School Health Policy Index

Question Title

* 1. School Information

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

Question Title

* 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.

Question Title

* 3. Which Policy Index is this?

Baseline (before TA work begins)

Midpoint (approximately 3 - 4 months after baseline)

Endpoint (approximately 3 - 4 months after the midpoint)

Question Title

* 4. School Protocols

	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.	A written procedure is available to guide the program and direct personnel for proper management of students’ who have asthma. Not in Place	A written procedure is available to guide the program and direct personnel for proper management of students’ who have asthma. Under Development	A written procedure is available to guide the program and direct personnel for proper management of students’ who have asthma. Partially in Place	A written procedure is available to guide the program and direct personnel for proper management of students’ who have asthma. Fully in Place
All students with asthma have an updated Asthma Action Plan from their private healthcare provider on file at the school.	All students with asthma have an updated Asthma Action Plan from their private healthcare provider on file at the school. Not in Place	All students with asthma have an updated Asthma Action Plan from their private healthcare provider on file at the school. Under Development	All students with asthma have an updated Asthma Action Plan from their private healthcare provider on file at the school. Partially in Place	All students with asthma have an updated Asthma Action Plan from their private healthcare provider on file at the school. 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.	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	Emergency Care Plans developed by the school nurse or other licensed healthcare professional are made available to all non-nursing school personnel. Under Development	Emergency Care Plans developed by the school nurse or other licensed healthcare professional are made available to all non-nursing school personnel. Partially in Place	Emergency Care Plans developed by the school nurse or other licensed healthcare professional are made available to all non-nursing school personnel. Fully in Place
Non-nursing personnel have a set of guidelines that provide specific directions about what to do during an asthma emergency.	Non-nursing personnel have a set of guidelines that provide specific directions about what to do during an asthma emergency. Not in Place	Non-nursing personnel have a set of guidelines that provide specific directions about what to do during an asthma emergency. Under Development	Non-nursing personnel have a set of guidelines that provide specific directions about what to do during an asthma emergency. Partially in Place	Non-nursing personnel have a set of guidelines that provide specific directions about what to do during an asthma emergency. Fully in Place
All school personnel are informed of their roles and responsibilities regarding students with asthma.	All school personnel are informed of their roles and responsibilities regarding students with asthma. Not in Place	All school personnel are informed of their roles and responsibilities regarding students with asthma. Under Development	All school personnel are informed of their roles and responsibilities regarding students with asthma. Partially in Place	All school personnel are informed of their roles and responsibilities regarding students with asthma. Fully in Place

Question Title

* 5. Asthma Team Collaboration

	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.	School engages in regular collaboration with private healthcare providers regarding asthma patients’ ongoing needs. Not in Place	School engages in regular collaboration with private healthcare providers regarding asthma patients’ ongoing needs. Under Development	School engages in regular collaboration with private healthcare providers regarding asthma patients’ ongoing needs. Partially in Place	School engages in regular collaboration with private healthcare providers regarding asthma patients’ ongoing needs. Fully in Place
School engages in regular collaboration with private healthcare providers regarding students’ Asthma Action Plans.	School engages in regular collaboration with private healthcare providers regarding students’ Asthma Action Plans. Not in Place	School engages in regular collaboration with private healthcare providers regarding students’ Asthma Action Plans. Under Development	School engages in regular collaboration with private healthcare providers regarding students’ Asthma Action Plans. Partially in Place	School engages in regular collaboration with private healthcare providers regarding students’ Asthma Action Plans. Fully in Place
School has an Emergency Care Plan in place in the event of an asthma emergency.	School has an Emergency Care Plan in place in the event of an asthma emergency. Not in Place	School has an Emergency Care Plan in place in the event of an asthma emergency. Under Development	School has an Emergency Care Plan in place in the event of an asthma emergency. Partially in Place	School has an Emergency Care Plan in place in the event of an asthma emergency. Fully in Place
School partners with or builds a “Wellness Committee”.	School partners with or builds a “Wellness Committee”. Not in Place	School partners with or builds a “Wellness Committee”. Under Development	School partners with or builds a “Wellness Committee”. Partially in Place	School partners with or builds a “Wellness Committee”. Fully in Place
Students are provided with education on how to effectively address asthma in the school setting.	Students are provided with education on how to effectively address asthma in the school setting. Not in Place	Students are provided with education on how to effectively address asthma in the school setting. Under Development	Students are provided with education on how to effectively address asthma in the school setting. Partially in Place	Students are provided with education on how to effectively address asthma in the school setting. Fully in Place
Families are provided with education on how to effectively address asthma in the school setting.	Families are provided with education on how to effectively address asthma in the school setting. Not in Place	Families are provided with education on how to effectively address asthma in the school setting. Under Development	Families are provided with education on how to effectively address asthma in the school setting. Partially in Place	Families are provided with education on how to effectively address asthma in the school setting. Fully in Place
School personnel are provided with education on how to effectively address asthma in the school setting.	School personnel are provided with education on how to effectively address asthma in the school setting. Not in Place	School personnel are provided with education on how to effectively address asthma in the school setting. Under Development	School personnel are provided with education on how to effectively address asthma in the school setting. Partially in Place	School personnel are provided with education on how to effectively address asthma in the school setting. 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.	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	Parents/guardians are encouraged to meet with school personnel prior to the start of school to provide necessary information regarding their child’s asthma. Under Development	Parents/guardians are encouraged to meet with school personnel prior to the start of school to provide necessary information regarding their child’s asthma. Partially 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. 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:

