PERS: Funded District Questionnaire

Promoting Adolescent Health through School-Based HIV Prevention

Att3_Funded District Qnr Items

OMB: 0920-1275

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OMB No: 0920-1275

Exp. Date: XX/XX/XXXX










“Promoting Adolescent Health through School-Based HIV Prevention”





Attachment 3

Funded District Questionnaire Items


















Public reporting burden of this collection of information is estimated to average 2 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: OMB-PRA (0920-1275)





Program Evaluation Reporting System:

Funded District Questionnaire (Component 2)



  1. Currently, does your district provide a list of instructional competencies for staff teaching skills-based health education and sexual health education in grades 6, 7, or 8? If the list of instructional competencies was created or changed more than 6 months ago, please answer NO. (Check YES or NO)


[If no to Q1, skip to Q2]


1A. If yes to Question 1, upload here:


1B. During the past 6 months did the district use the list of instructional competencies to plan or deliver professional development (PD) training(s) for those teaching sexual health education? (Choose one)

  1. Yes, we used the list of instructional competencies to plan and deliver PD training(s)

  2. No, we did not use the list of instructional competencies to plan and deliver PD training(s)

  3. We did not offer PD training(s) in the past 6 months

  4. No, we do not HAVE a list of instructional competencies to plan and deliver PD training(s).


  1. Currently, does your district provide a list of instructional competencies for staff teaching skills-based health education and sexual health education in grades 9, 10, 11, or 12? (Check YES or NO)


[If no to Q2, skip to Q2b]


2A. If yes to Question 2, upload here:


2B. If yes, during the past 6 months did your district use the list of instructional competencies to plan or deliver professional development (PD) training(s) for those teaching sexual health education? If the list of instructional competencies was created or changed more than 6 months ago, please answer NO. (Choose one)

  1. Yes, we used the list of instructional competences to plan and deliver PD trainings

  2. No, we did not use the list of instructional competences to plan and deliver PD trainings

  3. We did not offer PD training(s) during the past 6 months

  4. No, we do not HAVE a list of instructional competencies to plan and deliver PD training(s).


  1. Currently, does your district have a skills-based health education course requirement, including HIV, other STDs, or pregnancy prevention topics, in the following grades or range of grades? (Check YES or NO for each)

    1. Grade 6

    2. Grade 7

    3. Grade 8

    4. Grade 9

    5. Grade 10

    6. Grade 11

    7. Grade 12

    8. Middle School (no specific grade)

    9. High School (no specific grade)


  1. Currently, does your district have an approved scope and sequence to guide health education that includes specific sexual health education learning outcomes and content for grades 6, 7, or 8? If the approved scope and sequence was created or changed more than 6 months ago, please answer NO. (Check YES or NO)


[If no to Q4, skip to Q6]


4A. If yes, upload here:


  1. Currently, has your district identified at least one sexual health education instructional program that is consistent with the approved health education scope and sequence for grades 6, 7, or 8? (Check YES or NO)

    1. Yes

    2. No

    3. We do not have an approved health education scope and sequence for grades 6, 7, or 8.



  1. Currently, does your district have an approved scope and sequence to guide health education that includes specific sexual health education learning outcomes and content for grades 9, 10, 11, or 12? If the approved scope and sequence was created or changed more than 6 months ago, please answer NO. (Check YES or NO)



[If no to Q6, skip to Q7]


6A. If yes, upload here:


  1. Currently, has your district identified at least one sexual health education instructional program(s) that is consistent with the approved health education scope and sequence for grades 9, 10, 11, or 12? (Check YES or NO)

    1. Yes

    2. No

    3. We do not have an approved health education scope and sequence for grades 9, 10, 11, or 12.



  1. During the past 6 months, did your district review the extent to which one or more sexual health education instructional programs delivered in grades 6, 7, or 8 are skills- based? (Choose one)

  1. Yes, we completed a review during the past 6 months

  2. No, we completed a review prior to the past 6 months

  3. No, we are currently conducting a review

  4. No, we have not completed a review


8A. Which of the following tools were used to review the extent to which the sexual health education instructional program(s) was skills-based? (Check YES or NO for each).

