Form Approved
OMB No: 0920-0445
Expiration Date: 10/31/2002

Health Services
School Questionnaire

Health Services
School Questionnaire

                                                                 Questions 

Standard Health Services	1 - 59
   Student Health Records	1
   Required Immunizations and Vaccinations	2 - 5
   Procedures for Student Medication	6 - 8
   Approach to People with HIV/AIDS	9-13
   Staffing Characteristics	14 - 33
   Facilities and Equipment	34 - 35

   Provision of Health Services	36 - 59
      Illness and Injury	36 - 41
      Screening	42 - 44
      Other Services	45 - 59

Services Provided at Other Sites	60 - 62
   Providers	60 - 61
   Services	62

Respondent Background	63 - 78

School-Based Health Center Services	80 - 90
   Program Organization	80 - 82
   Staffing Characteristics	83
   Facilities and Equipment	84
   Provision of Health Services	85 - 89
   Billing	90

Public reporting burden for this collection of information is estimated to average 45 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-24, Atlanta, GA  30333; Attention PRA (0920-0445).

Special Instructions

This questionnaire will be administered using Computer Assisted Personal Interviewing.  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 dont know), 3) navigate complex skip patterns,   4) access information that was provided in previous contact with a school, and 5) perform other useful functions. The programming specifications for the interview are not included in this printed version of the questionnaire.

If you would like more information about this study or would like clarification of any questions in this questionnaire, please call Tim Smith at 1-800-647-9664, extension 6095.

Standard Health Services

What is your job title at the school? (In which role do you spend more time?)

1) Principal	11)	Guidance Counselor
2)	Asst. Principal/Other School	12)	Social Worker
Administrator	13)	Psychologist
3) School Secretary	14)	Other Mental Health/Social Services
4) Physical Ed Teacher		Provider
5) Athletic Director	15)	Nurse
6)	Health Ed Teacher	16)	Health Aide
7) Other Teacher	17)	Physician
8)	Food Service Manager	18)	Other Health Services Provider
9) Commercial Food Service Provider	19)	SBHC Health Services Staff
10) Other School Food Service Staff	20)	SBHC Mental Health/Social Services Staff
50)	Other Staff

SHOW CARD 1

1. As I read the items on this card, please tell me if each is kept in any type of student record. 

        	Yes	No

a. A physical health history?	1	2
b. An emotional or mental health history?	1	2
c. Tuberculosis skin test results?	1	2
d. Screening records?	1	2
e. Immunization or vaccination status?	1	2
f. Medication needs?	1	2
g. Dietary needs or restrictions?	1	2
h. Physical activity restrictions?	1	2
i. Emergency contact information?	1	2
j. An authorization for emergency treatment?	1	2
k. Insurance coverage information?	1	2

     If this is a middle, junior, or senior high school skip to Q5.

2. The next questions are about immunizations and vaccinations.  Please tell me if each of the following is required for entry into kindergarten or first grade.

        	Yes	No

a. A measles-containing vaccine, such as MMR?	1	2
b. A polio vaccine, such as OPV?	1	2
c. Diphtheria?	1	2
d. Tetanus?	1	2
e. Haemophilus influenzae type b or Hib?	1	2
f. Influenza?	1	2
g. Hepatitis B?	1	2
h. Chicken pox or varicella?	1	2
i. Pneumococcal?	1	2

3. Are students who have not received the required school-entry immunizations or vaccinations immediately excluded from attending classes?

Yes	1	==>	Skip to Q6
     No	2

4. How many days can students who have not received the required school-entry immunizations or vaccinations attend class?

_____	Days

5. The next questions are about immunizations and vaccinations.  Please tell me if each of the following is required for entry into this school.

        	Yes	No

a. A second measles-containing vaccine?	1	2
b. Hepatitis A?	1	2
c. Hepatitis B?	1	2
d. Chicken pox or varicella?	1	2
e. Tetanus?	1	2

6. Is there a system in place for notifying teachers when any of their students have...

        	Yes	No

a. HIV (human immunodeficiency virus) or AIDS 
        (acquired immunodeficiency syndrome)?	1	2
b. Any other chronic health condition, such as diabetes 
        or asthma?	1	2
c. Any other communicable health condition, such as 
        measles or chicken pox?	1	2
     

SHOW CARD 2

7. Looking at this card, please tell me what documentation is required before school faculty or staff may administer prescription drugs to a student.
     MARK ALL THAT APPLY.

