if they have not received the required immunizations for entry into kindergarten or first grade? 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 entry into kindergarten or
first grade are immediately excluded from
attending classes 1

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

This district does not have a policy that
excludes students from attending classes
if they have not received the required
immunizations for entry into kindergarten or
first grade 3

IF DISTRICT DOES NOT CONTAIN MIDDLE SCHOOLS, SKIP TO THE INSTRUCTIONS BEFORE Q7.

5. Has your district adopted a policy stating that students entering middle school will have…

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 (Tdap) vaccine? 1 2

6. A meningococcal conjugate vaccine? 1 2

7. A human papillomavirus (HPV) vaccine? (Girls only) 1 2

6. Which of the following statements best describes your district’s policies related to whether students are excluded from attending classes if they have not received the required immunizations for entry into middle 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 entry into middle school
are immediately excluded from
attending classes 1

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

This district does not have a policy that
excludes students from attending classes
if they have not received the required
immunizations for entry into middle school 3

IF DISTRICT DOES NOT CONTAIN HIGH SCHOOLS, SKIP TO Q9.

7. Has your district adopted a policy stating that students entering high school will have…

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 (Tdap) vaccine? 1 2

6. A meningococcal conjugate vaccine? 1 2

7. A human papillomavirus (HPV) vaccine? (Girls only) 1 2

8. Which of the following statements best describes your district’s policies related to whether students are excluded from attending classes if they have not received the required immunizations for entry into high 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 entry into high school
are immediately excluded from attending
classes 1

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

This district does not have a policy that
excludes students from attending classes
if they have not received the required
immunizations for entry into high school 3

9. Does your district 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

IF DISTRICT DOES NOT CONTAIN ELEMENTARY SCHOOLS, SKIP TO Q12.

The next questions ask about tuberculosis (TB) screening and TB testing for students prior to entry into kindergarten or first grade. 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.

10. Which of the following statements best describes your district’s policies for tuberculosis (TB) screening of students prior to entry into kindergarten or first grade?

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 district’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.

11. Which of the following three statements best describes your district’s policies for tuberculosis (TB) testing of students prior to entry into kindergarten or first grade?

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

12. Which of the following three statements best describes your district’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).

The district requires periodic TB testing
for all students 1

The district requires periodic TB testing
only for students previously identified
through screening 2

The district does not require periodic
TB testing for any students 3

IF Q11 IS 4 OR SKIPPED APPROPRIATELY AND Q12 IS 3, SKIP TO THE INTRODUCTION TO Q15.

IF Q12 IS 3, SKIP TO Q14.

13. Which of the following three statements best describes your district’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

14. Which method does your district 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

The next questions ask about your district’s policies regarding who may administer medications to students at school.

15. Has your district adopted a policy stating that some students may 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

16. Has your district adopted a policy related to who may administer…

Yes No

1. Prescription medications to a student at school? 1 2

2. Over-the-counter medications to a student at school? 1 2

17. Has your district adopted a policy stating that when someone who is not a licensed healthcare professional administers prescription medications to students, they must be…

Yes No

1. Licensed or certified to administer medications? 1 2

2. Trained to administer medications? 1 2

18. Has your district adopted a policy stating that when someone who is not a licensed healthcare professional administers over-the-counter medications to students, they must be…

Yes No

1. Licensed or certified to administer medications? 1 2

2. Trained to administer medications? 1 2

19. Has your district adopted a policy stating that schools will have written instructions from the physician or prescriber before school nurses, teachers, or any other school staff may administer prescription medications to a student?

Yes 1

No 2

No school staff may administer prescription
medications 3

20. Has your district adopted a policy stating that schools will have written instructions from the physician or prescriber before school nurses, teachers, or any other school staff may administer over-the-counter medications to a student?

Yes 1

No 2

No school staff may administer
over-the-counter medications 3

21. Has your district adopted a policy stating that schools will have a written request from the parent or guardian before school nurses, teachers, or any other school staff may administer prescription medications to a student?

Yes 1

No 2

No school staff may administer prescription
medications 3

22. Has your district adopted a policy stating that schools will have a written request from the parent or guardian before school nurses, teachers, or any other school staff may administer over-the-counter medications to a student?

Yes 1

No 2

No school staff may administer
over-the-counter medications 3

23. Has your district adopted a policy stating that schools will have written information on possible side-effects before school nurses, teachers, or any other school staff may administer prescription medications to a student?

Yes 1

No 2

No school staff may administer prescription
medications 3

24. Has your district adopted a policy stating that schools will have written information on possible side-effects before school nurses, teachers, or any other school staff may administer over-the-counter medications to a student?

