State Resources - Maryland
Guidelines for Maryland School-Based Health Centers

Objectives of Guidelines

To provide quality care within School-Based Health Centers is the key goal for Maryland State guidelines. High quality health care services will provide the best health outcomes for school-age children and adolescents and improve a child's readiness to learn. The objectives for Maryland's School-Based Health Center (SBHC) Guidelines are: (1) to provide a framework through which communities can engage in decision making for the development or expansion of SBHC programs; and (2) to promote the long term financial stability of SBHC.

Uses of the Maryland SBHC Guidelines

These guidelines were developed to guide the process for planning and implementation of new SBHCs as well as sustaining the existing SBHCs in Maryland and assisting in the expansion of these centers. The guidelines are not intended to be absolute; therefore, there is no enforcement component. Instead, they should serve as suggested practices and guiding principles for a new and developing field of health care delivery.

Some uses of the guidelines are: (1) as an assessment tool in assisting communities in planning, implementing and evaluating SBHCs; (2) as an assessment tool for site visit teams of local experts assisting local communities; (3) to communicate with parents, educators, and other community members about what may be expected from SBHCs; (4) to promote local agency resources to SBHC services; and (5) to identify SBHC development needs. They should be adapted to fit local circumstances, existing resources, and the numbers and health needs of the students in the school.

I. PLANNING

Detailed planning is essential to the successful implementation of School-Based Health Centers (SBHCs). The following presents a guide to the tasks involved in planning and creating a SBHC.

The role of the Planning Group is to provide the vision and leadership in moving from the needs assessment to the successful implementation of the school-based health center. This group should include representatives from a variety of community and agency groups that are interested in services to youth and children. Planning groups should reflect the unique nature of the community for which the SBHC is being planned and representation may include members from the following groups:

The planning group should identify a facilitator or one person who will coordinate the planning group.

A sponsor or lead agency should be identified early in the planning process. This agency would take the lead in providing and/or coordinating resources for the health center. The agency would provide leadership, hire or provide in-kind staff support, develop contractual relationships and identify strategies for or underwrite the long term financial stability of the SBHC. Examples: local health department; local education agency (LEA), hospital/community health nurse (CHN), or Managed Care Organization (MCO).

Systems Reform means changing the way decisions are made, the way services are funded and delivered. Decisions are made through an interagency process, from State planning to local planning and implementation, and from crisis- based to data and outcome-based planning. Services are funded by: (1) whenever possible, redirecting costly out-of-home services to services that support family preservation; (2) maximizing federal funding opportunities; (3) developing interagency budgets; and (4) making funding decisions based on goals and outcomes. Services are delivered, rather than from an individual but to a family focus, and from out-of-home to home and community-based services. Since 1990, the General Assembly has enacted legislation that mandates the establishment of Local Management Boards (LMBs) in every Maryland jurisdiction, the establishment of the Subcabinet Fund, and the development of a plan for a continuum of care and services that is family and child oriented and emphasizes prevention, early intervention and community-based services. The job of the LMB is to ensure the implementation of a local, interagency service delivery system for children, youth and families. Ultimately the goal of Systems Reform is for LMBs to decide program priorities, so it is important for the SBHC planning group to collaborate with LMBs. If the planning group is part of a jurisdiction-wide effort to implement SBHCs, the group could consider being a subcommittee of the LMB. This may help ensure maximization of interagency collaboration and take advantage of existing resources.

The needs assessment should provide a comprehensive profile of the physical and mental health needs of the youth in the community to be served by the SBHC. This is one of the most critical components of the planning process. It establishes the need for a SBHC in the school district or community being considered. Without a clear identification of need, one risks the placement of these services where they may not be fully utilized or sustainable long term.

The needs assessment must demonstrate the need at the individual school and may address the local jurisdiction as a whole. Where possible, use school-specific data that can be organized to show the zip codes or census tracts where most of the school population lives. It should show need in four areas: economic deprivation, poor health status, poor educational performance, and poor access to and utilization of health care. To show these needs, use Maryland State Department of Education (MSDE) Maryland School Performance Program Report Card, as well as MSDE and Department of Health and Mental Hygiene (DHMH) statistics. Planning teams should supplement these sources with local data. An excellent way to obtain access and utilization data is a survey of parents and students (as age-appropriate). Examples of useful data to show needs are:

Poor educational performance
Mobility rate
School drop out rate
Students absent more than 20 days
School attendance rate
Suspension rate
Expulsion rate
Educational attainment (from Report Card)
School Improvement Plan

