Form 13 School Physical Activity and Nutrition Policies and

SSA ATTACHMENT 19

HEALTHY COMMUNITIES STUDY

HEALTHY COMMUNITIES STUDY

SCHOOL ENVIRONMENTAL ASSESSMENT

PROTOCOL FOR SCHOOL NUTRITION AND PHYSICAL ACTIVITY POLICIES

AND PRACTICES QUESTIONNAIRE

The following document contains the school environmental assessment protocol that will be followed to obtain information on the policies and practices related to nutrition and physical activity for each school from which the sample of children/families was recruited. The school liaison at each recruited school will be asked by NORC to complete a web-based survey on the school’s nutrition and physical activity policies and practices.

School Policies and Practices Related to Nutrition and Physical Activity Public reporting burden for this collection of information is estimated to average 25 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0649). Do not return the completed form to this address. Please complete this questionnaire about the following school: Name of school [PRE-LOADED SCHOOL NAME] Discuss these questions with other school personnel as needed to get the most accurate responses possible. Personnel that may be particularly helpful include the school principal, district or school curriculum director or relevant subject matter lead, and physical activity coordinator. If you have any questions, please contact NORC at 1-866-209-0129 or via email at HCS@norc.org. Thank you for your continued assistance with this study! Please answer questions for the current school year (if school is in session) or the previous school year (if school is not in session or data is not yet available for the current year).

School Liaison ID: ___________________ Date: ____ /____ /_______ (mm/dd/yyyy)

Current or Most Recent School Year: ____ (yyyy) to ____ (yyyy)

1.

What is/was the average daily attendance for the current/most recent school year at this school? Please record a percent.

__________% of Students

1a.

How many total students are/were enrolled at this school during the current/most recent school year?

__________Number of Students

For each of the following items, indicate to what extent and for how long your school has been doing the following: EXAMPLE: if this school “Requires a specified number of hours of nutrition instruction for all grade levels” and has had this 100% implemented for the past 4 years, select the “Completely (>90% implemented)” option and enter 4 for the number of years. If the school has been open for 15 years and has never required nutrition instruction at any grade level, select "To a limited extent or not at all (<10% implemented)” and enter 15 for the number of years.

2.

Requires a specified number of hours of nutrition instruction for all grade levels.

To a limited extent or not at all (<10% implemented) 1 To some extent (10-50% implemented) 2 To a large extent (51-90% implemented) 3 Completely (>90% implemented) 4 # years: _____

3.

Implements a comprehensive, sequential nutrition education program that includes all grade levels?

To a limited extent or not at all (<10% implemented) 1 To some extent (10-50% implemented) 2 To a large extent (51-90% implemented) 3 Completely (>90% implemented) 4 # years: _____

4.

Has a team that meets on a regular basis to plan or review a comprehensive nutrition education program or curriculum.

To a limited extent or not at all (<10% implemented) 1 To some extent (10-50% implemented) 2 To a large extent (51-90% implemented) 3 Completely (>90% implemented) 4 # years: _____

5.

Uses nutrition instruction materials that are based on health education content standards.

To a limited extent or not at all (<10% implemented) 1 To some extent (10-50% implemented) 2 To a large extent (51-90% implemented) 3 Completely (>90% implemented) 4 # years: _____

6.

Has implemented the Nutrition Education Goals of the local wellness policy.

To a limited extent or not at all (<10% implemented) 1 To some extent (10-50% implemented) 2 To a large extent (51-90% implemented) 3 Completely (>90% implemented) 4 # years: _____

7.

Has implemented the Physical Activity Goals of the local wellness policy.

To a limited extent or not at all (<10% implemented) 1 To some extent (10-50% implemented) 2 To a large extent (51-90% implemented) 3 Completely (>90% implemented) 4 # years: _____

8.

How does this school compare to other schools of the same level [elementary, middle] in the district with regard to implementation of the nutrition components of the wellness policy?

Less fully implemented than most 1 About the same as most 2 More fully implemented than most 3 There are no other schools at our level in the district 4

9.

How often did your school health or wellness council, committee, or team meet during the past 12 months?

Did not meet 0 1-2 times 1 3-4 times 2 5-6 times 3 >6 times 4 No school council…(Skip to Q.10) 5

9a.

For how many years has this school health or wellness council, committee, or team been meeting on a regular basis?

_____ Number of Years

10.

Currently, does someone in your district or school coordinate school health or wellness, for example, a school health coordinator, AND, IF SO, at what level do they provide this coordination?

No………..(Skip to Q.11) 0 Yes, at both the district and school levels 1 Yes, at the district level only 2 Yes, at the school level only 3

10a.

How long has this person been in this position?

_____ Number of Years and _____ Number of Months

The next questions are about your school’s policies and practices related to physical activity and/or physical education.

11. In the past 12 months has your school…

Yes No

a.

Sought positive media attention for physical education?

b.

Provided families of all students with information on physical activity?

c.

Offered school-wide physical activity or sports events, such as fun runs, to families of all students?

d.

Provided awards or recognition for outstanding physical activity programs, such as intramural or interscholastic sports programs?

12. In the past 12 months, has your school collaborated on physical activity programs with any of the following?

Yes No

a.

A local health department.

b.

A local hospital.

c.

A local mental health or social services agency.

d.

A health organization, such as the American Heart Association or American Cancer Society.

e.

A local college or university.

f.

A local business.

g.

A local parks or recreation department.

h.

A local youth organization, such as the Boys and Girls Clubs.

i.

Alliance for a Healthier Generation.

j.

A local service club, such as the Rotary Club.

k.

A local health or fitness club.

l.

A local professional sports team.

m.

A local department of transportation or public works.

n.

A local law enforcement agency.

The next questions ask about the use of physical activity as punishment for bad behavior and excluding students from physical activity or physical education as punishment for bad behavior.

13.

Has your school adopted a policy that prohibits teachers from excluding students from all or parts of recess as punishment for bad behavior or failure to complete class work?

Yes 1 No 0

14.

Has your school adopted a policy that prohibits teachers from using physical activity, for example running/walking laps or pushups, to punish students for bad behavior?

Yes 1 No 0

15.

Has your school adopted a policy prohibiting physical education teachers from excluding students from all or part of physical education class(es) as a punishment for bad behavior?

Yes 1 No 0

The last few questions ask about your school’s active transport policies and practices.

16. Does your school do any of the following activities to support or promote walking or biking to and from school?

Yes No

a.

Use paid or volunteer crossing guards.

b.

Use a walking school bus (a walking school bus is a group of children walking to or from school with one or more adults).

c.

Use law enforcement officials to promote traffic safety near the school.

d.

Use law enforcement officials to prevent crime near the school.

e.

Provide bicycle racks at school.

f.

Provide promotional materials to students or parents such as safety tips or maps of bicycle or walking routes to schools.

g.

Use traffic calming devices to slow driving speeds near the school.

h.

Use reduced speed limits in a specified school zone during peak school travel times.

17.

On an average school day, what percent of students walk or bike TO your school in the morning? Please check () only one answer.

Less than 10% 1 10-20% 2 21-30% 3 31-40% 4 41-50% 5 51-60% 6 61-70% 7 71-80% 8 81-90% 9 More than 90% 10

18.

On an average school day, what percent of students walk or bike home (or to some other destination) FROM your school in the afternoon? Please check () only one answer.

Less than 10% 1 10-20% 2 21-30% 3 31-40% 4 41-50% 5 51-60% 6 61-70% 7 71-80% 8 81-90% 9 More than 90% 10

19.

Does your school prohibit students from walking or biking to or from school?

Yes 1 No 0