Yes 1

No 2

No school staff may administer
over-the-counter medications 3

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

25. In your district, how are standard health services for students funded?
    MARK ALL THAT APPLY

School district budget 1

Medicaid 2

State Children’s Health Insurance Program
(SCHIP) 3

Private insurance 4

Public grants 5

Private grants 6

Other 7

The next question asks about schools in your district that serve as Medicaid providers by providing standard health services to students.

26. In your district, do any schools serve as Medicaid providers by providing standard health services to students?

Yes 1

No 2

The next questions ask about collaboration on health services activities with other district-level staff and outside organizations.

27. During the past 12 months, have district-level health services staff worked on school health services activities with district-level…

No district-
level staff
Yes No in this area

1. Health education staff? 1 2 3

2. Physical education staff? 1 2 3

3. Nutrition or food service staff? 1 2 3

4. Mental health or social services staff? 1 2 3

5. School-based health center staff? 1 2 3

28. During the past 12 months, have district-level health services staff worked on school health services activities 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

29. During the past 12 months, has anyone from your district provided families of all students with information on school health services?

Yes 1

No 2

The next question asks about different aspects of your district’s school health services program that might have been evaluated during the past two years.

30. During the past two years, has your district evaluated…

Yes No N/A

1. School health services programs? 1 2

2. School health services policies? 1 2 3

3. Professional development or in-service
   programs for health services staff? 1 2 3

4. Student use of school health services? 1 2

5. Student or family satisfaction with
   school health services? 1 2

The next question asks about your district’s policy regarding students who are seriously injured on school property. For the purposes of this question, “seriously injured” means an injury requiring emergency medical services (EMS) response or immediate care by a physician or other healthcare professional.

31. Has your district adopted a policy stating that schools will complete a report after a student is seriously injured on school property?

Yes 1

No 2 SKIP TO THE
INTRODUCTION TO Q34

32. Has your district adopted a policy stating that the following information will be recorded on student injury reports?

Yes No

1. Location where injury occurred, such as a playground,
   field, hallway, or stairway 1 2

2. Activity during which injury occurred, such as baseball,
   sitting, or throwing 1 2

3. Nature of injury, such as bruise or burn 1 2

4. School staff who were present when the injury occurred 1 2

5. Cause of injury, such as a fall, equipment, or
   another student 1 2

6. Response of school staff to the injury, such as
   an EMS call or treatment provided by school staff 1 2

7. Immediate outcome of injury, such as hospitalization or
   school days missed by student 1 2

33. Has your district adopted a policy stating that schools will submit student injury report data to the school district or local health department?

Yes 1

No 2

The next question asks about your district’s policy regarding students who experience a serious illness at school. For the purposes of this question, “serious illness” means one requiring EMS response, or immediate care by a physician or other healthcare professional.

34. Has your district adopted a policy stating that schools will complete a report when a student experiences a serious illness at school?

Yes 1

No 2

35. Has your district adopted a policy stating that schools will report notifiable diseases among students to the state or local health department?

Yes 1

No 2

The next questions ask about other reporting requirements your district might have.

36. Are schools in your district required to submit information on student weight status, such as body mass index (BMI), to the state, school district, or local health department?

Yes 1

No 2

37. Does your district or local health department have real-time access to student attendance or absenteeism information for all schools in the district?

Yes 1 SKIP TO Q39

No 2

38. How often are schools in your district required to submit information on student attendance or absenteeism to the school district or local health department?

Daily 1

Weekly 2

Monthly 3

Quarterly 4

Annually 5

Only on designated days during the
school year 6

Other time frame 7

Schools are not required to submit information
on student attendance or absenteesism 8 SKIP TO Q40

39. Are schools in your district required to submit information to the school district or local health department on the reasons for student absences?

Yes 1

No 2

40. Does your district recommend that schools use a specified electronic system for reporting student attendance or absenteeism information?

Yes 1

No 2

41. Are schools in your district required to close or dismiss all students when the percentage of absent students or staff reaches a specified level?

Yes 1

No 2

The next question asks about your district’s policy regarding the availability of supplies for the application of standard precautions.

42. Has your district adopted a policy stating that supplies for applying standard or universal precautions, including disposable gloves and bandages, will be 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

The next questions are about district policies on student health screenings. For the purposes of these questions, “student health screenings” means screenings conducted for most students in the school or in certain grades at the school. Please do not include screenings conducted for special populations of students, for example screenings conducted only for special education students.

43. Has your district adopted a policy stating that schools will screen students for hearing problems?

Yes 1

No 2 SKIP TO Q45

44a. Has your district adopted a policy stating that a student’s parents or guardians will be notified when the student’s hearing screening indicates a potential problem?

Yes 1

No 2

44b. Has your district adopted a policy stating that a student’s teacher will be notified when the student’s hearing screening indicates a potential problem?

Yes 1

No 2

44c. Has your district adopted a policy stating that schools must provide referrals to community healthcare providers when the student’s hearing screening indicates a potential problem?

