Elementary School Data Collection Form
Table I - Annual Risk Assessment and biennial Physical Examination
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Student - unique ID number |
Gender
0=male
1=female |
Age in years |
Marker - Had risk assessment in past 12 months
0= no risk assessment
1=risk assessment |
Marker- Had physical exam in past 24 months
0=no exam
1= exam |
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( There should be 20 lines on each table) |
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Total |
0=
1= |
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0=
1= |
0=
1= |
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Measurement
1= 0-25% of charts with both markers documented
2= 26-50% "
3= 51-75% "
4= 76-95% "
5= >95% " |
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References: _____Bright Futures, ______ HEDIS, ______ USPHTF, _______ AAP, _______ PIPP, _________ Other (Please Identify)
Resources: _______Physical space is adequate for confidential screening/exams; _______Medical record forms available, _________ Permission by parent or other responsible adult, ___________________Assessment form (Identify whose form you used or if you developed your own)
Evaluation of Tool - Table I
(Please check the number on the scales that corresponds to your evaluation of the tools Table I).
Time ______1(Minimal amount) _______2 _______3 _________4 _________5 (excessive amount)
Ease of Use ______1(very easy) _______2 _______3 _________4 _________5 (very difficult)
Usefulness ______1(not at all useful) _______2 _______3 _________4 _________5 (very useful)
Table II: Asthma Chronic
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Student- Unique ID Number |
Gender
0=male
1=female |
Age in Years |
Marker- Asthma Plan
0=no asthma plan
1=asthma plan |
Marker - Number of visits in green zone or with documented improvement in clinical condition (*) / Number of visits since asthma plan in place |
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Total |
0=
1= |
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0=
1= |
Number of visits in green zone =
Number of visits since asthma plan= |
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Measurement
1= 0-40% of charts have asthma plan
2= 41-60% "
3= >60% "
4= Above plus 50-75% of visits show the student in green zone or (*)
5= Above plus >75% of visits show student in green zone or (*) |
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(*) No symptoms of cough or wheeze, improved lung function, reduction in number of severe attacks, minimized sleep disturbance, improved attendance in school, and or reduction in number of hospitalizations
References: _______ AAAAI, ___________ NHLBI, ________ AAP, __________
Other
Resources: ________Asthma plan, _______Peak flow meters, ___________ Primary care physician, __________ Parental permission, ____________
Evaluation of Tool - Table II
(Please check the number on the scales that corresponds to your evaluation of the tools Table II.)
Time ______1(Minimal amount) _______2 _______3 _________4 _________5 (excessive amount)
Ease of Use ______1(very easy) _______2 _______3 _________4 _________5 (very difficult)
Usefulness ______1(not at all useful) _______2 _______3 _________4 _________5 (very useful)
Table III: Incomplete Immunizations
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Student- Unique ID Number |
Gender0=male
1=female |
Age in Years |
Marker- students with incomplete immunizations who were brought up to date
0= no
1=yes |
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Total |
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Measurement
1=0-25% of records show that students behind in immunizations are brought up to date
2= 26-50% "
3= 51-75% "
4= 76-95% "
5= >95% " |
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References: ____________AAP Red Book, _______________State Registries _______________ Local Health Departments, _____________Other
Resources: _____________List of required immunization by state, ______________Educational material for parents and students,______________ Parent permission, ___________Chart form for immunization records, __________Policy for tracking students with incomplete immunizations, ____________ Policy regarding communication and collaboration with school personnel to identify students needing immunization , ____________ Other
Evaluation of Tool - Table III
(Please check the number on the scales that corresponds to your evaluation of the tools Table III )
Time ______1(Minimal amount) _______2 _______3 _________4 _________5 (excessive amount)
Ease of Use ______1(very easy) _______2 _______3 _________4 _________5 (very difficult)
Usefulness ______1(not at all useful) _______2 _______3 _________4 _________5 (very useful)
Table IV: High Risk for Unintentional Injury
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Student- Unique ID Number |
Gender
0=male
1=female |
Age in Years |
Marker- students at risk for unintentional injury had prevention materials sent home or documentation that student had received instruction regarding risk reduction.