Poor health condition
Morbidity and mortality rate of the target population
Hospitalizations for asthma for under age 21
Hospitalizations for dehydration for under age 21
Oral health status
Hearing and vision screening results
Cases of malnutrition
Cases of obesity
Accident and injury rate
Teen birth rates
Incidences of sexually transmitted diseases
Number of AIDS cases of ages 20-30 years who may have contacted the virus in teen years
Prevalence of low birth weight babies born to adolescent mothers

Mental Health Indicators (Direct and Indirect Measures of Need)
Direct Measures
Number of students currently utilizing or wait listed for mental health services
Number of suicide attempts

Indirect Measures
Prevalence of eating disorders
Incidences of runaway behavior
Number of children living in foster care or adopted
Proportion of children coded as Seriously Emotionally Disturbed (SED) in school population
Proportion of children coded for special education services with a known emotional component (i.e., learning disabilities)
Number of children/students who frequently change households or living arrangements
Proportion of youth referred to Juvenile Intake with identified mental health issues
Schools with population exposed to high levels of community violence
Schools with reported high incidences of membership in cults or other unusual groups associated with mental health problems
Number of CPS investigations of child abuse, sexual abuse, and/or neglect
Number of out-of-home placements

Economic deprivation
Medicaid eligibility
Free and reduced price meal eligibility.

Poor access to and utilization of health care
Immunization status
Emergency room usage by age
Medicaid eligibility
Early Prevention, Screening, Diagnosis, and Treatment (EPSDT) results
Hearing and vision screening follow-ups
Non-English speaking population
Teen birth
Incidences of sexually transmitted diseases
Prevalence of low birth weight babies born to teen mothers.

In addition, planning teams should consider:

- needs identified by students, parents and community(ies)
- extent to which existing services address the needs of the target population.

In making the final decisions, the planning group should weigh the following:

- need for primary health and mental health services
- level of health and mental health problems extracted from data available from the school nurse, school psychologist, guidance counselors, social workers and community agencies
- level of community and parental support
- support of the school principal and faculty
- geographic proximity to other community health care providers
- availability of adequate clinic space
- age of the students to be served.

School-Based Health Centers require the approval of and partnership with the school system. This is most crucial for the success of the program. In the planning stages of SBHCs, one should have the involvement and support of the following:

- local board of education
- local superintendent of schools
- principal
- school faculty and staff - school health services supervisors and staff
- School Improvement Team

Successful implementation of School-Based Health Centers depends on the availability of long term financing. This must be addressed in the planning stage. Plans for funding the initial planning, start up and long-term funding streams of SBHCs should include:

- third party reimbursement
- private/public funds available including medical institutions
- local in-kind contributions
- volunteer health provider time to augment health center staff
- Local Management Boards
- community and private sector support/donations.

A well planned, designed, and constructed (or renovated) school-based health center can support and enhance the operation and delivery of the required programs and services. There are several factors that should be considered as plans are developed before any design work or construction begins. The time and effort spent in the planning phase will contribute to the effective and efficient physical solution to meet the requirements of the center. Information on this subject is provided in Appendix #1.

As previously stated, the role of the Planning Group is to provide the vision and leadership in moving from the needs assessment to the successful implementation of the school-based health center. The purpose of the Advisory Board is to continue to shape, guide and support the SBHC on an ongoing basis. The support of the community and parents is essential to the successful implementation and ongoing growth of the SBHC. Ideally, the Advisory Board should be made up of students, parents, medical and mental health professionals, clergy, the school nurse, the principal, a school board member, school management team member (if one exists), a representative from the sponsoring agency, community organizations, elected officials, and private sector sponsors. Even after the planning group disbands, the advisory group continues. For continuity purposes, the Advisory Board may wish to incorporate members of the original Planning Group. Some of the ways the Advisory Board can accomplish its purpose of shaping, guiding and supporting SBHCs are through:

- monitoring the progress of the health center
- reviewing the programming
- suggesting new programing
- examining and offering suggestions on written materials
- assuming a public relations role with the community
- helping the SBHC identify and secure additional resources
- review program evaluation results

II. CONSENT TO ENROLL

School-based health centers will obtain consent from parents prior to providing health care to children. The enrollment forms should incorporate language specific to the age of the school's population, i.e., elementary school would differ from language of high school, etc. (See attached Appendix #2 sample enrollment form).