Yes 1

No 2

45. Has your district adopted a policy stating that schools will screen students for vision problems?

Yes 1

No 2 SKIP TO Q47

46a. Has your district adopted a policy stating that a student’s parents or guardians will be notified when the student’s vision screening indicates a potential problem?

Yes 1

No 2

46b. Has your district adopted a policy stating that a student’s teacher will be notified when the student’s vision screening indicates a potential problem?

Yes 1

No 2

46c. Has your district adopted a policy stating that schools must provide referrals to community healthcare providers when the student’s vision screening indicates a potential problem?

Yes 1

No 2

47. Has your district adopted a policy stating that schools will screen students for oral health problems?

Yes 1

No 2 SKIP TO Q49

48a. Has your district adopted a policy stating that a student’s parents or guardians will be notified when the student’s oral health screening indicates a potential problem?

Yes 1

No 2

48b. Has your district adopted a policy stating that a student’s teacher will be notified when the student’s oral health screening indicates a potential problem?

Yes 1

No 2

48c. Has your district adopted a policy stating that schools must provide referrals to community healthcare providers when the student’s oral health screening indicates a potential problem?

Yes 1

No 2

49. Has your district adopted a policy stating that schools will screen students for weight status using body mass index (BMI)?

Yes 1

No 2 SKIP TO Q52

50. Has your district adopted a policy stating that a student’s parents or guardians will be notified when the student’s weight status screening indicates a potential problem?

Yes 1

No 2

51. Has your district adopted a policy stating that schools must provide referrals to community healthcare providers when the student’s weight status screening indicates a potential problem?

Yes 1

No 2

52. Has your district adopted a policy stating that schools will screen students for mental health problems?

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q54

53a. Has your district adopted a policy stating that a student’s parents or guardians will be notified when the student’s mental health screening indicates a potential problem?

Yes 1

No 2

53b. Has your district adopted a policy stating that a student’s teacher will be notified when the student’s mental health screening indicates a potential problem?

Yes 1

No 2

53c. Has your district adopted a policy stating that schools must provide referrals to community healthcare providers when the student’s mental health screening indicates a potential problem?

Yes 1

No 2

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

54. Has your district adopted a policy stating that schools will provide each of the following services to students?

Yes No

1. First aid 1 2

2. Cardiopulmonary resuscitation (CPR) 1 2

3. Administration of medications 1 2

4. Seasonal influenza vaccine 1 2

5. Immunizations other than seasonal influenza 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 of 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 Q54O–Q IF DISTRICT CONTAINS MIDDLE OR HIGH SCHOOLS. OTHERWISE SKIP TO THE INTRODUCTION TO Q56.

15. Prenatal care referrals 1 2

16. Identification, treatment of, or referral for
    sexually transmitted diseases (STDs) 1 2

17. Contraceptives 1 2

44. Has your district adopted a policy stating that middle or high schools will make condoms available to students?

Yes 1

No 2

The next questions ask about health services that might be provided in one-on-one or small group sessions by any school staff, but not as part of classroom instruction.

45. Has your district adopted a policy stating that schools will provide…

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

46. Has your district adopted a policy stating that schools will 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

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

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

(Q57 continued)

Yes No

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

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

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

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

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

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

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

22. Job readiness skills programs? 1 2

47. Has your district adopted a policy stating that school nurses will participate in the development of Individualized Education Programs (IEPs) when indicated?

Yes 1

No 2

48. Has your district adopted a policy stating that school nurses will participate in the development of Individualized Health Plans (IHPs)?

Yes 1

No 2

49. Has your district adopted a policy stating that school nurses will participate in the development of 504 plans, when indicated?

Yes 1

No 2

50. Has your district adopted a policy stating that health services staff will follow “Do Not Resuscitate” (DNR) orders?

Yes 1

No 2

The next questions ask about your district’s education requirements for newly hired health services staff.

51. Based on policies adopted by your district, 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

Specific education requirements are not
described 5

52. Based on policies adopted by your district, will a newly hired school nurse have a…

Yes No

1. Licensed Practical Nurse’s (LPN) license? 1 2

2. Registered Nurse’s (RN) license? 1 2

53. Based on policies adopted by your district, will a newly hired school nurse have…

Yes No N/A

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

2. A state school nurse certification? 1 2 3

54. Has your district adopted a policy stating that school nurses are required to earn continuing education credits on health services topics?

Yes 1

No 2

The next questions ask about your district’s policies for staffing schools with health services staff.

55. Has your district adopted a policy specifying a maximum student-to-school nurse ratio?

Yes 1

No 2

56. Has your district adopted a policy stating that each school will have a specified ratio of school nurses to students?

