Middle 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
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Age in years |
Marker - Had risk assessment in past 12 months
0= no risk assessment 1=risk assessment
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Marker- Had physical exam in past 24 months
0=no exam
1= exam
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( There must be 20 blank rows in this column for each table) |
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Total |
0=
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0=
1=
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0=
1=
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Measurement
1= 0-50% receive intervention
2= 51-95% receive intervention
3= >95 % receive intervention
4= Above plus 50% compliant with plan
5= Above plus 20% report smoking cessation
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References: _____Bright Futures, ________ GAPS, ______ HEDIS, ______ USPHTF, _______ AAP, _______ PPIP,_________ 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: Tobacco Use
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Unique student ID Number |
Gender
0 =Male
1=Female
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Age in Years |
Marker : smoker receiving treatment or referral
0=no
1=yes
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Marker: smoker adhering to intervention
0=no
1=yes
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Marker : stopped smoking
0=no
1=yes
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Total |
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0=
1=
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0=
1=
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0=
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1= 0-50% receive intervention
2= 51-95% receive intervention
3= >95 % receive intervention
4=Above plus 50% compliant with plan
5=Above plus 20% report smoking cessation
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References: _________ USPHS Clinical Practice Guideline for Treating
Tobacco Use & Dependence in JAMA, __________ ALA, _______AMA, ____________
AAP, __________ETR, ________________PPIP, __________Other
Resources: ________ age appropriate screen, ________ treatment plan or referral for treatment, ______________ Policy on adolescent confidentiality and receipt of health services, ________________Names of school and community substance abuse resources, ____________ Information about prevention for parents, ____________ School-wide health promotion events
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: Risk of Pregnancy
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Unique student ID Number |
Gender
0 =Male
1=Female
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Age in Years |
Marker: Those at risk of pregnancy with prevention plan
0=no
1=yes
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Marker: Reduction of pregnancy risk
0=no
1=yes
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Total
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0=
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0=
1=
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Measurement
1= 0-50% of at risk students have documented prevention plan
2= 51-95% "
3= >95% "
4= Above plus 50% of charts have documented a risk reduction
5= Above plus >50% of charts have documented a risk reduction
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References: ________GAPS, _________Bright Futures, _________AMA, _________Planned
Parenthood, ___________SEICUS, ____________ PPIP, ______________ETR, _________
Other
Resources: __________Staff education, comfort, confidence re: adolescent pregnancy prevention, ______________ Policy on adolescent confidentiality and receipt of health services, _______ Patient health education materials, _______ Family Planning services on site or referral for, ___________Methods available to treat, ______Stages of Change Work, __________Planned Parenthood, _________ SEICUS
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: Poor School Performance
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Student- Unique ID Number |
Gender
0=male 1=female
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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
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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=
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0=
1=
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0=
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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 V: Parent Child Conflict
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Unique student ID Number |
Gender
0 =Male 1=Female
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Age in Years |
Marker: students with history of parent child conflict are evaluated
and assessed for contributing factors and co morbidities
0=no
1=yes
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Marker: students with history of parent child conflict have a plan to
address problem
0=no
1=yes
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Marker: students showing reduction of conflict
0=no
1=yes
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Total |
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0=
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0=
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0=
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Measurement
1= 0-50% evaluated and assessed
2= 51-95% "
3= >95% "
4= Above plus 75% have a plan
5= Above plus 35% show reduction in conflict
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References: _________ GAPS, ___________ Bright Futures Mental Health,
___________ DSM -PC __________Other
Resources: ________Policy regarding confidentiality, _____________List of community resources and agencies for families, ___________On-site mental health services, _____________Medical and mental health evaluation for contributing factors (e.g., chemical use, family chemical use, physical abuse, depression, etc.), _____________"Family Conflict Scale", _____________Screen for co-morbidities
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: Students treated for ADD and ADHD
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Student- Unique ID Number |
Gender
0=male 1=female
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Age in Years |
Marker- Students with treatment plan in record
0= no
1=yes
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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=
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0=
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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, _________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
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Age in Years |
Marker: Evaluation, plan and /or referral in progress or completed
0= no
1= yes
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Marker: Documented improvement in depression
0=no
1= yes
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Total |
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0=
1=
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0=
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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)