     Written instructions from the physician or prescriber	1
     Written request from the parent or guardian	2
     Written information on possible side-effects	3
School faculty and staff are not allowed to administer any
        medication	4

8. I am going to read a list of medications that might be required by students while at school.  At this school, would a student ever be permitted to self-medicate using...

        	Yes	No

a. A prescription inhaler?	1	2
b. Epinephrine?	1	2
c. Insulin or other injected medications?	1	2
d. Any other prescribed medication?	1	2
e. Any over-the-counter medications?	1	2

     My next questions are about students and staff who have HIV or AIDS. 

9. Has this school adopted a policy on students who have HIV or AIDS?

     Yes	1
No	2	==>	Skip to Q11

10. Does the policy state that students who have HIV or AIDS be allowed to...

        	Yes	No

a. Attend classes like other students as long as they 
        are able?	1	2
b. Participate in school sports like other students as long 
        as they are able?	1	2
c. Participate in any other school activities as long as they 
        are able?	1	2

11. Has this school adopted a policy on faculty and staff who have HIV or AIDS?

     Yes	1
No	2	==>	Skip to Q13

12. Does the policy state that faculty and staff who have HIV or AIDS be allowed to continue working as long as they are able?

     Yes	1
     No	2

Most of the questions that I ask during this interview focus on standard health services, meaning those health services offered when needed to students at the school, usually by a school nurse.  By health services, I mean services such as first aid, administration of medications, identification and treatment of acute illnesses, or immunizations or vaccinations. 

13. But first, it would be helpful to know if there is a school-based health center at this school.  Please look at the definition card to see what I mean by a school-based health center.  Is there a school-based health center at this school?

     Yes	1
No	2

The next questions are about school nurses.  By school nurse, I mean any nurse, whether employed by the school, district, or health department, who provides any standard health services to students at this school.  Please include both contracted providers and regular school staff.

14. Is there a part-time or full-time school nurse who provides standard health services to students at this school?
     
     Yes	1
No	2	==>	Skip to Q22 

15. How many part-time or full-time school nurses provide standard health services to students at this school?

_____	Nurses

16. I would like to find out about the time that each nurse spends at this school.  During the past 30 days, how many hours per week has the nurse spent at this school?

     Nurse 1 _____  Hours/week
     Nurse 2 _____  Hours/week
     Nurse 3 _____  Hours/week
     Nurse 4 _____  Hours/week

17. Does the school nurse participate in the development of Individualized Education Plans, or IEPs, when indicated?

     Yes	1
     No	2
     
18. Does the school nurse participate in the development of Individualized Health Plans, or IHPs?

     Yes	1
     No	2

     
19. During the past 12 months, has the school nurse talked to or taught ...HSB090

        	Yes	No

     Answer a-c if this is a middle, junior, or senior high school.
a. A health education class at this school?	1	2
b. A physical education class?	1	2
c. A biology or other science class?	1	2
     Answer d-e if this is an elementary school.
d. Students at this school as part of a health education
        lesson or unit?	1	2
e. Students at this school as part of a physical education
        unit or class?	1	2

20. During the past 12 months, has the school nurse worked on standard school health services activities with...
  
        	Yes	No

a. Health education staff from this school?	1	2
b. Physical education staff from this school?	1	2
c. Food service staff?	1	2
d. Mental health or social services staff?	1	2

21.	During the past 12 months, has the school worked on standard school health services activities for students with staff or members from...

        	Yes	No

a. A local health department?	1	2
b. A local hospital?	1	2
c. A local mental health or social services agency?	1	2
d. A health organization, such as the American Heart
        Association or the American Red Cross?	1	2
e. A local college or university?	1	2
f. A local business?	1	2

22.	At this school, what is the minimum level of education required for a newly-hired school nurse?

     Associates degree in nursing	1
     Associates degree in some other field	2
     Undergraduate degree in nursing	3
     Undergraduate degree in some other field	4
     Graduate degree in nursing	5
     Graduate degree in some other field	6
     No requirement	7

23.	Is a newly-hired school nurse required to have...

        	Yes	No

a. A licensed practical nurses (LPNs) license?	1	2
b. A registered nurses (RNs) license?	1	2

24.	Is a newly-hired school nurse required to be state certified as a school nurse?

     Yes	1
No		2

25. Is there a part-time or full-time school physician who provides standard health services to students at this school?

Yes	1	
No		2 	

26. Is there a physician who can be called to consult as needed during the school day?
     
Yes	1
     No		2

     If there is not a part-time or full-time school physician (Q25 is No), skip to Q29.

27. How many part-time or full-time school physicians provide standard health services to students at this school?

_____	Physicians

28. I would like to find out about the time that each physician spends at this school.  During the past 30 days, how many hours per week has the physician spent at this school?

