High School Data Collection Form
Table I: Annual Risk Assessment and Biennial Physical Exam
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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 must be 20 rows in this column for every chart) |
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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, ________GAPS, ______ HEDIS, ______ USPHTF, _______ AAP, _______ PPIP, _______ HEADSS, _________ Other (Please Identify)
Resources: _______Physical space is adequate for confidential screening/exams; _______Medical record forms available, _________ Permission by parent or other responsible adult, __________Policy on adolescent confidentiality and receipt of health services
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: Alcohol Use
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Unique student ID Number |
Gender
0 =Male
1=Female |
Age in Years |
Marker: Those using alcohol have been evaluated for co morbidities and abuse
0=no
1=yes |
Marker: Those abusing alcohol or at high risk for abuse have intervention, plan and referral
0=no
1=yes |
Marker: Reduction risk or of abuse
0=no
1=yes |
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Total |
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0=
1= |
0=
1= |
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Measurement
1= 0-50% evaluated for co morbidities and abuse
2= 51-95% "
3= >95% "
4= Above plus 50% of those evaluated with evidence of intervention, plan or referral
5= Above plus 10% report drinking cessation |
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References: __________GAPS,___________NIDA, ____________SAMHSA, __________
AAP, _____________ETR, _________________PPIP, _______________Other
Resources: __________Policy regarding communication and collaboration with School Administration, School Nurse, Guidance Counselor, Social Worker, School Psychologist and Faculty, _____________Policy on adolescent confidentiality and receipt of health services, _____________Names of school and community substance abuse, ______________Referral relationship with substance abuse programs, _______________Information about prevention for parents, __________________ Screening tool (ie CAGE, AUDIT),_____________Screen for co morbidities
Evaluation of Tool - Table II
(Please check the number on the scales that corresponds to your evaluation of the tools TableI 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: Risk of Personal Violence
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Unique student ID Number |
Gender
0 =Male
1=Female |
Age in Years |
Marker: those at risk for personal violence with prevention plan
0=yes
1=no |
Marker: Reduction of personal violence risk
0=no
1=yes |
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Total |
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0=
1= |
0=
1= |
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Measurement
1= 0-50% with intervention, plan and referral
2= 51-95% "
3= >95% "
4= Above plus 25-50% reduced risk
5= Above plus > 50% reduced risk |
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References: ___________CDC, _____________Hamilton Fish Institute, _______________SAMHSA,
_________PPIP, _____________GAPS, _______________Other
Resources:___________ List of categories of violence to be prevented eg, rape, abuse, weapons, fighting, gangs, suspension, arrest, _____________Screen for co morbidities, _____________Primary prevention aides for students, parents, ___________List of community resources, ____________Planned school-wide health and personal safety promotional events
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: Risk of STI
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Unique student ID Number |
Gender
0 =Male
1=Female |
Age in Years |
Marker: those at risk for STI are tested and treated
0=no
1=yes |
Marker: documented reduction of risk
0=no
1=yes |
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Total |
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0=
1= |
0=
1= |
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Measurement
1= 0-50% with appropriate assessment and treatment
2= 51-95% "
3= >95% "
4= Above plus 25%-50% report reduced risk at next visit
5= Above plus >50% report reduced risk at next visit |
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References: ___________GAPS, _________________CDC Guidelines, _______________IOM,
__________PPIP, _____________Other
Resources: ______________Risk assessment for STI, _______________Protocols for diagnoses and treatment of STIs, ____________Referral resources for further evaluation & treatment, ______________On site resources for dx & rx of STI, ____________List of contributing factors to STI, e.g., sexual contact, _________Stages of Change training
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)
Table V: Poor School Performance
|
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=
1= |
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)
Table VI: Students treated for ADD and 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 evaluation 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, ___________AHCPR, ________ DSM- IV, ________
DSM- PC, _________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 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 Risk for Depression
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Unique student ID Number |
Gender
0 =Male
1=Female |
Age in Years |
Marker: Evaluation, plan and /or referral in progress or completed
0= no
1= yes |
Marker: Documented improvement in depression
0=no
1= yes |
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Total |
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0=
1= |
0=
1= |
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Measurement
1= 0-50% with completed evaluation, referral and plan
2= 51-95% "
3= >95% "
4= Above plus 25%-50% show improvement
5= Above plus> 50% show improvement |
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References: ____________________GAPS, _____________________DSM-PC, _______________AHCPR,
___________________SAMHSA, ________________Other
Resources: __________ Teen confidentiality, _____________Pediatric Symptom Checklist, ________________Access to resources for full mental health evaluation, ___________________Psychiatric referral
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)