0=no
1= yes |
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Total |
0=
1= |
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0=
1= |
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Measurement
1= 0-25% show evidence of prevention materials sent home
2= 26-50% "
3= 51-75% "
4= 76-95% "
5= >95% " |
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References: _________Bright Futures, ________AAP, ________ CDC __________
Children's Safety Network, ________ Safe Kids, __________PPIP_________ Other
Resources: _____________List of significant injuries to be prevented, __________Screening form in history, __________Primary prevention handouts/ aides for students and parents, ___________List of community resources, ________ School-wide health and safety promotional events _________ other
Evaluation of Tool - Table IV
(Please check the number on the scales that corresponds to your evaluation of the tools Table IV)
Time ______1(Minimal amount) _______2 _______3 _________4 _________5 (excessive amount)
Ease of Use ______1(very easy) _______2 _______3 _________4 _________5 (very difficult)
Usefulness ______1(not at all useful) _______2 _______3 _________4 _________5 (very useful)
Identify the focus of injury prevention activities (check all that apply): _______seat belt use, ________helmet use, _______playground injuries, _______ firearms safety, ___________ sports safety, ________ other (please identify)
Table V: Students Treated for ADD/ADHD
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Student- Unique ID Number |
Gender
0=male
1=female |
Age in Years |
Marker- Students with treatment plan in record
0= no
1=yes |
Marker _ Students with compliance and effectiveness of treatment plan in record
0= no
1=yes |
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Total |
0=
1= |
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0=
1= |
0=
1= |
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Measurement
1= 0-20% of charts with plan
2= 21-50% of charts with plan
3=>50% of charts with plan
4= Above plus 50% of charts with compliance check and effectiveness evaluation
5= Above plus >50% of charts with compliance check and effectiveness evaluation |
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References: ________ AAP, ________ DSM- IV, ________ DSM-PC, _______AHCPR,
________NIMH,
_________Other
Resources: ________Knowledge of treatment plan from provider, _________Knowledge of student performance, _____School IEP, __________Medication log, __________ Policy regarding communication and collaboration with School Administration, School Nurse, Guidance Counselor, Social Worker, School Psychologist and Faculty, __________Connors Parent Rating Scale-ADHD Index 1997, _________Connors Parent Rating Scale-DSMIV Sx. 1997, ___________Connors Teachers Rating Scale ADHD Index-1997, ________Connors Teachers Rating Scale DSMIV Sx 1997, __________AAP Practice Guidelines ADHD Algorithm
Evaluation of Tool - Table V
(Please check the number on the scales that corresponds to your evaluation of the tools Table V)
Time ______1(Minimal amount) _______2 _______3 _________4 _________5 (excessive amount)
Ease of Use ______1(very easy) _______2 _______3 _________4 _________5 (very difficult)
Usefulness ______1(not at all useful) _______2 _______3 _________4 _________5 (very useful)
Table VI: Child Abuse
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Student- Unique ID Number |
Gender
0=male
1=female |
Age in Years |
Marker- Students at risk for abuse reported
0= no
1= yes |
Marker- Evidence of ongoing case management for students who remain in school
0=no
1=yes |
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Total |
0=
1= |
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0=
1= |
0=
1= |
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Measurement
1= 0-50% of students identified are connected to appropriate agency
2= 51-95% "
3= >95% of students identified are connected to appropriate agency
4= Above plus 50-75% of students remaining in school are receiving ongoing case management
5= Above plus >75% of students remaining " |
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References: _________ AAP, ___________School Policy, __________ State
Regulations,
___________ Guidelines for specific professional disciplines,___________ Other
Resources: _________Policy regarding reporting suspected child abuse, __________Local resources, _________Child Abuse Quarterly Medical Update, ___________Institute for Professional Education, ________Policy regarding communication and collaboration with School Administration, School Nurse, Guidance Counselor, Social Worker, School Psychologist and Faculty, ____________ Other
Evaluation of Tool - Table VI
(Please check the number on the scales that corresponds to your evaluation of the tools Table VI.)
Time ______1(Minimal amount) _______2 _______3 _________4 _________5 (excessive amount)
Ease of Use ______1(very easy) _______2 _______3 _________4 _________5 (very difficult)
Usefulness ______1(not at all useful) _______2 _______3 _________4 _________5 (very useful)
Table VII: Poor School Performance
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Student- Unique ID Number |
Gender
0=male
1=female |
Age in Years |
Marker- Students with school failure are assessed for medical and mental health problems and plan is in place
0-=no
1=yes |
Marker - Students with school failure are referred and followed up for education plan to address problem
0=no
1=yes |
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Total |
0=
1= |
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0=
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0=
1= |
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Measurement
1= 0-50% of charts show record of medical and mental evaluation and referral
2= 51-95% "
3= >95% "
4= Above plus 50-75% have evidence of follow-up plan, linkage and referral for academic services
5= Above plus >75% " |
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References: ____________ Bright Futures, _________ DSM- PC, ______________Other
Resources: __________ Name of school academic counselors for students, ________ Policy regarding communication and collaboration with School Administration, School Nurse, Guidance Counselor, Social Worker, School Psychologist and Faculty, _________ Information regarding absences and discipline, __________Identified list of performance indicators from school: dropping grades, failing 2+, suspension from school, skipping school, trouble getting homework done, lack of interest
Evaluation of Tool - Table VII
(Please check the number on the scales that corresponds to your evaluation of the tools Table VII.)
Time ______1(Minimal amount) _______2 _______3 _________4 _________5 (excessive amount)
Ease of Use ______1(very easy) _______2 _______3 _________4 _________5 (very difficult)
Usefulness ______1(not at all useful) _______2 _______3 _________4 _________5
(very useful)