III. CONFIDENTIALITY

The SBHC must protect the confidentiality of specified student information and records. Inherent in the acquisition and maintenance of medical information is the responsibility for protecting the confidentiality of that information. Traditionally, children have received only limited health services in school. The advent of SBHCs has increased the types and intensity of these health services.

In order to provide the care, medical information must be accessible for the health professionals' use. The SBHC must maintain and communicate that information in a confidential manner. The SBHC should develop a confidentiality policy. An appropriate basis for a confidentiality policy is the 1992 Maryland State Department of Education document entitled "Confidentiality Guidelines for Student Education Records and Communications." (Appendix #3).

In many cases, it will be necessary and appropriate for SBHC staff to obtain consent to release information to a student's primary care provider, parents, teacher(s), school nurse, etc. Such sharing of information can maximize the quality of care a child receives, ensure coordination of care, and ensure that persons responsible for helping students outside of the health center, e.g., parents and teachers have information that enables them to provide appropriate support. In all cases, specific releases should be obtained prior to sharing of information.

For further information on confidentiality, see Appendix #4 For National Association of State School Nurse Consultants, Inc., document entitled "Confidentiality of Health Information in Schools." Also, see Appendix #5 For National Association of School Psychologists document entitled "Principles for Professional Ethics" and Appendix #6, American Psychological Association's article entitled "Casebook on Ethical Principles of Psychologists."

IV. ACCESS to RECORDS

The confidentiality policy developed by the SBHC should state that the SBHC will:

- Keep health records in locked files or under the direct supervision of a staff member when not in use.
- Restrict access to the records. Only persons with a legitimate medical interest in the child should have access to the records.
- Allow access by parents and other staff only in accord with the Federal and State Regulations on accessing medical records. (Appendix #7A and 7B).
- Report and record information of a sensitive nature (e.g., HIV status, reproductive health care) in accord with State and Federal Regulations. (Appendix #8A and 8B).
- Disclosure of a student's or staff member's HIV status should be based on written informed consent, which lists the contents and recipients of information. For students, the consent form must be signed by parents/guardians.
- Release records to other persons only with the signed informed consent of the patient or parent, as required by Federal and State laws.
- A standardized interagency request for information should be developed which requires the requesting agency to be specific about the type of information requested and the purpose for which it is intended.
- The consenting person should sign the Request for Information so that they can see the information being sought and for what purpose it will be used.
- The SBHC should designate the persons authorized to initiate and respond to the requests.

V. ACCESSABILITY STANDARDS

School-Based Health Centers will be accessible and designed to eliminate or diminish barriers to care for students and increase participation by parents and guardians.

The SBHC should have regularly scheduled hours of operation and, to the extent possible:

- accommodate working parents and guardians
- allow for urgent appointments
- permit scheduled appointments that do not interrupt classroom time unnecessarily

The SBHC must have in place a telephone answering method that notifies students, parents and guardians where and how to access 24 hour back up services when the center is not open.

Enrollment and registration processes must provide for effective collection of information regarding third-party billing resources and the identity of primary care providers. The SBHC may not deny care to students without insurance.

The SBHC information (i.e., hours of operation, location, etc.) should be displayed in a public location in the school, and in multiple languages if appropriate to the student population.

The SBHC and all of the rooms and support spaces must be accessible to individuals with disabilities.

Identify the anticipated hours of operation on a daily, weekly, monthly, and annual basis. A preliminary calendar (for one year) should be developed which identifies all programs and services that will be operated and their time of operation.

VI. CULTURAL COMPETENCE/SENSITIVITY

The SBHCs are encouraged to ensure that its staff has education in cultural diversity that reaches beyond language and is appropriate to the specific SBHC. Translation services, appropriate to the major school population, should be provided by the staff or interpreters in a manner that ensures confidentiality.

The SBHC should conform with anti-discrimination laws.

VII. PROFESSIONAL QUALIFICATIONS

Health care for students should be provided by a licenced, registered or certified health practitioners, including but not limited to nurse practitioners, nurses, and physicians, who are educated and experienced in community and school health, and who have knowledge of health promotion and illness prevention strategies for children and adolescents. The SBHC's sponsoring agency must ensure that all providers have appropriate professional qualifications and supervision.

The SBHC's sponsoring agency must develop a written verification process that includes the review of their current original licensure or certification.

