Form 2 Administrator Survey

Admininistrator

OMB No.: ####-####
Expiration Date: ##/##/####

Generation Health Study Survey
Administrator Questionnaire
Public reporting burden for this collection of information is estimated to average 20 minutes per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN:
PRA (####-####). Do not return the completed form to this address.

The purpose of this questionnaire is to assess physical education, nutrition, tobacco, violence, and health programs and
policies in your school. Follow the instructions for each question, checking the response that best represents your answer.
Thanks for your cooperation. Your answers will be kept confidential.

Instructions for Completing the Survey
 Read all the printed answers before marking your choice.
 Mark the circle for the one answer that best fits your situation.
 Use a No. 2 pencil.
 Make heavy marks that fill the circle for your answer.
 Erase cleanly any answer you wish to change.
 Please do not make stray marks of any kind.

3. Which of these facilities for physical activity
exist in the indoor school area, the school
yard (within 200 meters), or in the school
neighborhood (200 yards to 2000 yards)?
(Mark “no” or “yes” for each item.)

The following four questions ask about physical
education and after school physical activity programs.
1a. Is physical education (PE) required for students
in grade 10 in this school?
 No (SKIP TO QUESTION 2)

Yes

Don’t know (SKIP TO QUESTION 2)
1b. Please indicate the number of days per week
in which physical education (PE) classes are
required in your school for grade 10: (Please
mark one circle. If PE is not required for the entire
school year, please estimate average for full school
year, e.g., 3 days/week for 1/3 of school year =
1day/week average across full school year.)

No
a. Gymnasium,

sport hall
b. Swimming

facilities
c. Football and/

or soccer field
d. Court space with
permanent
improvements
for other ball

activities
e. Areas for
boarding/skating
f. Open field space
with no markings
g. Playground

equipment
h. Activity trails

i. Green fields/
parks/nature

reserve
j. Wooded areas

k. Water (sea, river,
lake)

5 days
4 days
3 days
2 days
1 day
0 days

Grade 10
1c. Please indicate how much time per week is
allocated to physical education (PE) classes that
are required in your school for grade 10: (If
PE is not required for the entire school year, please
indicate the number of hours per week during those
weeks it is required.)

Grade 10 ___hours ___minutes (per week)
2. Does this school offer 10th-grade students
opportunities to participate in intramural
activities or physical activity clubs?
(Mark one circle.)
 No

Yes

Yes

Do students have access
to this in unstructured
school time? (Breaks,
free hours)
No
Yes

4. Does the school organize physical activities
for 10th-graders during the school day outside
Physical Education classes? (Please mark one circle
for each line.)
48

Yes, 3-5 days per week
Yes,1-2 days per week
Yes, 2-3 days per month
No

a. Before school hours
b. In lunchtime
c. In breaks
d. After school
e. Other times during the school day

2

8. Can students purchase any of the following
items from vending machines or at the school
store, cafeteria, or snack bar? (Please mark one
circle for each line.)

The following six questions ask about nutritionrelated policies and practices at this school.
5a. Are 10th graders allowed to leave campus
during their lunch period?
 No (SKIP TO QUESTION 6)
 Yes

48

Yes, daily
Yes, some days
No

a. Chocolate candy
b. Other kinds of candy
c. Salty snacks that are not low in fat,
such as regular potato chips
d. Salty snacks that are low in fat, such as
such as pretzels, baked chips, or other
low fat chips
e. Fruits
f. Vegetables
g. Soft drinks, sports drinks, or fruit drinks
that are not 100% juice
h. 100% fruit juice
i. Bottled water
j. Whole milk
k. Skim (non-fat) or low-fat milk
l. Chocolate milk
m. Warm drinks (coffee, tea, hot cocoa)
n. Yogurt
o. Regular cookies, crackers, cakes, pastries,
or other non-low-fat baked goods
p. Low-fat cookies, crackers, cakes,
pastries, or other low-fat baked goods
q. Pizza

5b. Which of the following off-campus food sources
are close enough for students to walk or drive
to during lunch?
 Fast food restaurants
 Other restaurants, cafeterias, or diners
 Supermarkets, convenience stores, or other
stores

Off-campus lunch wagons or push carts
 Other food sources (Specify)
_______________________________________
6. How often do school organizations sell pizza or
other main entrée items during lunch?
 Every day
 Three to four times a week

One to two times a week

Less than once a week

Never

School district forbids organizations from selling
food during lunch periods

Don’t know
7. Does your school’s cafeteria offer any of the
following options?

9. Does this school… (Mark “no” or “yes” for each
item.)

No
Yes
a. Offer a la carte breakfast items

to students?
b. Participate in the USDA
reimbursable School Breakfast

Program?
c. Offer any other breakfast meals

to students?

