0920-22HN Attachment C_SBAS_Site Baseline Survey

Attachment C

OMB Control No.: 0920-XXXX

Expiration date: XX/XX/XXXX

Site Baseline Survey

Public reporting burden of this collection of information is estimated to average 10 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, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX

Site Baseline Survey

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Thank you for being willing to participate in the school nurse led active surveillance process! We sincerely appreciate it. The purpose of this short survey is to get a baseline understanding of where you are and what your needs are so we can plan and support you in this process.


This should only take a few minutes to complete.  Thank you!

Is chronic absenteeism currently being tracked in your district (or at least the school you will be in for this process)?

• Yes (if yes, what is the definition being used for chronically absent)? ________________________________________________

• No

Are reasons (i.e. health-related) for chronic absenteeism tracked in your district (or at least the chosen school)?

• Yes

• No

What electronic system is used for tracking data such as absenteeism in your district? (If a different system is used for health than for academic student tracking-please indicate both)

________________________________________________________________

Does your district have policies related to any of these topics? (check all that apply)

• Sharing data outside of district

• Process for addressing chronic absenteeism

• Human subject review committee (or institutional review board)

• Other policy that may impact this project (please describe) ________________________________________________

This project involves several different skills related to data collection, school nursing process, chronic conditions, and chronic absenteeism. Everyone has different experiences with and knowledge levels of these topic-please rate how knowledgeable you are in the following skills/topics (this is just so we know how to organize trainings. NO judgement :)...)

	Feel like a novice (need a more in-depth training)	Moderately knowledgeable (review training would be helpful)	Very Knowledgeable (don't need training)
Collecting data
Chronic absenteeism-what is it?
Chronic absenteeism-school nurses role in addressing it?
Chronic absenteeism-school-wide approach
Addressing complex social determinants of health
Motivational Interviewing
Myalgic encephalomyelitis/ chronic fatigue syndrome
Developing nursing care plans

What day/time of the week that would be best to hold a 1 hour community of practice call during the month of February and March?

	9-10am EST	1-3pm EST	4-6pm EST
Monday
Tuesday
Wednesday
Thursday
Friday

Are there any dates that should be avoided (i.e. spring break, school holiday, staff meeting)?

________________________________________________________________

Please indicate the name of the  nurse who will be participating in this project.

________________________________________________________________

What is the nurse's email?

________________________________________________________________

What is the nurse's phone number?

________________________________________________________________

Is there anyone else I should include in emails about these trainings/meetings? If so-please provide their name and email.

________________________________________________________________

Any other concerns or information that you would like to share?

________________________________________________________________

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