The process of reviewing professional qualifications should remain ongoing and up-to-date. At a minimum, the sponsoring agency should obtain verification of the following from primary sources:

- a current licence or certification to practice, which may not be a copy or facsimile of the license or certificate
- a valid drug enforcement agency (DEA) certificate as applicable
- evidence of board certification or board eligibility for physicians
- work history
- liability coverage for malpractice, as applicable.
- Professional liability claims history.

The applicant must complete an application for employment that includes an attestation to correctness and completeness of the application. The employment application must require a statement from the applicant regarding:

- reasons for any inability to perform the essential functions of the position, with or without accommodations
- lack of impairment due to chemical dependency or substance abuse
- history of loss of licence or sanctions on license
- felony convictions.

Criminal history records checks are required as provided by Maryland Law for all personnel working in schools (Annotated Code of Maryland, Family Law Article, Section S-561 and COMAR 12.15.02.03 - See Appendix 9).

The sponsoring agency should request information on practitioners from monitoring organizations (see Appendix 10 for example). These organizations may include but are not restricted to:

- information from National Practitioners Data Bank and other data banks
- information from the State Licensing Boards for health care practitioners (see Appendix 11)
- information on previous sanction activity by Medicare and Medicaid and
- NP written agreement.

If the SBHC provides mental health or substance abuse treatment services directly, providers of these services should have experience and/or education necessary to work with the school population of children, adolescents, and their families.

SBHCs are encouraged to promote staff participation in professional

development/training programs to update and enhance their knowledge of child and adolescent health, diversity, and other issues as identified by each SBHC.

SBHC staff are trained in emergency care, including general first aid, cardiopulmonary resuscitation, and the Heimlich maneuver. The school should incorporate the SBHC into its existing disasters and crisis intervention plans which are coordinated with the community emergency response system. All SBHC staff should be trained in implementing the plan.

VIII. ADMINISTRATION AND STAFFING

It is recommended that SBHCs establish linkages with existing community medical, mental health, substance abuse, social services groups and local health departments, professional schools, and community hospitals. It is vital that SBHCs be integrated with the school administration and school health services structure.

In addition, it is recommended that a job description be developed for staff listed below. The minimum suggested staffing for school-based health centers is:

- One full time registered nurse who serves as clinical manager and school nurse
- An authorized prescriber (pediatric nurse practitioner, nurse midwife or physician) who may serve either part time or full time
- Mental health provider
- Clerical assistant or community worker.

Additional SBHC staffing may include:

- Oral health provider (dental hygienist/dentist)
- Health assistant
- Addictions counselor.

The authorized prescriber and the mental health provider's status as full time or part time should depend on: student enrollment; the services needed by students; and other health care resources available on site.

IX. SERVICES

Medical Services

Medical services should be provided in accordance with standards such as the AAP "Guidelines for Health Supervision," AMA GAPS, and/or the Maryland State EPSDT program guidelines. Available services may include:

Age and developmentally appropriate primary care services which may include but are not limited to:

- Comprehensive medical, family and psychosocial history
- Comprehensive physical examination
- Immunizations
- Developmental assessment
- Vision/hearing and dental screening
- Diagnosis and treatment for acute illness and injury
- Management of known and stable chronic conditions in conjunction with speciality and/or primary care provider
- Prescription and/or dispensing medication for acute illness and stable chronic conditions
- Routine screening laboratory
- Speciality referrals
- Dental referrals
- Case management

- Health education (one-on-one and/or group)
- Health promotion and risk reduction activities.

Age and developmentally appropriate reproductive health care may be provided

according to community acceptance, documented need and community norms. Services may include the following:

- Routine gynecological (GYN) evaluations
- Family planning services and/or referral
- Prescribing and/or dispensing prescription and non-prescription contraceptives
- On-site pregnancy testing and/or referral for testing
- Comprehensive pregnancy options counseling
- Referral for prenatal care
- Diagnosis and treatment for STD or referral for diagnosis and treatment of STD
- HIV risk assessment
- HIV pre-and post-test counseling and testing or referral for counseling and testing
- Reproductive health education
- Case management.

Mental Health/Social Work Services

The SBHC should provide mental health and substance abuse services either on site or through referral arrangements. Optimally, students would have access to these services on-site; minimally, students would be referred for services that would offer:

- immediate response to emergency/crisis situations
- urgent appointments whenever possible within the same day and no later than three calendar days after the request for services is made and
- non-urgent appointments within seven calendar days.

