Health Education
Our school has written, sequential nutrition education curriculum aligned with the Texas Essential Knowledge and Skills   Yes No   Which statement describes how health education is taught in your school? (Check all that apply)   Health education is taught as its own class separate from P.E. Health education is taught in conjunction with P.E. Health education is incorporated into other subjects Health education is not taught at all   If health education is incorporated into other subjects, please provide a lesson plan exemplifying this.   When is health education offered? (Check all that apply)   K 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade Health Education is not offered

Health Education
Our school offers a quick course for health education, such as a summer class or self-paced module.   Yes No   Our school allows some students to be exempt from taking a health education course.   Yes No   Please describe exemptions:   What credentials does the health education teacher hold?   Certified Health Education Specialist (CHES) College degree in health education or related field No health education specific credentials Other   Please describe credentials:   How many credits (or classes) of health education are each student required to take?   1 credit 2 credits 3 credits 4 or more credits

Physical Education
Our school provides separate times for structured physical education and recess (they are not combined).   Yes No
Elementary Only (Next question)
Students in my school participate in structured physical activity for:   Less than 135 minutes a week Exactly 135 minutes a week More than 135 minutes a week Does not apply
High School Only (Next 2 questions)
Students in my school are required to take:   Less than 1.5 physical education credits Exactly 1.5 physical education credits More than 1.5 physical education credits Does not apply   At least .5 of the physical education credits must include Foundations of Personal Fitness.   Yes No Does not apply

Physical Education
Physical education is taught by a certified physical education teacher.   Yes No   Our school has a written, sequential physical education curriculum aligned with the Texas Essential Knowledge and Skills.   Yes No   Please provide an outline of curriculum   Our school uses incentives to encourage participation in physical education.   Yes No   Please describe the incentives that are used:

Physical Education
Our physical education teacher uses written lesson plans with objectives that guide instruction at all grade levels.   Yes No   How many times per week would a typical P.E. class meet?   1x/week 2x/week 3x/week 4x/week 5x/week   In an average P.E. class, what percent of the time are the students physically active?   Less than 20% 20% - 39% 40%- 59% 60% - 79% 80% or greater   What assessment strategies are used in physical education classes? (Check all that apply)   Written Rubrics/guidelines for skills Rubrics/guidelines for social and self responsibility Portfolios Self reflection and goal setting None Other   Please describe other assessment strategies:

Physical Education
Our school offers ALL students and opportunity for unstructured physical activity, such as recess, outdoor time, or supervised open gym time, for at least 20 minutes per school day:   Every school day 3 to 4 days a week 1 to 2 days a week Unstructured physical activity opportunities are not offered routinely or are not offered to all students   What does your school do to promote physical activity at the school, in the home, and in the community? (Check all that apply)   Newsletters Activity Calendars Activity Events Activity Clubs Summer Shape-up Governor's Challenge Walk to School Programs Fit Kids Challenge None Other   Please describe other promotion activities:   In the past 12 months, how many physical activity events, such as Walk to School Day, Jump Rope for Heart, Fun Run, or a Family Fitness Night has your school sponsored?   Sponsored 4 or more events Sponsored 2 or 3 events Sponsored 1 event No events sponsored   Our school offers before and/or after school physical activity programs for students, such as sports and walking or exercise clubs.   Yes No   In the past 12 months, how many educational messages outside of the classroom has your school provided in order to promote physical activity, such as displaying informational posters in prominent places or having routine articles about healthy eating in the school newsletter?   We provided 4 or more messages We provided 2 or 3 messages We provided 1 message No messages provided

Physical Education
What community organizations have partnerships with the school to promote being active outside of school hours? (Check all that apply)   PTA or PTO Boys and Girls Club YMCA/YWCA Parks and recreation departments After-school programs Bicycling association No partnerships exist Other   Please describe other partnerships with community organizations:   How does your school work with the above community organizations to promote physical activity? (Check all that apply)   Provide access to school facilities for community members to be physically active Proved access to community facilities for students and school staff to be physically active Co-sponsored events with community groups or organizations No partnerships exist Other   Please describe:   Short Answer:  What is a unique practice your school uses to enhance physical education time?

