2006 SCHOOL HEALTH PROFILE
SCHOOL PRINCIPAL QUESTIONNAIRE

This questionnaire will be used to assess school health programs and policies across your 
state or school district.  Your cooperation is essential for making the results of this survey 
comprehensive, accurate, and timely.  Your answers will be kept confidential.

INSTRUCTIONS
1.  This questionnaire should be completed by the principal (or the person acting in that 
    capacity) and concerns only activities that occur in the school listed below.  Please 
    consult with other people if you are not sure of an answer.
2.  Please use a #2 pencil to fill in the answer circles completely.  Do not fold, bend, or 
    staple this questionnaire or mark outside the answer circles.
3.  Follow the instructions for each question.
4.  Write any additional comments you wish to make at the end of the questionnaire.
5.  Return the questionnaire in the envelope provided.

Person completing this questionnaire

Name: 
Title: 
School name: 
District: 
Telephone number: 

To be completed by the SEA or LEA conducting the survey

School name: 

Survey ID:


1.  Are any of the following grades taught in this school?  (Mark yes or no for each 
    grade.)

a.  Grade 6    Yes/No
b.  Grade 7    Yes/No
c.  Grade 8    Yes/No
d.  Grade 9    Yes/No
e.  Grade 10   Yes/No
f.  Grade 11   Yes/No
g.  Grade 12   Yes/No
	
If you answered NO to all grades in Question 1, you are finished.  Please return this 
questionnaire.


REQUIRED HEALTH EDUCATION
(Definition: Required health education is defined as instruction about health education 
topics such as injuries and violence, alcohol and other drug use, tobacco use, nutrition, HIV 
infection, and physical activity that students must receive for graduation or promotion 
from this school.)

2. Is health education required for students in any of grades 6 through 12 in this 
   school? (Mark one response.)

a.  Yes
b.  No        If no, skip to Question 7

3. Is required health education taught in each of the following ways to students in 
   grades 6 through 12 in this school? (Mark yes or no for each method.)
  								
a.  In a combined health education and physical education course	Yes/No
b.  In a course mainly about another subject other than health
    education such as science, social studies, or English		Yes/No
    

REQUIRED HEALTH EDUCATION COURSE
(Definition: A required health education course is taught as a separate semester-, quarter-, 
or year-long unit of instruction for which the student receives credit.   It is not health 
education units or lessons integrated into other subjects.)

4.  How many required health education courses do students take in grades 6 through 
    12 in this school? (Mark one response.)

a.  0 courses        If o courses, Skip to Question 7
b.  1 course 
c.  2 courses 
d.  3 courses  
e.  4 or more courses 

5.  Is a required health education course taught in each of the following grades in this 
    school?  (Mark yes, no, or not applicable for each grade.)

a.  6		Yes/No/Not Applicable
b.  7		Yes/No/Not Applicable
c.  8		Yes/No/Not Applicable
d.  9		Yes/No/Not Applicable
e.  10		Yes/No/Not Applicable
f.  11		Yes/No/Not Applicable
g.  12		Yes/No/Not Applicable
       
      
6.  If students fail a required health education course, are they required to repeat it? 
    (Mark one response.)

a.  Yes
b.  No


HEALTH EDUCATION 

7.  Who coordinates health education in this school? (Mark one response.)

a.  No one coordinates health education in this school 
b.  District administrator 
c.  District health education or curriculum coordinator 
d.  School administrator 
e.  Health education teacher 
f.  School nurse 
g.  Someone else 

8.  Are newly hired staff who teach health topics required to be certified, licensed, or 
    endorsed by the state in health education? (Mark one response.)

a.  Yes
b.  No
c.  Not applicable (i.e., state does not offer certification, licensure, or endorsement in health education)

9.  Is there one or more than one group (e.g., a school health council, committee, or 
    team) at this school that offers guidance on the development of policies or 
    coordinates activities on health topics?  (Mark one response.)

a.  Yes 
b.  No 


REQUIRED PHYSICAL EDUCATION 
(Definition: Required physical education is defined as instruction that helps students 
develop the knowledge, attitudes, skills, and confidence needed to adopt and maintain a 
physically active lifestyle that students must receive for graduation or promotion from this 
school.)

10. Is physical education required for students in any of grades 6 through 12 in this 
    school? (Mark one response.)

a.  Yes
b.  No         If no, skip to question 15


REQUIRED PHYSICAL EDUCATION COURSE
(Definition: A required physical education course is taught as a semester-, quarter-, or 
year-long unit of instruction for which the student receives credit.  It is not physical activity 
units or lessons integrated into other subjects.  It is not recess, intramural activities, 
physical activity clubs, or school sports.)  