The SBHC should provide or make available comprehensive primary medical, social, mental health, and health education services designed to meet the psychosocial and physical needs of children and youth within the context of the student's family, culture, and environment including mental health assessments, crisis intervention, counseling, and referrals to a treatment continuum of services including emergency psychiatric care, community support programs, inpatient care, and outpatient programs.

The State Department of Health and Mental Hygiene's Specialty Mental Health System ASO needs to preauthorize mental health services beyond primary mental health for a child experiencing a severe or pervasive mental health problem. Upon ASO authorization, mental health services will be Medicaid reimbursable for eligible children, possibly for a series of sessions/services needed by the child.

Mental Health Services (if provided on-site)

The SBHC should provide mental health care in both individual and group settings, including assessment, treatment, referral, and crisis intervention. Services include:

- Physical or sexual abuse, identification, referral and counseling
- Alcohol or other substance abuse assessment, counseling and referrals
- Depression or other affective disorders
- Behavioral or conduct problems
- Adjustment and anxiety disorders and
- Other psychiatric disorders.

Drug and Alcohol Services (if provided on-site)

The SBHC should provide substance abuse assessment, counseling/referral, and group and family counseling. Staff and parental involvement are essential in any drug and alcohol programs offered through SBHCs.

Recommended mental health care practitioners are: psychologists, social workers, certified professional counselors, psychiatrists, and nurse psychotherapists.

Social Services (if provided on-site)

The SBHC should provide initial assessments and referrals to social service agencies, and may provide some on-site services. Services include:

Social service assessment, referral, and follow-up for needs such as:

- Basic needs (food, shelter, clothing)
- Legal services
- Public assistance
- Assistance with Medicaid and other health insurance enrollment
- Employment services and
- Day-care services.

Transportation arrangements to back up facility or referral site.

Dental Services

SBHCs should strive for the following dental services. These can include screenings, cleanings, sealants, and topical fluoride treatments provided by a licensed dentist or hygienist. A dental hygienist may provide these services without a dentist on the premises if the SBHC applies for a waiver from the State Board of Dental Examiners under COMAR 10.44.21 (see Appendix 12). Services requiring a licensed dentist may be offered through a SBHC which can include fillings and extractions.

The SBHC should provide, at a minimum, periodic oral screening by a health care provider with referrals to an established dental network for those services beyond the scope of the SBHC.

Health Education

The SBHC should provide health education for the students, their families, and health center staff, and where possible and appropriate support the provision of comprehensive health education in the classroom. Services include:

- One-on-one patient education
- Group/targeted education at the SBHC
- Family and community health education
- Health education for health center and school staff
- Mental Health
- Tobacco, alcohol and other drugs
- Personal responsibility and connection to services
- Nutrition and fitness
- Safety and injury prevention
- Family life/human sexuality (as age appropriate)
- Disease prevention.

Conclusion

Great diversity exists around the country in the definition of a school-based health center, in the range of services provided in a SBHC, and in the staffing and organization of these centers. This diversity is reflected in the SBHCs currently existing in Maryland.

School-Based Health Centers - Facility Needs and Requirements

Introduction

The programs and services in a school-based health center can vary from site to site even within the same school system. The school-based health center, however, should be planned and designed to meet the specific needs and requirements for the community that it will serve. The form, space and associated factors (identified below), must follow the functions, and the program and service requirements specified. This planning concept should be considered for new construction, additions, and/or renovations when school-based health centers are being planned, designed, and constructed. A written description of the items listed below will facilitate the planning process or self-assessment.

Goals and Planned Usage

Identify the school-based health center programs and services that will be provided in the center. Selections can be made through a study of school and community needs.

Operational Schedule

Identify the anticipated hours of operation on a daily, weekly, monthly and annual basis. A preliminary calendar (for one year) should be developed which identifies all programs and services that will be operated and their time of operation.

Number of Users

Identify the numbers and ages of the individuals that are anticipated to be utilizing the center. Consideration should be given to caseloads and anticipated occupancy at any given time of the center's operation. This would include a comprehensive list of the staffing requirements for each program and service. Full-time, part-time, and on-call staff should be determined.

Relationship to School Health Services

The relationship between the school-based health center and the school health services functions must be clearly identified. Consideration should be given to combining these two programs and services to develop an effective and efficient unit that will serve the school population and the school's larger community.