Health Services
Our school has a nurse that is available/accessible to provide services to all our students.   Yes No   Our school provides resources to assist students in acquiring free or reduced healthcare.   Yes No   Our school conducts health screenings for students   Yes No   Health screenings are conducted for the following: (Check all that apply)   K 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade   What health screenings are provided? (Check all that apply)   Scoliosis Dental Vision Hearing Blood Sugar Body Mass Index Height Weight Blood Pressure Other   Pleas describe other health screenings:   Our school provides resources about healthcare providers in our community.   Yes No

Nutrition Services
Our menu, for reimbursable school lunch, offers at least one serving of fruit (preferably fresh), one serving of vegetable (preferably fresh), and one serving of whole grain bread at each school, daily.   Yes No   In the past 12 months, how many events has your school sponsored in order to promote healthy eating, such as Nutrition Health Fair or a Got Milk Campaign?   We sponsored 4 or more events We sponsored 2 or 3 events We sponsored 1 event We did not sponsor any events   Short Answer: If you sponsored an event, please provide a brief description of that event.

Nutrition Services
In the past 12 months, our school promoted healthy eating through: (Check all that apply)   Posters Flyers Tablemats Bulletin boards Information on menus Information on a website Articles in a school newsletter Local media Public Service Announcements on a PA system Student Led Advertising Contests Participation in Health Observances No Promotion is done Other   Please describe other ways your school promoted healthy eating:   How many promotions were sponsored in the last 12 months?   We provided 4 or more promotions We provided 2 or 3 promotions We provided 1 promotion We did not provide any promotions

Nutrition Services
Our school food service manager is a: (Check only one)   Registered Dietitian Registered Dietetic Technician Certified Dietary Manager Professionally Trained Food Service Manager (4-year degree) School Nutrition Specialist Other   Please describe your food service manager's credentials:   How many hours does the food service staff member, who is responsible for menu planning, participate in professional development activities related to a healthy school environment?   Fewer than 6 hours per year 6-8 hours per year 9-14 hours per year 15 hours per year   How many hours does each food service staff member, responsible for preparing and serving the food, participate in professional development activities related to a healthy school environment?   Fewer than 6 hours per year 6 hours per year 7-9 hours per year 10 hours per year or more   Do the students have at least 10 minutes of uninterrupted time to eat breakfast after receiving their meal?   Yes No No school breakfast program   Do the students have at least 20 minutes of uninterrupted time to eat lunch after receiving their meal?   Yes No   Our school nutrition service provides accommodations for food allergies.   Yes No   Please describe/provide accommodations:

Counseling
Our school has counselors available for student use.   Yes No   What services do the counselors provide? (Check all that apply)   Grief counseling Divorce counseling Behavior problems counseling Other   Please describe other counseling services:   Our school provides a homeless liaison for students.   Yes No   Our school counselor has a Standard School Counselor Certificate issued by the Texas Education Agency.   Yes No   Our school has community resources, such as medical, housing, and nutritional assistance, available to our students.   Yes No   Our school uses community partners to help provide counseling services to our students.   Yes No   Please describe community partners:

Healthy School Environment
Our school recommends hand washing before eating and allows an adequate amount of time for all students to wash for a minimum of 20 seconds.   Yes No   Our school has a support from administration for physical education, health education, and nutrition initiatives.   Yes No   The area surrounding our school is a safe environment for students walking to school.   Yes No   Our school rewards our students without using food.   Yes No   Recess time is given:   Before lunch After lunch Both depending on grade level There is no recess time   Short Answer:  Please describe the types of discipline used in the cafeteria.   Our school provides a safe environment through: (Check all that apply)   Hall monitors Well lit hallways Lighting on playgrounds Non-slip strips on stairways A student drop-off location next to the school building Mirrors at blind corners in the hallways No leaks when raining All doors except the front are locked Classroom doors are able to be locked from the inside All unlocked doors are constantly monitored by a staff member Fire drills Tornado drills Bomb threat drills Lockdown drills Providing training for our staff in all mandated drills and lockdown procedures Providing Training for our staff in the Texas Behavior Support Initiative Providing training for our staff in classroom management skills Providing training for our staff in current drug trends Providing training for our staff in bullying and violence prevention Having a visitor policy in effect, requiring a sign-in procedure for all visitors, including visible identification Parents are an integral part of the student discipline procedures and actions Providing opportunities for student leadership related to violence prevention and safety issues Having a Crisis Management Plan in effect that is reviewed and updated annually