11. How many required physical education courses do students take in grades 6 
    through 12 in this school? (Mark one response.)

a.  0 courses  	If o, skip to question 15
b.  1 course
c.  2 or 3 courses
d.  4 or 5 courses
e.  6 or 7 courses
f.  8 or more courses

12. Is a required physical education course taught in each of the following grades in this 
    school? (Mark yes, no, or not applicable for each grade.)

a.  6		Yes/No/Not Applicable
b.  7		Yes/No/Not Applicable
c.  8		Yes/No/Not Applicable
d.  9		Yes/No/Not Applicable
e.  10		Yes/No/Not Applicable
f.  11		Yes/No/Not Applicable
g.  12		Yes/No/Not Applicable

13. Can students be exempted from taking a required physical education course for one 
    grading period or longer for any of the following reasons? (Mark yes or no for each reason.)

a.  Enrollment in other courses (i.e., math or science)	Yes/No
b.  Participation in school sports			Yes/No
c.  Participation in other school activities 
    (i.e., ROTC, band, or chorus)			Yes/No
d.  Participation in community sports activities	Yes/No
e.  Religious reasons					Yes/No
f.  Long-term physical or medical disability		Yes/No
g.  Cognitive disability				Yes/No
h.  High physical fitness competency test score		Yes/No
i.  Participation in vocational training		Yes/No
j.  Participation in community service activities	Yes/No

14. If students fail a required physical education course, are they required to repeat it? 
    (Mark one response.)

a.  Yes
b.  No


PHYSICAL EDUCATION AND PHYSICAL ACTIVITY 
	
15. Are newly hired staff who teach physical education required to be certified, licensed, 
    or endorsed by the state in physical education? (Mark one response.)

a.  Yes
b.  No
c.  Not applicable (i.e., state does not offer certification, licensure, or endorsement in 
    physical education)

16. Does this school offer opportunities for students to participate in intramural 
    activities or physical activity clubs? (Mark one response.)

a.  Yes
b.  No         If no, Skip to question 18

17. Does this school provide transportation home for students who participate in after-
    school intramural activities or physical activity clubs? (Mark one response.)

a.  Yes
b.  No

18. Outside of school hours or when school is not in session, do children or adolescents 
    use any of this school?s physical activity or athletic facilities for community-
    sponsored sports teams, classes, or lessons? (Mark one response.)

a.  Yes
b.  No
 
19. Does your school support or promote walking or biking to and from school (e.g., 
    through promotional activities, designating safe routes or preferred routes, or 
    having storage facilities for bicycles and helmets)?  (Mark one response.)

a.  Yes
b.  No


TOBACCO-USE PREVENTION POLICIES

20. Has this school adopted a policy prohibiting tobacco use? (Mark one response.)

a.  Yes 
b.  No         If no, Skip to Question 27

21. Does the tobacco-use prevention policy specifically prohibit use of each type of 
    tobacco for each of the following groups during any school-related activity? (Mark 
    yes or no for each type of tobacco for each group.)

Students
a.  Cigarettes							Yes/No
b.  Smokeless tobacco (i.e., chewing tobacco, snuff, or dip)	Yes/No
c.  Cigars							Yes/No
d.  Pipes							Yes/No

Faculty/Staff
a.  Cigarettes							Yes/No
b.  Smokeless tobacco (i.e., chewing tobacco, snuff, or dip)	Yes/No
c.  Cigars							Yes/No
d.  Pipes							Yes/No

Visitors
a.  Cigarettes							Yes/No
b.  Smokeless tobacco (i.e., chewing tobacco, snuff, or dip)	Yes/No
c.  Cigars							Yes/No
d.  Pipes							Yes/No

22. Does the tobacco-use prevention policy specifically prohibit tobacco use during each 
    of the following times for each of the following groups? (Mark yes or no for each time 
    for each group.)

Students
a.  During school hours		Yes/No
b.  During non-school hours	Yes/No

Faculty/Staff
a.  During school hours		Yes/No
b.  During non-school hours	Yes/No

Visitors
a.  During school hours		Yes/No
b.  During non-school hours	Yes/No

23. Does the tobacco-use prevention policy specifically prohibit tobacco use in each of 
    the following locations for each of the following groups? (Mark yes or no for each 
    location for each group.)