     Physician 1  _____  Hours/week
     Physician 2  _____  Hours/week
     Physician 3  _____  Hours/week
     Physician 4  _____  Hours/week

29. Are there part-time or full-time health aides who help provide standard health services to students at this school?

     Yes	1
No	2	==>	Skip to Q31

30. Are health aides at this school required to work under the supervision of a nurse or physician at all times?  

     Yes	1
     No	2

31. During the past 12 months, have the health services staff worked on standard school health services activities with...

        	Yes	No

a. Health education staff from this school?	1	2
b. Physical education staff from this school?	1	2
c. Food service staff?	1	2
d. Mental health or social services staff?	1	2

32.	During the past 12 months, have the health services staff worked on standard school health services activities with staff or members from...

        	Yes	No

a. A local health department?	1	2
b. A local hospital?	1	2
c. A local mental health or social services agency?	1	2
d. A health organization, such as the American Heart
        Association or the American Red Cross?	1	2
e. A local college or university?	1	2
f. A local business?	1	2

33.	During the past 12 months, has this school...

        	Yes	No

a. Provided families with information on the standard 
        school health services program?	1	2
b. Met with a parents organization, such as the PTA, to
        discuss the standard school health services program?	1	2
c. Invited family members to tour the standard school 
        health services facilities?	1	2
        
34. Next, I am going to read a list of facilities and equipment that may be available for health services staff in this school to use.HSB044  Does this school have...

        	Yes	No

a. A sick room, nurses office, or other area reserved for
        providing standard health services?	1	2
b. An answering machine or voice mail reserved for 
        health services staff?	1	2
c. A refrigerator reserved for standard health services?	1	2
d. A medical supply cabinet with a lock?	1	2
e. A separate medicine cabinet with a lock?	1	2
f. An exam table?	1	2
g. A scale?	1	2
h. A blood pressure gauge and cuff?	1	2
i. A portable first aid kit?	1	2
j. A microscope?	1	2
k. An otoscope-ophthalmoscope?	1	2
l. A peak-flow meter, not just for a specific individuals 
        use?	1	2
m. A glucose meter, not just for a specific individuals use?	1	2
n. A scoliometer?	1	2
o. A tympanometer?	1	2
p. Hemoglobin or hematocrit level test equipment?	1	2
q. A nebulizer, not just for a specific individuals use?	1	2
r. An audiometer?	1	2
s. A stadiometer, measuring tape, wall chart or anything 
        else to measure height?	1	2
t. A vision tester, eye chart, cards, or anything else to 
        measure vision?	1	2

35.	Are the supplies needed to apply universal precautions, including disposable latex gloves,
      antiseptic towelettes, and bandages, available...

        	Yes	No

a.	In all classrooms?	1	2
b. In the gymnasium, on playgrounds, or on playing fields?	1	2
c. On school buses or in other vehicles used to transport
        students?	1	2
        
36.	The next questions are about serious injuries meaning injuries requiring EMS response or
 immediate care by a physician or other health care professional, and the loss of at least a half day of school.  What does this school generally do after a student is seriously injured on school property?  Does this school...

        	Yes	No

a. Notify the students parents or guardians?	1	2
b. Notify the students teachers?	1	2
c. Report the incident to the state or local health 
        department?	1	2
d. Write an injury report?	1	2

If this school does not write an injury report after a student is seriously injured (Q36d is No), skip to Q40.

37. Does this school have a standard student injury report form?

     Yes	1
No	2	==>	Skip to Q40

SHOW CARD 3

38. Looking at this card, please tell me what information is recorded on student injury reports.
     MARK ALL THAT APPLY.

     Location where injury occurred (e.g., a playground, a
         field, a hallway, a stairway)	1
     Activity during which injury occurred (e.g., baseball,
         sitting, throwing)	2
     Nature of injury (e.g., bruise, burn)	3
     School staff who were present when the injury occurred	4
     Cause of injury (e.g., a fall, equipment, another student)	5
     Response of school staff to the injury (e.g., EMS call,
         treatment provided by school staff)	6
     Immediate outcome of injury (e.g., hospitalization, school
         days missed by student)	7
         
39. During the past 12 months, has this school reviewed student injury reports to identify hazardous school areas or activities or ways to prevent injuries?

     Yes	1
     No	2

40. The next questions are about serious illnesses at school, meaning illnesses requiring EMS response or immediate care by a physician or other health care professional, and the loss of at least a half day of school.  What does this school generally do after a student experiences a serious illness at school?  Does this school...