  • CDC’s Health Education Curriculum Analysis Tool (HECAT, 2012)

  • Tools to Access the Characteristics of Effective Sex and STD/HIV Education Programs (TAC)

  • No tool was used in the review

  • No review has been conducted

  • Other (specify):


  1. During the past 6 months, did your district review the extent to which one or more sexual health education instructional programs delivered in grades 9, 10, 11, or 12 are skills-based? (Choose one)

  1. Yes, we completed a review during the past 6 months

  2. No, we completed a review prior to the past 6 months

  3. No, we are currently conducting a review

  4. No, we have not completed a review

9A. Which of the following tools were used to review the extent to which the sexual health education instructional program was skills-based? (Check YES or NO for each).

  • CDC’s Health Education Curriculum Analysis Tool (HECAT, 2012)

  • Tools to Access the Characteristics of Effective Sex and STD/HIV Education Programs (TAC)

  • No tool was used in the review

  • No review has been conducted

  • Other(specify):


  1. Currently, does your district recommend or require priority schools to assess the ability of students to do the following in grades 6, 7, or 8? (Check YES or NO for each)

  1. Comprehend concepts important to prevent HIV, other STD, and pregnancy

  2. Analyze the influence of family, peers, culture, media, technology, and other factors on sexual risk behaviors

  3. Access valid information, products, and services to prevent HIV, other STD, and pregnancy

  4. Use interpersonal communication skills to avoid or reduce sexual risk behaviors

  5. Use decision-making skills to prevent HIV, other STD, and pregnancy

  6. Set personal goals that enhance health, take steps to achieve these goals, and monitor progress in achieving them

  7. Practice health-enhancing behaviors to avoid or reduce HIV, other STD, and unintended pregnancy

  8. Advocate for self and others to avoid or reduce sexual risk behaviors



  1. Currently, does your district recommend or require priority schools to assess the ability of students to do the following in grades 9, 10, 11, or 12? (Check YES or NO for each)

  1. Comprehend concepts important to prevent HIV, other STD, and pregnancy

  2. Analyze the influence of family, peers, culture, media, technology, and other factors on sexual risk behaviors

  3. Access valid information, products, and services to prevent HIV, other STD, and pregnancy

  4. Use interpersonal communication skills to avoid or reduce sexual risk behaviors.

  5. Use decision-making skills to prevent HIV, other STD, and pregnancy

  6. Set personal goals that enhance health, take steps to achieve these goals, and monitor progress in achieving them

  7. Practice health-enhancing behaviors to avoid or reduce HIV, other STD, and unintended pregnancy

  8. Advocate for self and others to avoid or reduce sexual risk behaviors



  1. Currently, does your district provide the following to those teaching sexual health education in grades 6, 7, or 8? (Check YES or NO for each)

  1. An approved health education scope and sequence that includes learning objectives, outcomes, and content to guide sexual health education instruction

  2. A written health education instructional program that includes goals, objectives, learning outcomes, and content addressing sexual health education

  3. Teacher pacing guides for sexual health education instruction

  4. Teaching resources (e.g., lesson plans, handouts) to support sexual health education instruction

  5. Strategies that are age-appropriate, relevant, and actively engage students in learning

  6. Methods to assess student knowledge and skills related to sexual health education




  1. Currently, does your district provide the following to those teaching sexual health education in grades 9, 10, 11, or 12? (Check YES or NO for each)

  1. An approved health education scope and sequence that includes learning objectives, outcomes, and content to guide sexual health education instruction

  2. A written health education instructional program that includes goals, objectives, learning outcomes, and content addressing sexual health education

  3. Teacher pacing guides for sexual health education instruction

  4. Teaching resources (e.g., lesson plans, handouts) to support sexual health education instruction

  5. Strategies that are age-appropriate, relevant, and actively engage students in learning

  6. Methods to assess student knowledge and skills related to sexual health education

  1. Currently, does your district have a School Health Advisory Council (SHAC), or similar advisory committee/council, that regularly provides district-level recommendations and guidance to improve health and sexual health education instructional programs, practices, and policies for students and staff? If the list of individuals serving the SHAC including member roles was created or changed more than 6 months ago, please answer NO. (Check YES or NO)