Students
a.  In school buildings								Yes/No
b.  Outside on school grounds, including parking lots and playing fields	Yes/No
c.  On school buses or other vehicles used to transport students		Yes/No
d.  At off-campus, school-sponsored events					Yes/No

Faculty/Staff
a.  In school buildings								Yes/No
b.  Outside on school grounds, including parking lots and playing fields	Yes/No
c.  On school buses or other vehicles used to transport students		Yes/No
d.  At off-campus, school-sponsored events					Yes/No

Visitors
a.  In school buildings								Yes/No
b.  Outside on school grounds, including parking lots and playing fields	Yes/No
c.  On school buses or other vehicles used to transport students		Yes/No
d.  At off-campus, school-sponsored events					Yes/No

24. Does your school have procedures to inform each of the following groups about the 
    tobacco-use prevention policy that prohibits their use of tobacco? (Mark yes, no, or 
    not applicable for each group.)

a.  Students		Yes/No/Not Applicable
b.  Faculty and staff	Yes/No/Not Applicable
c.  Visitors		Yes/No/Not Applicable

25. Does your school have procedures to inform students? families about rules related to 
    tobacco use by students?  (Mark one response.)

a.  Yes
b.  No
c.  Not applicable

26. When students are caught smoking cigarettes, how often are each of the following 
    actions taken? (Mark one response for each action.)

a.  Parents or guardians are notified	Never/Rarely/Sometimes/Always or almost always
b.  Referred to a school counselor 	Never/Rarely/Sometimes/Always or almost always
c.  Referred to a school administrator	Never/Rarely/Sometimes/Always or almost always
d.  Encouraged, but not required,
    to participate in an assistance, 
    education, or cessation program	Never/Rarely/Sometimes/Always or almost always
e.  Required to participate in an 
    assistance, education, or cessation 
    program				Never/Rarely/Sometimes/Always or almost always
f.  Referred to legal authorities	Never/Rarely/Sometimes/Always or almost always
g.  Placed in detention			Never/Rarely/Sometimes/Always or almost always
h.  Not allowed to participate in 
    extra-curricular activities or 
    interscholastic sports		Never/Rarely/Sometimes/Always or almost always
i.  Given in-school suspension		Never/Rarely/Sometimes/Always or almost always
j.  Suspended from school		Never/Rarely/Sometimes/Always or almost always
k.  Expelled from school		Never/Rarely/Sometimes/Always or almost always
l.  Reassigned to an alternative school	Never/Rarely/Sometimes/Always or almost always

27. Does your school provide referrals to tobacco cessation programs for each of the 
    following groups? (Mark yes or no for each group.)

a.  Faculty and staff	Yes/No
b.  Students		Yes/No


28. Is tobacco advertising prohibited in each of the following locations?  (Mark yes or no 
    for each location.)

a.  In the school building				Yes/No
b.  On school grounds including on the outside of
    the school building, on playing fields, or other 
    areas of the campus					Yes/No
c.  On school buses or other vehicles used to 
    transport students 					Yes/No
d.  In school publications (e.g., newsletters,
    newspapers, web sites, or other school 
    publications) 					Yes/No

29. Is tobacco advertising through sponsorship of school events prohibited? (Mark one 
    response.)

a.  Yes 
b.  No 

30. Are students at your school prohibited from wearing tobacco brand-name apparel 
    or carrying merchandise with tobacco company names, logos, or cartoon characters 
    on it? (Mark one response.)

a.  Yes 
b.  No  

31. Does your school post signs marking a tobacco-free school zone, that is, a specified 
    distance from school grounds where tobacco use is not allowed? (Mark one response.)

a.  Yes 
b.  No  


NUTRITION-RELATED POLICIES AND PRACTICES

32. How long do students usually have to eat lunch once they are seated? (Mark one 
    response.)

a.  Less than 20 minutes
b.  20 minutes or more
c.  This school does not serve lunch to students

33. Has this school adopted a policy stating that, if food is served at student parties, 
    after-school or extended day programs, or concession stands, fruits or vegetables 
    will be among the foods offered? (Mark one response.)

a.  Yes
b.  No

34. Can students purchase snack foods or beverages from one or more vending 
    machines at the school or at a school store, canteen, or snack bar? (Mark one 
    response.)

a.  Yes
b.  No       If no, skip to Question 37

35. Can students purchase each snack food or beverage from vending machines or at 
    the school store, canteen, or snack bar? (Mark yes or no for each food or beverage.)