        	Yes	No

a. Notify the students parents or guardians?	1	2
b. Notify the students teachers?	1	2
c. Report notifiable diseases to the state or local health 
        department?	1	2
d. Write an illness report?	1	2

If this school does not write an illness report after a student experiences a serious illness (Q40d is No), skip to Q42.
.

41. During the past 12 months, has this school reviewed illness reports to identify ways to prevent further occurrences of serious illness?
     
     Yes	1
     No		2

The next questions ask about student health screenings that might be conducted at this school.  Please think about screenings done in any grade while a student attends this school.

42. Are most students from this school screened at the school for...

        	Yes	No

a. Hearing problems?	1	2
b. Vision problems?	1	2
c. Oral health problems?	1	2
d. Tuberculosis or TB?	1	2
e. Height and weight or body mass?	1	2
f. Scoliosis?	1	2

If this school does not conduct any health screenings for the above listed items (Q42a-f are No), skip to Q45.

43. At this school, in which grades are students usually screened for the items listed in Q42a-f?

a. K	0
b. 1st	1
c. 2nd	2
d. 3rd	3
e. 4th	4
f. 5th	5
g. 6th	6
h. 7th	7
i. 8th	8
j. 9th	9
k. 10th	10
l. 11th	11
m. 12th	12

SHOW CARD 4

44. Looking at this card, please tell me what the school does when a students screening indicates a potential problem.
     MARK ALL THAT APPLY.

     Notify the students parents or guardians	1
     Notify the students teachers	2
     None of the above	3

     If students from this school are screened for tuberculosis (Q42d is Yes), answer Q44x.  Otherwise, skip to Q45.

44x.	Does this school notify the state or local health department when a students tuberculosis or TB screening indicates a potential problem?

     Yes	1
     No		2

SHOW CARD 5

45. As I read the list of services printed on this card, please tell me if each is provided when needed to students as part of standard health services at this school.

        	Yes	No

a. Is first aid provided?	1	2
b. CPR (Cardiopulmonary resuscitation)?	1	2
c. Administration of medications?	1	2
d. Prescriptions for medications?	1	2
e. Immunizations or vaccinations?	1	2
f. Identification or treatment of acute illnesses?	1	2
g. Identification or treatment of chronic illnesses?	1	2
h. Case management for students with chronic health
        conditions, such as asthma or diabetes?	1	2
i. Administration of sports physicals?	1	2
j. Identification of or referrals for dental problems?	1	2
k. Lab tests?	1	2
     Answer l and m if this is a middle, junior, or senior high school.
l. Prenatal care referrals?	1	2
m. Identification or treatment of STDs (sexually 
        transmitted diseases)?	1	2

46. Who provides the services listed in Q45a-m?
     MARK ALL THAT APPLY.

     School Nurse	1
     School Physician	2
     Health aide	3
     Other	4

     Answer Q47 if this is a middle, junior, or senior high school.

47. Does this school make condoms available to any students?

     Yes	1
No		2

Answer Q48 if immunizations or vaccinations are provided at this school (Q45 e is Yes).  Otherwise, skip to Q49.

SHOW CARD 6

48. As I read the list of immunizations and vaccinations on this card, please tell me if each is provided when needed to students as part of standard health services at this school. 

        	Yes	No

a. Is a measles-containing vaccine, such as MMR provided?	1	2
b. A polio vaccine, such as OPV?	1	2
c. Diphtheria?	1	2
d. Tetanus?	1	2
e. Haemophilus influenzae type b or Hib?	1	2
f. Influenza?	1	2
g. Hepatitis A?	1	2
h. Hepatitis B?	1	2
i. Chicken pox or varicella?	1	2
j. Pneumococcal?	1	2

49. The next questions are about medically fragile students who are dependent on nursing services or special technologies to enhance or sustain their lives.
Currently, how many medically fragile students are enrolled at this school?

     _____	Medically fragile students

     If there are no medically fragile students at this school (Q49 is zero), skip to Q 52.

50. Which of the following health services are provided when needed to these medically fragile students as part of standard health services at this school?

        	Yes	No

a. Catheterizations?	1	2
b. Stoma care?	1	2
c. Tube feedings?	1	2
d. Respirator care?	1	2
e. Suctioning?	1	2
f. Tracheostomy care?	1	2

51. Who provides these health services to medically fragile students at this school?
     MARK ALL THAT APPLY.

     School nurse	1
     School physician	2
     Health aide	3
     Other	4

52. At this school, are health services staff required to follow Do Not Resuscitate, or DNR orders?

     Yes	1
No		2

53. Now, please consider all the standard health services that students receive at this school.  Does this school keep records of standard health services that students receive?

