Sample Assessment 2008
Page 1: Demographic Information
* indicates a required question
Your School Name
*NOTE: The school building PRINICPAL DOES NOT need to complete the Keystone Healthy Zone Assessment or be a part of the School Health Council.
The PRINICPAL information is requested to ensure that he/she is aware of the school's KHZ school participation.
* 1. Principal Name:
* 2. Principal Email:
3. AUN Number: 999999999 The AUN is a 9-digit number assigned to all public school distrcits, other public schools, and private schools. This number is pre-populated for you when selecting your school
* 4. Student Enrollment For This Building:
5. School Building Number: 9999 This is the PA Department of Education-assigned school building number. It is prepopulated for you when selecting your school.
6. It is recommended that a team of staff/community members complete this assessment. Please check all team members that helped complete the assessment
* 7. List the contact information for the individual completing this online assessment.
Some of these fields will be pre-populated with your school's mailing address. You may change these if necessary.
Page 2: Coordinated School Health
* 1. Does your school have a formally appointed individual to lead school health initiatives (planning, implementing, and evaluating programs)
1a. If yes to Question 1, on average how many hours per week are allocated for this work
* 2. Does your school have a representative committee/council (e.g. school administrators, teachers, school nurses, food service staff, parents, counselors, students) that exists to oversee school wellness policies and programs (including those related to nutrition and physical activity)?
2a. If yes to Question 2, how many times does this committee meet per year?
2b. If yes to Question 2, please check all of the positions that are represented on this committee, and provide a contact email address.
2c. If you selected "Community Organizations" in Question 2b, please select which participate:
* 3. Do senior level administrators allocate money for school programs that support healthy eating and physical activity?
3a. If yes to Question 3, please select the range of money allocated for healthy eating and physical activity programs or practices:
* 4. Does your school consistently communicate school health policies to administrators, staff, students, parents, and community?
4a. If yes to Question 4, please check all communication methods that apply.
5. How does your school seek parental buy-in for the programs and policies to promote healthy eating and physical activity?
6. How does your school seek staff buy-in for the programs and policies to promote healthy eating and physical activity?
7. In what topic area does your school seek student buy-in for the wellness policy to promote healthy eating and physical activity?
8. What PANA programs and events has your school participated in the past year (2007-08)?
9. PANA promoted educational materials and programs over the past year. Which of these programs does your school use?
Page 3: Nutrition Services
PLEASE NOTE: If your school does not have Nutrition Services and these questions are not applicable, please check here: If you do not check this box, and leave the questions unanswered, you will be asked to complete the required questions.
Please obtain your school menu, school meals program participation rates, and any food and nutrition policies and procedures before completing this portion of the survey. Thank you!
* 10. What is the average daily participation (ADP) for the following in the school for which you are completing this assessment?:
a. National School Lunch Program
b. School Breakfast Program
* 11. How long is the scheduled meal period for breakfast?
11a. If school breakfast is offered, where is it served?
* 11b. Does your school's wellness policy include a goal or an objective to expand participation in school breakfast?
* 12. How long is the scheduled meal period for lunch?
* 13. Does your school have student vending machines?
13a. If yes to Question 13, please indicate the times during which students have access to vending machines in your school. (Please check all that apply.)
14. If your school has a written policy about FOOD and SNACKS, does the policy specify: (select all that apply)
15. If your school has a written policy about BEVERAGES, does the policy specify: (select all that apply)
* 16. Check the following competitive food areas which the written polic(ies) is/are applied to:
17. What strategies are in place to promote the sale of healthy food and beverage choices (check all that apply)?
* 18. Does your school have existing efforts in place to purchase Pennsylvania produce within your school food service department?
19. Does your school do the following activites to provide nutrition education (check all that apply)?
20. Does your school communicate consistent nutrition messages throughout the school?
20a. If yes, where? (Select all that apply)
Page 4: Physical Education
PLEASE NOTE: If your school does not have Physical Education and these questions are not applicable, please check here: If you do not check this box, and leave the questions unanswered, you will be asked to complete the required questions.
* 21. Can students substitute other activities for physical education classes (e.g. ROTC, band, athletics) for physical education credit?
* 22. Is there adequate equipment for every student to participate fully in each physical education lesson (e.g., equipment for every student as appropriate to avoid waiting in lines for turns; limited opportunities to practice)?
* 23. Have physical education teachers received any staff development related to health and physical education during the past 2 years? This might include workshops, conferences, continuing education, graduate courses, or any other kind of in-service.
23a. If yes to Question 23, check the topic areas that were addressed during the staff developments:
24. Does your school provide instruction for lifetime physical activities? Select all activities and settings that apply:
25. Select the resources used to support teaching lifetime physical activities (e.g. biking, boating, etc) in physical education class:
Page 5: Physical Activity Opportunities
* 26. Does your school provide opportunities for and encourage students to participate in before-school and after-school physical activity programs such as intramurals and clubs?
* 27. Does your school partner with community organizations to provide community access to school facilities for physical activities outside of normal school hours?
28. How many minutes of unstructured recess time do your students have each day? Leave unchecked for any non-applicable grades.
* 29. Does your school have a written policy that supports walking to school?
* 30. Does your school have a supervised walking program? (i.e. Walking School Bus , crossing guards, etc.)?
30a. If yes to Question 30, how often is the Walking School Bus available to the students?
* 31. If children who live within walking distance (1 mile) cannot safely walk to school, are steps being taken to correct hazards?
* 32. Does your school provide hazardous bussing?
* 33. Does your school teach bicycle and pedestrian safety?
Page 6: Other
The Pennsylvania Growth Screening Program was designed to monitor child health trends, raise awareness of health issues related to childhood obesity, and connect schools, parents, students, and healthcare providers to address this health issue, as recommended by the Institute of Medicine, Preventing Childhood Obesity: Health In the Balance, 2005.
* 35. Does your school utilize PANA's Youth Obesity Prevention and Weight Management Inventory?
36. Please share student growth screening results for your school building:
-SAMPLE ONLY-
PANA is partially supported by the PA Department of Health through a grant from the Centers for Disease Control and Prevention (CDC) with programs delivered by Penn State University Institute for the Collective Advancement of Activity and Nutrition.