Every day
3-4 times a week
1-2 times a week
Less than once a week
Never

a. Salad bar
b. Whole grains
(i.e., whole grain bread, brown rice)
c. Vegetarian entrées

3

10. Does this school… (Mark “no” or “yes” for each
item.)

No
Yes
a. Offer a la carte lunch items

to students?
b. Participate in the USDA
reimbursable School Lunch

Program?
c. Offer any other lunch meals

to students?

The next two questions are about staff and student
development.
14. During the past three years, did the school
facilitate staff development (such as workshops,
conferences, courses, continuing education, or
any other kind of in-service training) on the
following topics? (Please mark all that apply but at
least one circle for each line.)
Yes , for the cafeteria personnel
Yes, for the teachers
48
Yes, for the principal (school leadership)
No

11. On a typical day, about how many students are
eligible for free/reduced price meals? (Write in
the number of students or percentage.)

a. Nutrition
b. Physical activity
c. ICT (information and communication
technology/computer use)

_______________ number of students
or

_______________ percentage (%) of students

15. In the past 3 years, which of the following
programs/projects have your school
participated in? (Mark “no” or “yes” for each item.)

The following two questions ask about tobacco use
policy at this school.

No

a. Physical activity program
b. Nutrition program

c. Bullying and/or violence

prevention program

d. Anti-smoking program (e.g.:

smoke-free classes)
e. Alcohol and/or drugs program

f. Sex education program

12. Has this school adopted a policy prohibiting
tobacco use by faculty and staff? (Mark one
response.)
 No (SKIP TO QUESTION 14)

Yes
13. Does that policy specifically prohibit tobacco
use by faculty and staff in any of the following
locations? (Mark “no” or “yes” for each item.)

No

a. In school buildings
b. On school grounds

c. In school buses or other vehicles

used to transport students
d. At off-campus, school-sponsored
events

Yes

Yes

16. Does your school have a written plan for
responding to violence at the school?
(Mark one response.)
 No

Yes
The following two questions ask about student
health screenings that might be conducted at this
school. Please think about screenings done in any
grade while a student attends this school.
17. Are most students from this school screened at
the school for any of the following? (Mark “no”
or “yes” for each item.)

No
Yes

a. Height and weight (or body mass)
b. Hearing problems

c. Vision problems

d. Oral health problems

4

18. Please indicate what the school does when
a student’s screening indicates a potential
problem. (Mark “no” or “yes” for each item.)

a. Notify the student’s parents or

guardians
b. Notify the student’s teachers
c. Not applicable—no health
screenings

No

The following two questions ask about health education programs in this school.
21. Please indicate the number of days per week
in which health education (HE) classes are
required in your school for grade 10: (Please
mark one circle. If HE is not required throughout the
school year, please estimate average for full school
year, e.g., 3 days/week for 1/3 of school year = 1day/
week average across full school year.)

Yes

5 days
4 days
3 days
2 days
1 day
0 days

The following two questions ask about mental
health and social services provided at this school.
Please include both contracted providers and
regular school staff.

Grade 10

19. Are there part-time or full-time guidance
counselors, psychologists, or social workers
who provide standard mental health or social
services to students at this school? (Mark one
response.)
 No (SKIP TO QUESTION 21)

Yes

22. During this school year, which of the following
topics have been included in a required health
education course in grade 10? (Mark “no” or
“yes” for each item.)
No
Yes
a. Accident or injury prevention
 
b. Alcohol or other drug use
prevention
 
c. Dental and oral health
 
d. Emotional and mental health
 
e. Growth and development
 
f. Physical activity and fitness
 
g. Tobacco use prevention
 
h. Bullying prevention
 
i. Fighting prevention
 
j. Homicide prevention
 
k. Nutrition and dietary behavior
 
l. HIV (Human immunodeficiency
virus) prevention
 
m. Human sexuality
 
n. Pregnancy prevention
 
o. STI (sexually transmitted
infection) prevention
 
p. Suicide prevention
 

20. During the past 30 days, how many hours per
week in total have the guidance counselors,
psychologists, and/or social workers spent at
this school? (Mark one response.)
 Fewer than 5 hours

5 to 10 hours

11 to 15 hours

16 to 20 hours

21 hours or more

5

The following question asks about your current
position.

______________________________________________

23. What is your position in this school? (Mark one
response.)
 Principal

Assistant or Vice Principal

Other administrator

Other, (specify: _______________________.)

______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________

Thank you for your responses. Please seal this
completed questionnaire in the envelope provided
and give to the HBSC data collector who visits your
school.

______________________________________________
______________________________________________
______________________________________________

COMMENTS

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This is the end of the survey.
If there is time, please go back and review each question to be sure you have answered all the questions and followed the directions.
THANK YOU VERY MUCH FOR YOUR HELP!

Admini

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