On behalf of the Indiana Joint Asthma Coalition (InJAC), thank you in advance for helping to decrease the burden of asthma in Indiana’s school-aged children.

We recently created a Statewide Asthma Management Plan that has been approved for usage in all Indiana schools. We have also received a grant that will allow us to conduct live and online training on the newly-created plan. In order to fulfill a component of that grant, we will perform two evaluations on the state of asthma in our schools: one before the Asthma Management Plan is distributed, and one after a year of statewide usage.

This, the first evaluation, asks about your student body, those that have asthma in your school, and days missed due to asthma. The second evaluation will ask similar questions and we will compare the data at the end of the year. We ask that you do not include any students’ names in your responses. When reporting or publishing this information, we will NOT use any individual school names as they pertain to AMP usage. Information is not being collected to survey who is doing an ineffective job, but rather to see what works best and how other schools can adopt best practices.

We appreciate your willingness to assist us and we will keep all of our participants abreast of our evaluation results.

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* 1. Name of person taking survey:

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* 2. School Name

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* 3. School Address

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* 4. School Nurse(s)

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* 5. Other School Personnel Who Perform School Nurse Duties

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* 6. Best Contact

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* 7. Total Number of Students Enrolled for the 2013-2014 School Year

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* 8. Number of Students with Asthma for the 2013-2014 School Year (Please indicate if you do not have access to this information)

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* 9. Number of Students with an Asthma Action Plan at School for the 2013-2014 School Year

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* 10. Number of Students with Asthma Medications at School for the 2013-2014 School Year

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* 11. Total number of missed school days, among ALL enrolled students, for the 2013-2014 school year. (Please indicate if you do not have access to this information)

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* 12. Number of students with asthma that missed school days for the 2013-2014 school year. (Please indicate if you do not have access to this information)

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* 13. Total number of missed school days for the 2013-2014 school year, among ALL students with asthma (Please indicate if you do not have access to this information)

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* 14. Please include any additional comments here.

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* 15. Please indicate your $10 Gift Card preference

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