Yes 1

No 2

57. Has your district adopted a policy stating that each school will have someone to oversee or coordinate health services at the school?

Yes 1

No 2

The next questions ask about professional development that may have been offered to school nurses during the past two years. This might include workshops, conferences, continuing education, graduate courses, or any other kind of in-service.

58. During the past two years, has your district provided funding for or offered professional development to school nurses 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 vaccine? 1 2

5. Immunizations other than seasonal influenza? 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, for example hand hygiene
    or food safety? 1 2

59. During the past two years, has your district provided funding for or offered professional development to school nurses 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

60. During the past two years, has your district provided funding for or offered professional development to school nurses 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

(Q71 continued)

Yes No

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

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 (BMI)? 1 2

The next question asks about organizations in your district that might employ school nurses.

61. In your district, are school nurses employed by…

Yes No

1. The school district? 1 2

2. Schools? 1 2

3. Local health departments? 1 2

4. Some other organization or agency? 1 2

The next question asks about your district’s policy regarding school health aide supervision requirements. For the purposes of this question, “supervision” means training and monitoring.

62. Has your district adopted a policy stating that school health aides will work under the supervision of a Registered Nurse (RN) at all times?

Yes 1

No 2

School health aides are not employed by the
district 3

The next questions ask about training for teachers, administrators, and school staff other than school nurses.

63. During the past two years, has your district provided funding for or offered training to any teachers, administrators, and school staff other than school nurses on…

Yes No

1. CPR or use of AED equipment? 1 2

2. HIV infection or AIDS? 1 2

3. Severe food or other allergies? 1 2

4. Chronic health conditions, such as asthma or diabetes,
   including chronic disease management, recognizing and
   responding to severe symptoms, or reducing triggers? 1 2

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

64. Currently, how many school-based health centers offer health services to students in your district?

School-based health centers

65. Currently, how many school-based health centers offer mental health and social services to students in your district?

School-based health centers offering mental health and social services

IF Q75 AND Q76 ARE BOTH “0,” SKIP TO THE INTRODUCTION TO Q78.

66. In your district, how are school-based health center services for students funded?
    MARK ALL THAT APPLY

School district budget 1

Medicaid 2

State Children’s Health Insurance Program
(SCHIP) 3

Private insurance 4

Public grants 5

Private grants 6

Other 7

This next set of questions asks about health services delivered to students 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.

67. Currently, does your district have such arrangements to provide health services to students in your district?

Yes 1

No 2 SKIP TO Q82

The next question asks which organizations or healthcare professionals have arrangements with your district to provide health services to students.

68. Does your district have arrangements with…

Yes No

1. A school-linked health center? 1 2

2. A community health clinic or health center? 1 2

3. A local health department? 1 2

4. A local hospital? 1 2

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

6. A university, medical school, or nursing school? 1 2

7. A dental or dental hygiene school? 1 2

8. A managed care organization? 1 2

9. A private physician? 1 2

10. A private dentist? 1 2

The next question asks about arrangements your district may have with organizations or healthcare professionals to provide health services at other sites.

69. Does your district have arrangements with any organizations or healthcare professionals to provide…

Yes No

1. Primary care? 1 2

2. Prescriptions for medications? 1 2

3. Seasonal influenza vaccine? 1 2

4. Immunizations other than seasonal influenza? 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

14. Prenatal care or prenatal care referrals? 1 2

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

16. Contraceptives? 1 2

The next question asks about services provided at other sites to students in one‑on‑one or small group sessions.

70. Does your district have arrangements with any organizations or healthcare professionals to provide…

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

71. Currently, does someone in your district oversee or coordinate school health services?

Yes 1

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

72. Are you this person?

Yes 1

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

73. Who do you work for?
    MARK ALL THAT APPLY

School district 1

Local health department 2

Other (Specify) 3

The last set of questions asks about your educational background.

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

High school or GED 1 That is the last question.
Thank you very much for taking the time to complete this questionnaire.

Associate’s degree 2

Undergraduate degree 3

Master’s degree 4

Doctoral degree 5

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

Nursing 1

Education 2

Other (Specify) 3

IF Q85 IS 2, SKIP TO Q90.

76. Did you have an undergraduate minor?

Yes 1

No 2 SKIP TO THE INSTRUCTIONS BEFORE Q89

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

Nursing 1

Education 2

Other (Specify) 3

IF Q85 IS 3, SKIP TO Q90.

78. 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 (Specify) 7

79. 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

80. Do you have…

Yes No N/A

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

2. A state school nurse certification? 1 2 3

3. An ANCC certification? 1 2

4. Any other certifications? (Specify) 1 2

Thank you very much for taking the time to participate in this study.

If you would like more information about this study or would like clarification of any questions in this questionnaire, please call 800-287-1815.

Health Services District Questionnaire—Public Use Version 0