Asthma Environmental Intervention Knowledge and Practice Evaluation Tool

Do you work at a school-based health center?

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* 1. Do you work at a school-based health center?

Yes

Please list all of the common environmental asthma triggers you can think of:

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* 2. Please list all of the common environmental asthma triggers you can think of:

Please list potential sources that might trigger or exacerbate asthma in the classroom:

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* 3. Please list potential sources that might trigger or exacerbate asthma in the classroom:

Please list sources of outdoor air pollution that might worsen a patient’s asthma:

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* 4. Please list sources of outdoor air pollution that might worsen a patient’s asthma:

If a patient’s asthma is triggered by dust mites, can you list 3 ways to reduce exposure in the home?

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* 5. If a patient’s asthma is triggered by dust mites, can you list 3 ways to reduce exposure in the home?

Can you list a policy or systems change that could help reduce exposure to environmental asthma triggers for your patients?

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* 6. Can you list a policy or systems change that could help reduce exposure to environmental asthma triggers for your patients?

If a patient is exposed to environmental asthma triggers in his/her home, how confident would you be in your ability to help them?

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* 7. If a patient is exposed to environmental asthma triggers in his/her home, how confident would you be in your ability to help them?

Not confident

Somewhat confident

Confident

Very confident

If a patient is exposed to environmental asthma triggers in the school, how confident would you be in your ability to help them?

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* 8. If a patient is exposed to environmental asthma triggers in the school, how confident would you be in your ability to help them?

Not confident

Somewhat confident

Confident

Very confident

If a patient is exposed to environmental asthma triggers in his/her outdoor environment, how confident would you be in your ability to help them?

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* 9. If a patient is exposed to environmental asthma triggers in his/her outdoor environment, how confident would you be in your ability to help them?

Not confident

Somewhat confident

Confident

Very confident

Do you use a “trigger checklist” with your patients with asthma (either as part of their Asthma Action Plan or as a stand-alone tool)?

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* 10. Do you use a “trigger checklist” with your patients with asthma (either as part of their Asthma Action Plan or as a stand-alone tool)?

Never

Sometimes

Always

How often do you talk to your patients with asthma about environmental asthma triggers?

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* 11. How often do you talk to your patients with asthma about environmental asthma triggers?

Never

Sometimes

Always

If you answered "Sometimes" or "Always" above, please describe the guidance you are most likely to give to your patients about avoiding environmental asthma triggers:

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* 12. If you answered "Sometimes" or "Always" above, please describe the guidance you are most likely to give to your patients about avoiding environmental asthma triggers:

Do you ever talk with the following people about how to reduce environmental asthma triggers affecting a particular patient:

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* 13. Do you ever talk with the following people about how to reduce environmental asthma triggers affecting a particular patient:

	Yes	No
His/her teacher	His/her teacher Yes	His/her teacher No
The school nurse	The school nurse Yes	The school nurse No
The school principal	The school principal Yes	The school principal No
The parent/guardian	The parent/guardian Yes	The parent/guardian No

Other person/people. Please specify:

Have you ever had a role in a program or policy to improve indoor air quality at your school?

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* 14. Have you ever had a role in a program or policy to improve indoor air quality at your school?

Yes. Please describe:

Have you ever had a role in a program or policy to improve indoor air quality in housing?

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* 15. Have you ever had a role in a program or policy to improve indoor air quality in housing?

Yes. Please describe:

Have you ever had a role in a program or policy to improve outdoor air quality in your community?

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* 16. Have you ever had a role in a program or policy to improve outdoor air quality in your community?

Yes. Please describe:

We would like to contact you at a later date with a request to complete a post-test survey. This step is very important for helping us understand the impact of our resources. Thank you!

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* 17. We would like to contact you at a later date with a request to complete a post-test survey. This step is very important for helping us understand the impact of our resources. Thank you!

Name

Email Address