Bright Futures, HEDIS, USPHTF, AAP, PIPP, Other (Please

Elementary School Data Collection Form Final Version (2/1/01) 1 Table I Annual Risk Assessment and Biannual Physical Examination Student unique ID number ( There should be 20 lines on each table) Gender male female Age in years Marker Had risk assessment in past 12 months no risk assessment risk assessment Marker- Had physical exam in past 24 months no exam exam Total Measurement 0-25% of charts with both markers documented 2= 26-50% 3= 51-75% 4= 76-95% 5= >95% References: Identify) Bright Futures, HEDIS, USPHTF, AAP, PIPP, Other (Please

Elementary School Data Collection Form Final Version (2/1/01) 2 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)

Elementary School Data Collection Form Final Version (2/1/01) 3 Table II: Asthma Chronic Student- Unique ID Number Gender male female Age in Years Marker- Asthma Plan no asthma plan asthma plan Marker Number of visits in green zone or with documented improvement in clinical condition (*) / Number of visits since asthma plan in place Total Number of visits in green zone = Number of visits since asthma plan= Measurement 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 (*) (*) 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,

Elementary School Data Collection Form Final Version (2/1/01) 4 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)

Elementary School Data Collection Form Final Version (2/1/01) 5 Table III: Incomplete Immunizations Student- Unique ID Number Gender male female Age in Years Marker- students with incomplete immunizations who were brought up to date no yes Total Measurement 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% 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

Elementary School Data Collection Form Final Version (2/1/01) 6 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)

Elementary School Data Collection Form Final Version (2/1/01) 7 Table IV: High Risk for Unintentional Injury Student- Unique ID Number Gender male 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. no yes Total Measurement 0-25% show evidence of prevention materials sent home 2= 26-50% 3= 51-75% 4= 76-95% 5= >95% 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

Elementary School Data Collection Form Final Version (2/1/01) 8 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)

Elementary School Data Collection Form Final Version (2/1/01) 9 Table V: Students Treated for ADD/ADHD Student- Unique ID Number Gender male female Age in Years Marker- Students with treatment plan in record no yes Marker _ Students with compliance and effectiveness of treatment plan in record no yes Total Measurement 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 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,

Elementary School Data Collection Form Final Version (2/1/01) 10 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)

Elementary School Data Collection Form Final Version (2/1/01) 11 Table VI: Child Abuse Student- Unique ID Number Gender male female Age in Years Marker- Students at risk for abuse reported no yes Marker- Evidence of ongoing case management for students who remain in school no yes Total Measurement 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 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

Elementary School Data Collection Form Final Version (2/1/01) 12 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)

Elementary School Data Collection Form Final Version (2/1/01) 13 Table VII: Poor School Performance Student- Unique ID Number Gender male female Age in Years Marker- Students with school failure are assessed for medical and mental health problems and plan is in place 0-=no yes Marker Students with school failure are referred and followed up for education plan to address problem no yes Total Measurement 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% 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,

Elementary School Data Collection Form Final Version (2/1/01) 14 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)