Accessibility

The specific needs and requirements for access to and from the center depend upon: (a) the relationship between the school-based health center program and the school's health programs; (b) the days/nights of planned operation; © the weeks and/or months that the center will be open; and (d) the coordination of programs and services between participating agencies and entities. There should be direct access from the interior of the school building to the school-based health center for students to receive their services during regular school hours. Most programs will require an entrance from the outside directly into the school-based health center area to serve the public during regular school hours as well as in the evenings, weekends, and when school is not in session. The centers and all of the rooms and support spaces must be accessible to individuals with disabilities. Consideration should be given to access to the center by medical emergency vehicles.

Parking

Identify the number of parking spaces that should be provided or considered for staff and patients. Handicapped parking and accessibility must be provided.

Security

The entire school-based health center should be planned for a high level of security. Provisions should be made to separate the school-based health center from the other parts of the school building when the school is not in session. Particular attention must be given to records storage areas, and any areas where medical supplies and equipment will be located. Consideration should be given to a security system, and separate keying for this area and a procedure established to control access to these keys.

Spatial Requirements

The spatial requirements for each school-based health center will depend on the programs and services that will be provided. The spaces identified below are a partial listing of programs or services, and the range of square footage that might be required. It should be noted that in some situations, more than one space for a specified function may be required. It may also be possible, based on the staffing and duration of the programs and services, to have a space shared between two or more individuals to maximize the efficient use of the space and reduce capital expenditures. In reviewing the space required for the laboratory, consider the type of testing, functions to be performed, and the regulatory requirements. The figures cited below are net square footage (interior wall to wall for each space) and do not include wall thicknesses or circulation and corridor space.

Spatial Relationships

The programs, services, and functions should be studied to determine how the spaces should be clustered or arranged. Explain how the spaces for each of the programs, services, and functions should relate to each space identified.

Acoustical Requirements

Each space used for examinations or meetings with patients must be treated to ensure that private conversations held in the space will not be heard in any other space.

Climate Control Requirements

The entire school-based health center should be treated for heating, cooling, and ventilation for the periods of time that the center will be in use. A separate mechanical system should be considered for this area of the building, particularly if it will operate during non-school hours. Special attention should be given to the examination room, lavatories, and the lab room.

Plumbing Requirements

A sink with hot and cold water should be provided in each examination room, each lavatory and in the lab room.

Electrical/Electronic Requirements

Electrical outlets should be provided in all spaces as required by code. The electrical circuit for refrigerators and/or freezers should remain active at all times, even when school is not in session. Locations should be identified for telephones and computer terminals (with modem needs and/or local area networks). An intercom system internal to the school-based health center should be provided, possibly through the use of the telephone instrument. The school's central office and intercom system should be connected to the school-based health center as well.

Lighting Requirements

Natural lighting should supplement artificial lighting in the school-based health center. Lighting in each space should be able to be controlled by the occupant of the space. Special attention should be given to the lighting and ballasts selected for the space that will be used for vision and hearing testing.

Sanitary Requirements

The surface finishes in these areas should be designed for easy cleaning and sanitizing without sacrificing an aesthetically pleasing environment. This would include the treatment of floors, walls, windows, window blinds/shades, and counter tops. Provisions should be made for the containment and removal of medical waste, in accordance with the MOSHA law.

Display

Identify the requirements for bulletin boards, tack strips, display cases, display rack for educational/medical brochures, marker boards, and chalkboards for each space as required and appropriate.

Movable Furniture and Equipment

The movable furniture and equipment that are required for each space should be identified. This includes desks, tables, chairs, bookcases, cots or beds, locked storage cabinets for medications, syringes, etc., file cabinets, magazine racks, children's toy chest, computer terminals and printers, telephones, photocopier, wall clocks, refrigerator, freezer, specialized medical/dental equipment, and any other items that may be required. Any piece of furniture or equipment that needs electrical or plumbing connections should have its requirements specifically identified.

Funding - Capital Improvements

Identify the estimated square footage required for the programs and services that will be included in the school-based health center. This figure should be the gross square footage, which include the wall thicknesses and the circulation space in the center, and any connecting corridors that will be required. A budget should be developed that realistically reflects the estimated cost for new construction, renovations, and/or additions which are appropriate for the project.

Conclusion

The school-based health center can and should be planned, designed, and constructed to support and enhance the delivery of the programs and services that have been identified for the school and the community. This can best be accomplished by developing a clear and concise presentation of the needs and requirements for the center.

CHECK LIST

How well does the facility used for the school-based center meet the current and projected needs and requirements of the school and the community?

*Explain deficiency and identify what is required, below.

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