[If no to Q14, skip to Q15]



14A. If yes, upload a list including member roles (e.g., school nurse, teacher, parent, district health coordinator, or community member) serving on the SHAC or similar advisory committee/council. Upload here:



  1. During the past 6 months, did your district use any of the following strategies to engage parents in sexual health education? (Check YES or NO for each)

    1. Involve parents as members on the School Health Advisory Council (SHAC) or similar advisory committee/council

    2. Involve parents in decision making about health education instructional programs, inclusive of sexual health education content, with the help of tools such as Health Education Curriculum Analysis (HECAT)

    3. Involve parents in instructional activities that directly relate to implementing sexual health education instructional programs (e.g., homework assignments, classroom-based volunteer opportunities

    4. Other (specify):



  1. During the past 6 months, did your district provide or provide funding for professional development on any of the following sexual health education topics? (Check YES or NO)

    1. Understand current district policy or guidance regarding sexual health education instructional programs

    2. Build the instructional competencies and skills of those delivering sexual health education

    3. Develop and use a health education scope and sequence that includes learning objectives, outcomes and content for sexual health education

    4. Assess the sexual health education instructional program using the Health Education Curriculum Analysis Tool (HECAT) or a similar assessment tool.

    5. Select an appropriate sexual health education instructional program

    6. Deliver a specific sexual health education instructional program with appropriate fidelity

    7. Make appropriate adaptations to the sexual health education instructional program

    8. Develop interactive, relevant teaching tools and resources to engage students in sexual health education

    9. Incorporate sexual health service related skills-based instruction into sexual health education

    10. Strategies to engage parents in sexual health education  



  1. During the past 6 months, did your district receive technical assistance on sexual health education from Advocates for Youth at least once? (Check YES or NO)



  1. Currently, does your district have a school-based health center? (Check YES or NO)



  1. What is the focus of your sexual health services work?

    1. Only referrals

    2. Only school-based health centers

    3. Both referrals & school-based health centers



  1. Currently, does your district have the following components for referral of students to sexual health services? (Check YES or NO for each. If your district does not focus on referring students to sexual health services check YES to item A and NO to items B-H)

  1. Not applicable. The focus of our sexual health services work is only school-based health centers.

  2. Policy and procedures about how to make referrals

  3. Procedures separate from policy to make referrals

  4. Identification and training of designated school staff to make referrals

  5. Referral guide

  6. Communications and marketing to increase awareness and use of referrals

  7. Monitoring and evaluation of the referral system

  8. Management and oversight strategy for the referral system



  1. Currently, has your district identified sexual health services referrals for students that provide services specifically for gay, lesbian, bisexual, and transgender adolescents? (If your district is not focusing on referrals, please check Not Applicable)

    1. Yes

    2. No

    3. Not Applicable



  1. During the past 6 months, did your school-based health center(s) make the following services available to students: (Check YES or NO for each. If your district does not focus on school-based health centers check YES to item A and NO to items B-H.)

  1. Not applicable. The focus of our sexual health services work is only referrals.

  2. HIV testing

  3. STD testing

  4. Pregnancy testing

  5. Provision of condoms

  6. Provision of condom-compatible lubricants (i.e., water- or silicone-based)

  7. Provision of contraceptives other than condoms (e.g., birth control pill, birth control shot, intrauterine device [IUD])

  8. Human papillomavirus (HPV) vaccine administration



  1. In the past 6 months what was the total number of HIV tests, Chlamydia tests, and pregnancy tests that were provided at SBHCs that serve any of your priority schools? (Enter the number of tests. If your district does not focus on school-based health centers, enter “N/A”.)



  1. During the past 6 months, did at least one school-based health center(s) in your district implement a quality improvement process that includes a set of systematic and continuous actions to increase youth-friendly practices and services? (If your district does not focus on school-based health centers, choose Not Applicable.)