Question Title

* 6. School Environment

	Not in Place	Under Development	Partially in Place	Fully in Place
School helps to reduce or eliminate environmental asthma triggers during school.	School helps to reduce or eliminate environmental asthma triggers during school. Not in Place	School helps to reduce or eliminate environmental asthma triggers during school. Under Development	School helps to reduce or eliminate environmental asthma triggers during school. Partially in Place	School helps to reduce or eliminate environmental asthma triggers during school. Fully in Place
School helps to reduce or eliminate environmental asthma triggers on the bus.	School helps to reduce or eliminate environmental asthma triggers on the bus. Not in Place	School helps to reduce or eliminate environmental asthma triggers on the bus. Under Development	School helps to reduce or eliminate environmental asthma triggers on the bus. Partially in Place	School helps to reduce or eliminate environmental asthma triggers on the bus. Fully in Place
School is aware of environmental asthma triggers on field trips.	School is aware of environmental asthma triggers on field trips. Not in Place	School is aware of environmental asthma triggers on field trips. Under Development	School is aware of environmental asthma triggers on field trips. Partially in Place	School is aware of environmental asthma triggers on field trips. Fully in Place
School helps to reduce or eliminate environmental asthma triggers at off-campus school-sponsored events.	School helps to reduce or eliminate environmental asthma triggers at off-campus school-sponsored events. Not in Place	School helps to reduce or eliminate environmental asthma triggers at off-campus school-sponsored events. Under Development	School helps to reduce or eliminate environmental asthma triggers at off-campus school-sponsored events. Partially in Place	School helps to reduce or eliminate environmental asthma triggers at off-campus school-sponsored events. Fully in Place
All school grounds have tobacco-free policies on file.	All school grounds have tobacco-free policies on file. Not in Place	All school grounds have tobacco-free policies on file. Under Development	All school grounds have tobacco-free policies on file. Partially in Place	All school grounds have tobacco-free policies on file. Fully in Place
All school events (on and off campus) have tobacco-free policies on file.	All school events (on and off campus) have tobacco-free policies on file. Not in Place	All school events (on and off campus) have tobacco-free policies on file. Under Development	All school events (on and off campus) have tobacco-free policies on file. Partially in Place	All school events (on and off campus) have tobacco-free policies on file. Fully in Place
All school grounds have no idling policies on file.	All school grounds have no idling policies on file. Not in Place	All school grounds have no idling policies on file. Under Development	All school grounds have no idling policies on file. Partially in Place	All school grounds have no idling policies on file. Fully in Place
All school events (on and off campus) have no idling policies on file.	All school events (on and off campus) have no idling policies on file. Not in Place	All school events (on and off campus) have no idling policies on file. Under Development	All school events (on and off campus) have no idling policies on file. Partially in Place	All school events (on and off campus) have no idling policies on file. Fully in Place
The school monitors the local Air Quality Index (AQI) to reduce students’ exposure to unhealthy air quality.	The school monitors the local Air Quality Index (AQI) to reduce students’ exposure to unhealthy air quality. Not in Place	The school monitors the local Air Quality Index (AQI) to reduce students’ exposure to unhealthy air quality. Under Development	The school monitors the local Air Quality Index (AQI) to reduce students’ exposure to unhealthy air quality. Partially in Place	The school monitors the local Air Quality Index (AQI) to reduce students’ exposure to unhealthy air quality. Fully in Place
The school uses environmentally sensitive cleaning and maintenance products.	The school uses environmentally sensitive cleaning and maintenance products. Not in Place	The school uses environmentally sensitive cleaning and maintenance products. Under Development	The school uses environmentally sensitive cleaning and maintenance products. Partially in Place	The school uses environmentally sensitive cleaning and maintenance products. Fully in Place
The school implements integrated pest management (IPM) techniques.	The school implements integrated pest management (IPM) techniques. Not in Place	The school implements integrated pest management (IPM) techniques. Under Development	The school implements integrated pest management (IPM) techniques. Partially in Place	The school implements integrated pest management (IPM) techniques. Fully in Place

