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School Health Policy Index
*
1.
School Information
(Required.)
Name of School
Name of School District
Name of School Contact
Role of School Contact
Date this is being completed
Number of Students in the School with Asthma
Email Address
Phone Number
*
2.
Please provide some dates and times of the week you'd be available for a 15 - 20-minute Technical Assistance call to discuss the results.
(Required.)
*
3.
Which Policy Index is this?
(Required.)
Baseline (before TA work begins)
Midpoint (approximately 3 - 4 months after baseline)
Endpoint (approximately 3 - 4 months after the midpoint)
*
4.
School Protocols
(Required.)
Not in Place
Under Development
Partially in Place
Fully in Place
A written procedure is available to guide the program and direct personnel for proper management of students’ who have asthma.
Not in Place
Under Development
Partially in Place
Fully in Place
All students with asthma have an updated
Asthma Action Plan
from their private healthcare provider on file at the school.
Not in Place
Under Development
Partially in Place
Fully in Place
Emergency Care Plans developed by the school nurse or other licensed healthcare professional are made available to all non-nursing school personnel.
Not in Place
Under Development
Partially in Place
Fully in Place
Non-nursing personnel have a set of guidelines that provide specific directions about what to do during an asthma emergency.
Not in Place
Under Development
Partially in Place
Fully in Place
All school personnel are informed of their roles and responsibilities regarding students with asthma.
Not in Place
Under Development
Partially in Place
Fully in Place
*
5.
Asthma Team Collaboration
(Required.)
Not in Place
Under Development
Partially in Place
Fully in Place
School engages in regular collaboration with private healthcare providers regarding asthma patients’
ongoing needs.
Not in Place
Under Development
Partially in Place
Fully in Place
School engages in regular collaboration with private healthcare providers regarding students’
Asthma Action Plans.
Not in Place
Under Development
Partially in Place
Fully in Place
School has an
Emergency Care Plan
in place in the event of an asthma emergency.
Not in Place
Under Development
Partially in Place
Fully in Place
School partners with or builds a “Wellness Committee”.
Not in Place
Under Development
Partially in Place
Fully in Place
Students
are provided with education on how to effectively address asthma in the school setting.
Not in Place
Under Development
Partially in Place
Fully in Place
Families
are provided with education on how to effectively address asthma in the school setting.
Not in Place
Under Development
Partially in Place
Fully in Place
School personnel
are provided with education on how to effectively address asthma in the school setting.
Not in Place
Under Development
Partially in Place
Fully in Place
Parents/guardians are encouraged to meet with school personnel prior to the start of school to provide necessary information regarding their child’s asthma.
Not in Place
Under Development
Partially in Place
Fully in Place
If your school partners w/ or builds a "Wellness Committee," please specify if it is a school wellness committee and/or community-based wellness committee:
*
6.
School Environment
(Required.)
Not in Place
Under Development
Partially in Place
Fully in Place
School helps to reduce or eliminate environmental asthma triggers
during school.
Not in Place
Under Development
Partially in Place
Fully in Place
School helps to reduce or eliminate environmental asthma triggers
on the bus.
Not in Place
Under Development
Partially in Place
Fully in Place
School is aware of environmental asthma triggers
on field trips.
Not in Place
Under Development
Partially in Place
Fully in Place
School helps to reduce or eliminate environmental asthma triggers at
off-campus school-sponsored events.
Not in Place
Under Development
Partially in Place
Fully in Place
All
school grounds
have tobacco-free policies on file.
Not in Place
Under Development
Partially in Place
Fully in Place
All
school events (on and off campus)
have tobacco-free policies on file.
Not in Place
Under Development
Partially in Place
Fully in Place
All
school grounds
have no idling policies on file.
Not in Place
Under Development
Partially in Place
Fully in Place
All
school events (on and off campus)
have no idling policies on file.
Not in Place
Under Development
Partially in Place
Fully in Place
The school monitors the local Air Quality Index (AQI) to reduce students’ exposure to unhealthy air quality.
Not in Place
Under Development
Partially in Place
Fully in Place
The school uses environmentally sensitive cleaning and maintenance products.
Not in Place
Under Development
Partially in Place
Fully in Place
The school implements integrated pest management (IPM) techniques.
Not in Place
Under Development
Partially in Place
Fully in Place
*
7.
Medication Access and Documentation
(Required.)
Not in Place
Under Development
Partially in Place
Fully in Place
Procedures ensure that all students who have asthma have immediate access to quick-relief medication
at school.
Not in Place
Under Development
Partially in Place
Fully in Place
Procedures ensure that all students who have asthma have immediate access to quick-relief medication
at school-sponsored events.
Not in Place
Under Development
Partially in Place
Fully in Place
Procedures ensure that all students who have asthma have immediate access to quick-relief medication
during school transportation.
Not in Place
Under Development
Partially in Place
Fully in Place
Procedures ensure that all students who have asthma have immediate access to quick-relief medication
before and after physical activity.
Not in Place
Under Development
Partially in Place
Fully in Place
School personnel are required to carry a copy of each student’s Asthma Action Plan and Emergency Care Plan on field trips.
Not in Place
Under Development
Partially in Place
Fully in Place
Parents/guardians are provided documentation to allow students to be
administered medication.
Not in Place
Under Development
Partially in Place
Fully in Place
Parents/guardians are provided documentation to allow students to
carry and use medication.
Not in Place
Under Development
Partially in Place
Fully in Place
*
8.
Student Participation
(Required.)
Not in Place
Under Development
Partially in Place
Fully in Place
School encourages and supports full participation of students with asthma to engage in all types of physical activities including physical education, sports, recess, and field trips.
Not in Place
Under Development
Partially in Place
Fully in Place
Students who have asthma can choose alternative physical activities without fear of ridicule or grade reduction.
Not in Place
Under Development
Partially in Place
Fully in Place