Asthma Environmental Intervention Knowledge and Practice Evaluation Tool

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

Yes

No

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

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

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

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

1.

2.

3.

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

* 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

* 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

* 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

* 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

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

Never

Sometimes

Always

* 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:

* 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:

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

No

Yes. Please describe:

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

No

Yes. Please describe:

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

No

Yes. Please describe:

* 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