Question Title

* 7. Medication Access and Documentation

	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.	Procedures ensure that all students who have asthma have immediate access to quick-relief medication at school. Not in Place	Procedures ensure that all students who have asthma have immediate access to quick-relief medication at school. Under Development	Procedures ensure that all students who have asthma have immediate access to quick-relief medication at school. Partially in Place	Procedures ensure that all students who have asthma have immediate access to quick-relief medication at school. Fully in Place
Procedures ensure that all students who have asthma have immediate access to quick-relief medication at school-sponsored events.	Procedures ensure that all students who have asthma have immediate access to quick-relief medication at school-sponsored events. Not in Place	Procedures ensure that all students who have asthma have immediate access to quick-relief medication at school-sponsored events. Under Development	Procedures ensure that all students who have asthma have immediate access to quick-relief medication at school-sponsored events. Partially in Place	Procedures ensure that all students who have asthma have immediate access to quick-relief medication at school-sponsored events. Fully in Place
Procedures ensure that all students who have asthma have immediate access to quick-relief medication during school transportation.	Procedures ensure that all students who have asthma have immediate access to quick-relief medication during school transportation. Not in Place	Procedures ensure that all students who have asthma have immediate access to quick-relief medication during school transportation. Under Development	Procedures ensure that all students who have asthma have immediate access to quick-relief medication during school transportation. Partially in Place	Procedures ensure that all students who have asthma have immediate access to quick-relief medication during school transportation. Fully in Place
Procedures ensure that all students who have asthma have immediate access to quick-relief medication before and after physical activity.	Procedures ensure that all students who have asthma have immediate access to quick-relief medication before and after physical activity. Not in Place	Procedures ensure that all students who have asthma have immediate access to quick-relief medication before and after physical activity. Under Development	Procedures ensure that all students who have asthma have immediate access to quick-relief medication before and after physical activity. Partially in Place	Procedures ensure that all students who have asthma have immediate access to quick-relief medication before and after physical activity. 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.	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	School personnel are required to carry a copy of each student’s Asthma Action Plan and Emergency Care Plan on field trips. Under Development	School personnel are required to carry a copy of each student’s Asthma Action Plan and Emergency Care Plan on field trips. Partially in Place	School personnel are required to carry a copy of each student’s Asthma Action Plan and Emergency Care Plan on field trips. Fully in Place
Parents/guardians are provided documentation to allow students to be administered medication.	Parents/guardians are provided documentation to allow students to be administered medication. Not in Place	Parents/guardians are provided documentation to allow students to be administered medication. Under Development	Parents/guardians are provided documentation to allow students to be administered medication. Partially in Place	Parents/guardians are provided documentation to allow students to be administered medication. Fully in Place
Parents/guardians are provided documentation to allow students to carry and use medication.	Parents/guardians are provided documentation to allow students to carry and use medication. Not in Place	Parents/guardians are provided documentation to allow students to carry and use medication. Under Development	Parents/guardians are provided documentation to allow students to carry and use medication. Partially in Place	Parents/guardians are provided documentation to allow students to carry and use medication. Fully in Place

Question Title

* 8. Student Participation

	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.	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	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. Under Development	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. Partially 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. Fully in Place
Students who have asthma can choose alternative physical activities without fear of ridicule or grade reduction.	Students who have asthma can choose alternative physical activities without fear of ridicule or grade reduction. Not in Place	Students who have asthma can choose alternative physical activities without fear of ridicule or grade reduction. Under Development	Students who have asthma can choose alternative physical activities without fear of ridicule or grade reduction. Partially in Place	Students who have asthma can choose alternative physical activities without fear of ridicule or grade reduction. Fully in Place