    1. Yes

    2. No

    3. Not Applicable



  1. During the past 6 months, did your district conduct or allow other organizations to conduct a school-based STD screening event or some other STD testing like regular mobile van testing? (Check YES or NO)



  1. During the past 6 months, did your district provide or provide funding for professional development to school health staff on each of the following topics? (Check YES or No for each)

a. Assessing the capacity of schools to implement activities to increase student

access to sexual health services

b. Best practices for adolescent sexual health services provision including

making services youth-friendly

c. Basic sexual health overview including community specific information about

STD, HIV and unplanned pregnancy rates and prevention strategies

d. Recommended adolescent sexual health services

e. Laws and policies including minor consent for sexual health services

f. Incorporating sexual health service related skills-based instruction into sexual

health education

g. Importance of maintaining student confidentiality for sexual health services

h. How to provide parents with information about adolescent sexual health

services

i. How to make successful referrals of students to sexual health services

j. How to make school-based STD-testing events available

k. How to implement school-wide, student-led marketing campaigns

l. How to implement condom availability programs

m.How to ensure sexual health services are inclusive of LGBT students

n. How to create or use a student referral guide to sexual health services

o. Collaborating with SBHCs to improve student use and/or quality of sexual

health services

p. Assessing the capacity of districts to implement activities to increase student

access to sexual health services



  1. During the past 6 months, which types of school or school health staff attended professional development events on sexual health services that were provided or that were funded by your district? (Check YES or NO for each)

  1. School nurses

  2. School counselors

  3. SBHC staff

  4. Wellness Center staff

  5. Health paraprofessionals

  6. Social workers

  7. Teachers

  8. School staff

  9. School administrators

  10. Other:____________



  1. During the past 6 months, did your district receive technical assistance on sexual health services from Advocates for Youth at least once? (Check YES or NO)



  1. During the past 6 months, did your district receive technical assistance on sexual health services from American Academy of Pediatrics at least once? (Check YES or NO)



  1. Currently, does your district recommend or require staff at priority schools receive annual professional development on any of the following: (Check YES or NO for each)

  • Classroom management best practices (e.g., social skills training, environmental modification, conflict resolution and mediation, and behavior management)

  • How to support lesbian, gay, bisexual, and transgender (LGBT) students (e.g., bystander intervention skills, implementing safe spaces, use of inclusive language)

  • Additional professional development designed to strengthen safe and supportive environments


  1. Currently, does your district recommend or require schools disseminate any of the following resources to parents? (Check YES or NO for each)

    • Information to support parent- adolescent communication about sex

    • Information to support parent- adolescent communication about topics other than sex

    • Information about how to monitor their teen (e.g., setting parental expectations, keeping track of their child, responding when their child breaks the rules)

    • Information to support 1-on-1 time between adolescents and their health care providers


  1. Currently, does your district recommend or require priority schools implement any of the following school-based positive youth development programs? (Check YES or NO for each)

  • A program in which students receive service-learning opportunities, that is community service designed to meet specific learning objectives

  • A program in which family or community members serve as role models to students or mentor students

  • Some other type of school-based positive youth development program


  1. Currently, does your district recommend or require priority schools connect students to any of the following community-based positive youth development programs? (Check YES or NO for each)

  • A program in which students receive service-learning opportunities, that is community service designed to meet specific learning objectives

  • A program in which family or community members serve as role models to students or mentor students

  • Some other type of community-based positive youth development program


  1. Currently, does your district recommend or require middle schools to have a student-led club that supports LGBT youth (often known as Gay-Straight Alliances or Genders and Sexualities Alliances)? (Check YES or NO)


  1. Currently, does your district recommend or require high schools to have a student-led club that supports LGBT youth (often known as Gay-Straight Alliances or Genders and Sexualities Alliances)? (Check YES or NO)



  1. During the past 6 months, did your district receive technical assistance on safe and supportive environments from Children’s Hospital of Los Angeles at least once? (Check YES or NO)



  1. During the past 6 months, did your district receive technical assistance on safe and supportive environments from American Psychological Association at least once? (Check YES or NO)



  1. What, if any, additional program activities were not reflected in your answers to the questions above?



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