    Yes	1
No	2	==>	Skip to Q55

54. During the past 12 months, has this school reviewed health services records to identify students with chronic problems or possible outbreaks at school?	
    
    Yes	1
    No	2
    
55.	During the past 12 months, has this school...
        	Yes	No

a. Collected suggestions from students about the 
        standard health services program?	1	2	
b. Collected suggestions from school staff about the
        standard health services program?	1	2	
c. Collected suggestions from family members of students
        about the standard health services program?	1	2

The next questions ask about other ways that health services staff might help students.  As I ask these questions, please think about the activities of health services staff such as school nurses, physicians, and health aides, or others who provide standard health services at this school. Do not include activities of teachers in the classroom or activities of psychologists, social workers, or guidance counselors. Ill find out about their activities during a different interview.

SHOW CARD 7

56.	As I read the list of services printed on this card, please tell me if each is provided when needed by health services staff to students at the school in one-on-one or small-group discussions.  Do health services staff provide...

        	Yes	No

a. Nutrition and dietary behavior counseling, including 
        weight management?	1	2
     Answer b if this is a middle, junior, or senior high school.
b. Eating disorders prevention?	1	2
c. Physical activity and fitness counseling?	1	2
     Answer d-f if this is a middle, junior, or senior high school.
d. Pregnancy prevention?	1	2
e. HIV prevention?	1	2
f. STD prevention?	1	2
g. Suicide prevention ?	1	2
h. Tobacco use prevention?	1	2
i. Alcohol or other drug use prevention?	1	2
j. Violence prevention, for example bullying, fighting, 
        or homicide?	1	2
k. Accident or injury prevention?	1	2
a. 
57. Who provides the services listed in Q56a-k in one-on-one or small-group discussions?
     MARK ALL THAT APPLY.

     School nurse	1
     School physician	2
     Health aide	3
     Other	4

SHOW CARD 8

58. As I read the list of services printed on this card, please tell me if each is provided when needed by health services staff to students at the school.  Do health services staff provide...

        	Yes	No

     Answer a if this is a middle, junior, or senior high school.
a. Tobacco use cessation?	1	2
b. Alcohol or other drug use treatment?	1	2
c. Crisis intervention for personal problems?	1	2
d. Identification of or counseling for mental or emotional 
        disorders, such as anxiety or depression?	1	2
e. Stress management?	1	2
     Answer f if this is a middle, junior, or senior high school.
f. Eating disorders treatment?	1	2
g. Identification of or referral for physical, sexual, or 
        emotional abuse?	1	2
     Answer h if this is a middle, junior, or senior high school.
h. HIV testing and counseling?	1	2
i. Referrals for after-school programs such as day-care or 
        supervised recreation?	1	2
     Answer j-l if this is a middle, junior, or senior high school.
j. Services for gay, lesbian, or bisexual students?	1	2
k. Referrals for child care for teen mothers?	1	2
l. Assistance with enrolling in WIC or accessing food 
        stamps or food banks ?	1	2
m. Assistance with enrolling in Medicaid or CHIP 
        (Childrens Health Insurance Program)?	1	2
     Answer n if this is a middle, junior, or senior high school.
n. Job readiness skills programs?	1	2
a. 
59. Who provides the services listed in Q58a-n?
     MARK ALL THAT APPLY.

     School nurse	1
     School physician	2
     Health aide	3
     Other	4

Services Provided at Other Sites

This next set of questions asks about health services delivered to students from this school 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 health care 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.

60. Currently, do any organizations or health care professionals have a contract, memorandum of agreement, or other similar arrangement to provide health services to students from this school?

Yes	1
No		2	==>	Skip to Q63

SHOW CARD 9

61. Which of the organizations or health care professionals listed on this card have arrangements to provide health services when needed to students from this school?	
     MARK ALL THAT APPLY.

a. A school-linked health center	1
b. A local health department	2
c. A local hospital	3
d. A local mental health or social services agency	4
e. A university or medical school	5
f. A managed care organization	6
g. A private physician	7
h. A private dentist	8

SHOW CARD 10

62. As I read the list of services printed on this card, please tell me if there are arrangements with any organizations or health care professionals to provide these services when needed to students from this school. 