a.  Chocolate candy					Yes/No					
b.  Other kinds of candy				Yes/No
c.  Salty snacks that are not low in fat,
    such as regular potato chips			Yes/No
d.  Salty snacks that are low in fat, such as
    pretzels, baked chips, or other low-fat chips	Yes/No	
e.  Fruits or vegetables, not juice			Yes/No
f.  Low-fat cookies, crackers, cakes, pastries, 
    or other low-fat baked goods			Yes/No
g.  Soda pop or fruit drinks that are not 100% juice	Yes/No
h.  Sports drinks					Yes/No
i.  100% fruit juice or vegetable juice 		Yes/No
j.  Bottled water					Yes/No
k.  1% or skim milk					Yes/No
l.  2% or whole milk (plain or flavored)		Yes/No

36. Can students purchase candy; snacks that are not low in fat; soda pop, sports 
    drinks, or fruit drinks that are not 100% juice; or 2% or whole milk during the 
    following times? (Mark yes or no for each time.)

a.  Before classes begin in the morning				Yes/No
b.  During any school hours when meals are not being served	Yes/No
c.  During school lunch periods					Yes/No


VIOLENCE PREVENTION

37. Has your school ever used the School Health Index from the Centers for Disease 
    Control and Prevention to assess your school?s health and safety policies and 
    programs?  (Mark one response.)

a.  Yes
b.  No

38. Does your school implement each of the following safety and security measures? 
    (Mark yes or no for each measure.)
   
a.  Require visitors to report to the main office or reception 
    area upon arrival							Yes/No
b.  Maintain a "closed campus" where students are not allowed to 
    leave school during the school day, including during lunchtime	Yes/No
c.  Use staff or adult volunteers to monitor school halls 
    during and between classes						Yes/No
d.  Routinely conduct locker searches					Yes/No
e.  Require students to wear school uniforms				Yes/No
f.  Require students to wear identification badges			Yes/No
g.  Use metal detectors, including wands				Yes/No
h.  Use security or surveillance cameras, either inside or outside
    the building							Yes/No
i.  Use police, school resource officers, or security guards during 	Yes/No
    the regular school day

39. Does your school have or participate in each of the following programs? (Mark yes 
    or no for each program.)

a.  A peer mediation program		Yes/No
b.  A safe-passages to school program	Yes/No
c.  A program to prevent gang violence	Yes/No
d.  A program to prevent bullying	Yes/No

40. Does your school have a comprehensive plan to address crisis preparedness, 
    response, and recovery in the event of a natural disaster or other emergency or 
    crisis situation?  (Mark one response.)

a.  Yes
b.  No


HEALTH SERVICES

41. Is there a school nurse who provides standard health services to students at this 
    school?  (Mark one response.)

a.  Yes
b.  No

42. At this school, would a student ever be permitted to carry and self-administer each 
    of the following medications? (Mark yes or no for each medication.)
	
a.  A prescription quick-relief inhaler			Yes/No
b.  An epinephrine auto-injector (e.g., EpiPen)		Yes/No
c.  Insulin or other injected medications		Yes/No
d.  Any other prescribed medications			Yes/No
e.  Any over-the-counter medications			Yes/No

43. Does your school provide each of the following health services to students at this 
    school? (Mark yes or no for each activity.)

a.  Identification or school-based management of chronic		 
    health conditions, such as asthma or diabetes			Yes/No
b.  Identification or school-based management of acute illnesses	Yes/No
c.  An Asthma Action Plan (or Individualized Health Plan) 
    for all students with asthma					Yes/No
d.  Immunizations 							Yes/No
e.  Assistance with enrolling in Medicaid or SCHIP 
    (State Children's Health Insurance Program)				Yes/No


HIV INFECTION POLICIES

44. Has this school adopted a policy on students and/or staff who have HIV infection or 
    AIDS? (Mark one response.)

a.  Yes
b.  No  ==> You are finished.  Please return the questionnaire.

45. Does that policy address each of the following issues for students and/or staff with 
    HIV infection or AIDS? (Mark yes or no for each issue.)

a.  Attendance of students with HIV infection    				Yes/No
b.  Procedures to protect HIV-infected students and staff from discrimination	Yes/No
c.  Maintaining confidentiality of HIV-infected
    students and staff								Yes/No
d.  Worksite safety (i.e., universal precautions
    for all school staff)							Yes/No
e.  Confidential counseling for HIV-infected
    students									Yes/No
f.  Communication of the policy to students,
    school staff, and parents							Yes/No
g.  Adequate training about HIV infection					Yes/No
h.  Procedures for implementing the policy					Yes/No

Thank you for your responses.  Please return this questionnaire.

COMMENTS