Health Promotion for Staff
Our school district has a staff wellness program that encourages healthy eating/healthy weight programs such as hosting a weight management/loss program, guest speaker, walking club, etc.   Yes No   Does your school have an identified staff wellness coordinator?   Yes No   Which of the following steps have been taken to develop, implement, and improve a staff wellness program?   An assessment has been done of staff wellness needs An assessment of the school environment that impacts staff wellness has been completed A comprehensive staff wellness action plan has been developed The staff wellness program being implemented includes a pre and post-program evaluation None Other   Please describe other steps taken to improve staff wellness program:   Which of the following physical activity and healthy eating opportunities are included in the Staff Wellness Program? (Check all that apply)   Food and beverages served at staff function meets the school district national food and beverage guidelines Education activities for school staff members on healthy lifestyle behaviors, healthy eating, physical activity, and injury prevention Installation of convenient walking routes and fitness equipment Making arrangements for staff use of public recreation centers of private fitness facilities with organized programs and incentives to encourage their use Application of nutritional standards for food and beverages in vending machines available to staff members on the school campus Establishment of peer support groups for weight management, stress managements, tobacco-use cessation, family guidance, and other identified issues Time during the day, such as release time, during which teachers and other staff members can participate in health-promoting activities or district has other ways to create a supportive environment in the district and schools None Other   Please describe other physical activity and healthy eating opportunities:

Health Promotion for Staff
Which of the following health components are in the Staff Wellness Program? (Check all that apply)   Policies to prohibit tobacco use on school grounds by students, staff members, and school visitors Periodic screening at school for blood pressure, blood cholesterol, body mass index, and other health indicators Annual administration of individual health-risk appraisals to help staff members establish personal health-improvement goals Linkages to established Employee Assistance Programs have been made An ongoing assessment process to update and improve the effectiveness of the staff wellness plan None Other   Please describe other health components in the Staff Wellness Program:   Our school district staff has a staff wellness program that provides physical activity programs for our staff.   Yes No   Our staff wellness program provides programs, such as: (Check all that apply)   Classes Workshops Facilities Pedometer/Walking Programs Special Events Reduced /Free Health Club Memberships Health Screenings Flu Shot Clinics Walk Across Texas Physical Activity Contests Nutrition Contests Weight Loss Contests Relay for Life Newsletters

Family/Community Involvement
Does your school district have a School Health Advisory Committee (SHAC) that oversees school district health policies and programs regarding physical activity, healthy eating, and a tobacco free lifestyle?   Yes, our district does have a SHAC No, our district does not have a SHAC   Select which of the following groups are represented on your SHAC. (Check all that apply)   School Administration (Principal, Assistant Principal, or Superintendent) Nutrition Services (Food Service Director or Manager) Physical Education (PE teacher) Health Education (Health Teacher/Health Educator/Classroom teacher who teaches health) Family Involvement (Parent/Guardian) Health Services Provider or School Nurse School Counselor, Psychologist, or Social Worker Students (on the committee for middle/high school; input from elementary schools) Classroom Teacher (other than PE or Healthy Community Involvement (Examples: County Health Department, Texas AgriLife Extension, Health Association, Cancer Society) Other (Examples:  Member of PTA/PTO, Coordinated School Health Regional Coordinator, Director of Before/After School Care Program, Athletic Director, Coach, Playground/Recess Supervisor, Pediatrician, Dentist, Registered Dietician   In the past 12 months, our SHAC has met:   Did not meet/none 1 time 2-3 times 4 or more times Not applicable/do not have a SHAC   What policies and programs does SHAC oversee? (Check all that apply)   Physical Activity Physical Education Healthy Eating/Nutrition Environment Tobacco-free Lifestyle Drug Education and Prevention Staff Wellness School Wellness Policy Parent and Community Involvement We do not have a SHAC Other   Please describe other policies and programs that the SHAC oversees:

Family & Community Involvement
During the past 12 months, what functions did the SHAC carry out at your school? (Check all that apply)   Program Planning Parent and Community Involvement Advocacy for School Health Recruitment of Community Health Resources Fiscal Planning Evaluation, Accountability, and Quality Control We do not have a SHAC Other   Please describe other functions carried out by the SHAC at your school:   Does your school building have a committee or team that oversees school health policies and programs regarding physical activity, healthy eating, and a tobacco-free lifestyle?   Yes, our school does have this committee No, our school does not have this committee   Does your school provide opportunities for students and their parents to be involved in joint health promotion activities with their child(ren), such as nutrition education and physical activity?   Yes No

Family/Community Involvement
What type of health promotion activities, involving parents, has your school sponsored over the past 12 months? (Check all that apply)   Nutrition Education Physical Activity Drug Prevention Tobacco Prevention None Other   Please describe other health promotion activities:   Which describes your school's PTO?   There is no PTO There is a PTO, but they are not active Active Very Active   How many members serve your PTO?   1-10 11-20 21-30 31-40 More than 40 We do not have a PTO   How often does your PTO meet each school year?   1-3 times 4-6 times 7-9 times 10-12 times More than 12 times We do not have a PTO

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