     	Yes	No

a. Primary care?	1	2
b. Administration of medications?	1	2
c. Prescriptions for medications?	1	2
d. Immunizations or vaccinations?	1	2
e. Identification or treatment of acute illnesses?	1	2
f. Identification or treatment of chronic illnesses?	1	2
g. Case management for students with chronic health
        conditions, such as asthma or diabetes?	1	2
h. Administration of sports physicals?	1	2
i. Dental care or identifying or referring dental problems?	1	2
j. Lab tests?	1	2
     Answer k-l if this is a middle, junior, or senior high school.
k. Prenatal care or prenatal care referrals?	1	2
l. Identification or treatment of STDs?	1	2

Respondent Background

63. Currently, does someone at this school oversee or coordinate standard health services?

     Yes	1
No	2	==>	Skip to Q79

64. Are you this person?

     Yes	1
No	2	==>	Skip to Q79

SHOW CARD 11

65. Looking at this card, please tell me who you work for.
     MARK ALL THAT APPLY.

     School district	1
     This school	2
     A local health department	3
     A local hospital	4
     A local mental health or social services agency	5
     A university or medical school	6
     A managed care organization	7
     Other	8

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

Less than high school	1	==>	Skip to Q73
High school or GED	2	==>	Skip to Q73
Associates degree	3	
Undergraduate degree	4	
     Masters degree	5
     Doctoral degree	6

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

     Nursing	1
     Public health	2
     Biology or other science	3
     Health care administration	4
     Business	5
     Counseling	6
     Psychology	7
     Social work	8
     Education	9
     Other	10

68. Did you have an undergraduate minor?

     Yes	1
     No	2

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

     Nursing	1
     Public health	2
     Biology or other science	3
     Health care administration	4
     Business	5
     Counseling	6
     Psychology	7
     Social work	8
     Education	9
     Other	10

70. In what area or areas was your graduate work?
     MARK ALL THAT APPLY.

     Nursing	1
     Medicine	2
     Public health	3
     Biology or other science	4
     Health care administration	5
     Business	6
     Counseling	7
     Psychology	8
     Social work	9
     Education	10
     Other	11

71. Do you have...

        	Yes	No

a. An LPNs license?	1	2
b. An RNs license?	1	2
c. A medical doctors (MDs) license?	1	2

72. Are you currently certified by a state agency or board to provide health services?

    Yes	1
    No	2

SHOW CARD 12

73. As I read the list of topics on this card, please tell me if you received any staff development on each topic during the past 2 years.  This might include workshops, conferences, continuing education, graduate courses, or any other kind of in-service. 

        	Yes	No

a. First aid?	1	2
b. CPR?	1	2
c. Administration of medications?	1	2
d. Prescriptions for medications?	1	2
e. Immunizations or vaccinations?	1	2
f. Identification or treatment of acute illnesses?	1	2
g. Identification or treatment of chronic illnesses?	1	2
h. Case management for students with chronic health
        conditions, such as asthma or diabetes?	1	2
i. Sports physicals?	1	2
j. Dental problems?	1	2
k. Lab tests?	1	2
l. Prenatal care?	1	2
m. Identification or treatment of STDs?	1	2

74. Which of these topics would you like to receive further staff development on?
     MARK ALL THAT APPLY.

     First aid	1
     CPR	2
     Administration of medications	3
     Prescriptions for medications	4
     Immunizations or vaccinations	5
     Identification or treatment of acute illnesses	6
     Identification or treatment of chronic illnesses	7
     Case management for students with chronic health 
        conditions, such as asthma or diabetes	8
     Sports physicals	9
     Dental problems	10
     Lab tests	11
     Prenatal care	12
     Identification or treatment of STDs	13
     None	14
     
SHOW CARD 13

75. As I read the list of topics on this card, please tell me if you received any staff development on each topic during the past 2 years.  This might include workshops, conferences, continuing education, graduate courses, or any other kind of in-service. 

        	Yes	No

a. Nutrition and dietary behavior counseling, including 
        weight management?	1	2
b. Eating disorders prevention?	1	2
c. Physical activity and fitness counseling?	1	2
d. Pregnancy prevention?	1	2
e. HIV prevention?	1	2
f. STD prevention?	1	2
g. Suicide prevention?	1	2
h. Tobacco use prevention?	1	2
i. Alcohol or other drug use prevention?	1	2
j. Violence prevention, for example bullying, fighting, 
        or homicide?	1	2
k. Accident or injury prevention?	1	2

76. Which of these topics would you like to receive further staff development on?
     MARK ALL THAT APPLY.

     Nutrition and dietary behavior counseling, including 
        weight management	1
     Eating disorders prevention	2
     Physical activity and fitness counseling	3
     Pregnancy prevention	4
     HIV prevention	5
     STD prevention	6
     Suicide prevention	7
     Tobacco use prevention	8
     Alcohol or other drug use prevention	9
     Violence prevention, for example bullying, fighting, 
        or homicide 	10
     Accident or injury prevention	11
     None	12
     
SHOW CARD 14

77. Finally, as I read the list of topics printed on this card, please tell me if you received any staff development on each topic during the past 2 years.  This might include workshops, conferences, continuing education, graduate courses, or any other kind of in-service. 

