Attachment B – School Surveillance GenIC
Form Approved
OMB Control No.: 0920-1154
Expiration date: 01/31/2023
Public reporting burden of this collection of information is estimated to average 6 hours 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, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-1154
Collected by School Nurses in Pilot Sites
User Demographics (Entered at a point in time, 1x/year)
First Name
Last Name
Highest level of education achieved:
Options:
Doctorate in nursing
Doctorate in other field
MS in nursing
Med
MPH
Masters in other field
BS nursing
BS/BA other field
Associates degree nursing
Associates degree in other field
Diploma in nursing
Technical program/certificate
High school diploma/GED
Certifications:
Options:
National Certification as a school nurse
State Certified/credentialed as a school nurse
School nurse teacher
State teacher certification
Other
School Demographic Data (Entered at a point in time, 1x/year)
Percentage of students on free/reduced lunch
Percentage of student where English is not the primary language
Which of the following best describes your current model of practice in this school (select one).
RN provides direct care to students on a daily basis with the assistance of an LPN or UAP (in one building)
RN provides direct care to students on a daily basis (one nurse covering more than one building with no health clerk, aide, secretary or UAP covering with RN not present
RN who oversees health clerks or aides who work in the health office(s) (one nurse covering more than one building)
RN who oversees one or more LPNs as a team to provide care (one nurse covering more than one building)
RN who trains unlicensed personnel (including secretaries) to perform routine procedures needed in the schools (one nurse covering more than one building
Other
Official number of enrolled students in the school
Tell us about your school nurse workforce. First, we would like to know about Registered Nurses (RNs):
Total number of RN FTEs with an assigned caseload providing direct services with a designated case load
Total number of supplemental/float RN FTEs
Total number of RNs with special assignment FTEs
Total number of RN FTEs providing administrative or supervisory school health services
*Ideally, as a data check: electronic platform would total all the numbers entered above and show: Total number of RN FTES
Do you have LPN/LVNs working in schools? Yes or No. [IF NO, then do not need to complete the following questions.]
Total number of LPN/LVN FTEs with an assigned caseload providing direct services with a designated case load:
Total number of supplemental/float LPN/LVN FTEs
Total number of LPN/LVN with special assignment FTEs
Total number of LPN/LVN FTEs providing administrative or supervisory school health services
Do you have health aides (non-RN, non-LPN/LVN) in your school/state? Yes or No. [IF NO, then do not need to complete the following questions.]
Total number of health aide (non-RN, non-LPN/LVN) FTEs with an assigned caseload providing direct health services (e.g. give medication, staff health office, perform specific health procedures):
Total number of supplemental/float health aide (non-RN, non-LPN/LVN) FTEs
Total number of health aide (non-RN, non-LPN/LVN) with special assignment FTEs
Total number of assistant FTEs providing administrative support services to RNs or LPNS/LVNs
Chronic Conditions (Entered at a point in time, 1x/year)
Did you collect chronic condition data for this year? Yes or No. [IF NO, then do not need to complete the following questions.]
Did you track the number of students chronically absent this year? Yes or No [IF NO, then do not need to complete the following questions.]
If yes to both of the questions above, list chronic conditions and number of students chronically absent as you currently have them.
If yes to chronic conditions only, answer just the questions about number of students with chronic conditions.
Chronic Condition Data Points (Entered at a point in time, 1x/year. Collected by grade or by school.)
Total number of students who are chronically absent:
Date data entered
Number of students with a diagnosis of asthma from a health care provider
Of this number, how many are chronically absent?
Number of students with a diagnosis of Type 1 Diabetes from a health care provider
Of this number, how many are chronically absent?
Number of students with a diagnosis of Type 2 Diabetes from a health care provider
Of this number, how many are chronically absent?
Number of students with a diagnosis of a seizure disorder from a health care provider
Of this number, how many are chronically absent?
Number of students with a diagnosis of life-threatening allergy from a health care provider
Of this number, how many are chronically absent?
Number of students with a diagnosis of ME/CFS from a health care provider
Of this number, how many are chronically absent?
Health Office Visit Outcomes (Entered at a point in time, 1x/year. Collected by grade or by school.)
Number of student encounters/health office visits to RN resulting in the student returning to class or staying in school during the school year
Number of student encounters/health office visits to the RN resulting in 911 being called or regionally appropriate equivalent during the school year
Number of student encounters/health office visits to the RN resulting in the student being sent home during the school year
Number of student encounters/health office visits to LPN/LVN resulting in the student returning to class or staying in school during the school year
Number of student encounters/health office visits to the LPN/LVN resulting in 911 being called or regionally appropriate equivalent during the school year
Number of student encounters/health office visits to the LPN/LVN resulting in the student being sent home during the school year
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Erin Maughan |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |