Asthma Environmental Intervention Knowledge and Practice Evaluation Tool Question Title * 1. Do you work at a school-based health center? Yes No Question Title * 2. Please list all of the common environmental asthma triggers you can think of: Question Title * 3. Please list potential sources that might trigger or exacerbate asthma in the classroom: Question Title * 4. Please list sources of outdoor air pollution that might worsen a patient’s asthma: Question Title * 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. Question Title * 6. Can you list a policy or systems change that could help reduce exposure to environmental asthma triggers for your patients? Question Title * 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 Question Title * 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 Question Title * 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 Question Title * 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 Question Title * 11. How often do you talk to your patients with asthma about environmental asthma triggers? Never Sometimes Always Question Title * 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: Question Title * 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: Question Title * 14. Have you ever had a role in a program or policy to improve indoor air quality at your school? No Yes. Please describe: Question Title * 15. Have you ever had a role in a program or policy to improve indoor air quality in housing? No Yes. Please describe: Question Title * 16. Have you ever had a role in a program or policy to improve outdoor air quality in your community? No Yes. Please describe: Question Title * 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 * Done