        	Yes	No

a. Tobacco use cessation? 	1	2
b. Alcohol or other drug use treatment?	1	2
c. Crisis intervention for personal problems?	1	2
d. Identification of or counseling for mental or emotional
        disorders, such as anxiety or depression?	1	2
e. Stress management?	1	2
f. Eating disorders treatment?	1	2
g. Identification of or referral for physical, sexual, or 
        emotional abuse?	1	2
h. HIV testing and counseling?	1	2
i. After-school programs such as day-care or supervised
        recreation?	1	2
j. Services for gay, lesbian, or bisexual students?	1	2
k. Child care options for teen mothers?	1	2
l. Enrolling in WIC or accessing food stamps or food 
        banks?	1	2
m. Enrolling in Medicaid or CHIP (Childrens Health 
        Insurance Program)?	1	2
n. Job readiness skills programs?	1	2

78. Which of these topics would you like to receive further staff development on?
     MARK ALL THAT APPLY.

     Tobacco use cessation	1
     Alcohol or other drug use treatment	2
     Crisis intervention for personal problems	3
     Identification or or counseling for mental or emotional
        disorders, such as anxiety or depression	4
     Stress management	5
     Eating disorders treatment	6
     Identification or or referral for physical, sexual, or 
        emotional abuse	7
     HIV testing and counseling	8
     After-school programs such as day care or supervised 
        recreation	9
     Services for gay, lesbian, or bisexual students	10
     Child care options for teen mothers	11
     Enrolling in WIC or accessing food stamps or food banks	12
     Enrolling in Medicaid or CHIP (Childrens Health 
        Insurance Program)	13
     Job readiness skills programs	14
     None	15

79.	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.

School-Based Health Center Services

This set of questions asks about health services offered to students enrolled in your school-based health center  that is services, including diagnostic and treatment services, offered by nurses, doctors or other health professionals at the health center located on school property.

80.	Who can be enrolled to receive health services at the health center?

        	Yes	No

a. Can students from this school enroll?	1	2
b. Can students from other schools in the community 
        enroll?	1	2

81.	How many hours per week are health services at the health center offered to enrolled students?

_____	Hours/week

SHOW CARD 15

82.	This card shows different times that health services at a health center might be offered. When are they offered to students?
     MARK ALL THAT APPLY.

     Selected days during the school week	1
     Every day during the school week	2
     Saturdays or Sundays during the school session	3
     Evenings during the school session	4
     Vacation or inter-session	5
     Other	6

83.	Who provides health services to students enrolled at the health center?  Is there...

        	Yes	No

a. A registered nurse?	1	2
b. A nurse practitioner?	1	2
c. A clinical nurse specialist?	1	2
d. A physicians assistant?	1	2
e. A health aide?	1	2
f. A physician?	1	2
g. A dentist?	1	2
h. A nutritionist or registered dietician?	1	2

84.	Does your health center have...

        	Yes	No

a. A sick room, nurses office, or other area reserved for
        providing health services?	1	2
b. An answering machine or voice mail reserved for health 
center staff?	1	2
c. A refrigerator reserved for health services?	1	2
d. A medical supply cabinet with a lock?	1	2
e. A separate medicine cabinet with a lock?	1	2
f. An exam table?	1	2
g. A scale?	1	2
h. A blood pressure gauge and cuff?	1	2
i. A portable first aid kit?	1	2
j. A microscope?	1	2
k. An otoscope-ophthalmoscope?	1	2
l. A peak-flow meter, not just for a specific individuals 
        use?	1	2
m. A glucose meter, not just for a specific individuals use?	1	2
n. A scoliometer?	1	2
o. A tympanometer?	1	2
p. Hemoglobin or hematocrit level test equipment?	1	2
q. A nebulizer, not just for a specific individuals use?	1	2
r. An audiometer?	1	2
s. A stadiometer, measuring tape, wall chart or anything 
        else to measure height?	1	2
t. A vision tester, eye chart, cards, or anything else to 
        measure vision?	1	2
        
SHOW CARD 16

85. As I read the list of services printed on this card, please tell me if each is provided when needed to students enrolled in the health center.  Does your health center provide...

        	Yes	No

a. Primary care?	1	2
b. First aid?	1	2
c. CPR?	1	2
d. Administration of medications?	1	2
e. Prescriptions for medications?	1	2
f. Dispensation of medications?	1	2
g. Immunizations or vaccinations?	1	2
h. Identification or treatment of acute illnesses?	1	2
i. Identification or treatment of chronic illnesses?	1	2
j. Case management for students with chronic 
        health conditions, such as asthma or diabetes?	1	2
k. Administration of sports physicals?	1	2
l. Dental care or identification of or referrals for dental 
        problems?	1	2
m. Lab tests?	1	2
     Answer n-o if this is a middle, junior, or senior high school.
n. Prenatal care?	1	2
o. Identification or treatment of STDs?	1	2

Answer Q86 if your health center provides immunizations or vaccinations (Q85g is Yes).  Otherwise, skip to Q87.

SHOW CARD 17

86. As I read the list of immunizations and vaccinations printed on this card, please tell me if each is provided when needed to students enrolled in your health center. 

        	Yes	No

a. A measles-containing vaccine, such as MMR?	1	2
b. A polio vaccine, such as OPV?	1	2
c. Diphtheria?	1	2
d. Tetanus?	1	2
e. Haemophilus influenzae type b or Hib?	1	2
f. Influenza?	1	2
g. Hepatitis A?	1	2
h. Hepatitis B?	1	2
i. Chicken pox or varicella?	1	2
j. Pneumococcal?	1	2

The next questions ask about other ways that health services staff might help students.  As I ask these questions, please think about the activities of health center staff such as nurses, physicians, and health aides, or others who provide health services at your health center. Do not include activities of psychologists, social workers, or counselors. Ill find out about their activities during a different interview.

SHOW CARD 18

87. As I read the list of services printed on this card, please tell me if each is provided when needed to students enrolled in the health center in one-on-one or small-group discussions.

        	Yes	No

a. Nutrition and dietary behavior counseling, including 
        weight management?	1	2
     Answer b if this is a middle, junior, or senior high school.
b. Eating disorders prevention?	1	2
c. Physical activity and fitness counseling?	1	2
     Answer d-f if this is a middle, junior, or senior high school.
d. Pregnancy prevention?	1	2
e. HIV prevention?	1	2
f. STD prevention?	1	2
g. Suicide prevention?	1	2
h. Tobacco use prevention?	1	2
i. Alcohol or other drug use prevention?	1	2
j. Violence prevention, for example bullying, fighting, 
        or homicide?	1	2
k. Accident or injury prevention?	1	2

SHOW CARD 19

88. As I read the list of services printed on this card, please tell me if each is provided when needed to students enrolled in the health center.
      Do health services staff at your center provide...

        	Yes	No

     Answer a-b if this is a middle, junior, or senior high school.
a. Tobacco use cessation?	1	2
b. Alcohol or other drug use treatment?	1	2
c. Crisis intervention for personal problems?	1	2
d. Identification of or counseling for mental or emotional 
        disorders, such as anxiety or depression?	1	2
e. Stress management?	1	2
     Answer f if this is a middle, junior, or senior high school.
f. Eating disorders treatment?	1	2
g. Identification of or referral for physical, sexual, or 
        emotional abuse?	1	2
     Answer h if this is a middle, junior, or senior high school.
h. HIV testing and counseling?	1	2
i. Referrals for after-school programs such as day-care or 
        supervised recreation?	1	2
     Answer j-l if this is a middle, junior, or senior high school.
j. Services for gay, lesbian, or bisexual students?	1	2
k. Referrals for child care for teen mothers?	1	2
l. Assistance with enrolling in WIC or accessing food 
        stamps or food banks?	1	2
m. Assistance with enrolling in Medicaid or CHIP 
        (Childrens Health Insurance Program)?	1	2
     Answer n if this is a middle, junior, or senior high school.
n. Job readiness skills programs?	1	2

Answer Q89 if this is a middle, junior, or senior high school.  Otherwise, skip to Q90.

89. Does your health center make condoms available to...

        	Yes	No

a. Any students enrolled in the health center?	1	2
b. Any students from this school?	1	2

90. Does your health center bill for third-party reimbursement for health services provided to students?HSB161

     Yes	1
     No		2

91. 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.

Health Services School Questionnaire - Final Version    Revised: 10/26/99

30
Health Services School Questionnaire - Final Version    Revised: 10/26/99

Standard Health Services

Services Provided at Other Sites

Respondent Background

School-Based Health Center Services