1. Email address *

School Nurse Survey 2019-2020 A.C.A §6-18-709 requires the Division of Elementary & Secondary Education (DESE) toannually collect data to assist in the development of health recommendations andguidelines based on student needs. This data can be used to provide, at least annually,a report to the local school board of directors on health concerns and necessities ofstudents served by the district. DESE participates in the national studies for chronichealth conditions of school-age children and the implications for school nurses tobetter provide health care services improving the connection between health andacademic achievement. The collection of data from the school nurse survey aids inthe development of continuing education using personal competencies from theFramework for 21st Century School Nursing Practice and for securing grant fundingand opportunities.* Required

2.

3.

What is your LAST name? *

What is your FIRST name? *

4.

Mark only one oval.

APRN

RN

LPN

5.

Mark only one oval.

Arch Ford ESC

Arkansas River ESC

Crowely's Ridge ESC

Dawson ESC

DeQueen/Mena ESC

Great River ESC

Guy-Fenter ESC

Northcentral ESC

Northeast ESC

Northwest ESC

Ozarks Unlimited Resource (OUR) ESC

Southcentral ESC

Southeast ESC

Southwest ESC

Wilbur D. Mills ESC

Pulaski Area

What is your licensure? *

What Education Service Cooperative or the Pulaski Area is your district assigned? *

6.

Mark only one oval.

Yes

No

Was a school health report provided to your Superintendent or School Board of Directors from the previous year survey?

7. What is the name of your district: this is a drop-down box

8.

9.

Number of school campuses served and information provided for this survey: *

What is the name of your school campus or campuses? *

10. What county does your school reside: this is a drop-down box

Skip to question 11

Care Coordination

Medical AlertsEnter the number of students on campus or campuses with the diagnosis of any of the following chronic conditions:

11.

12.

13.

14.

15.

16.

Asthma *

Type 1 Diabetes *

Type 2 Diabetes *

Seizures *

Life-Threatening Allergy (Anaphylactic Reaction) *

ADD/ADHD *

17.

18.

19.

20.

21.

22.

23.

24.

Autoimmune Disorder

Blind/Visual Impairment

Cardiovascular Disorder

Circulatory Disorder (except Hypertension)

Congenital Disorder

Deaf/Hearing Impairment

Depression

Dermatological Disorder

25.

26.

27.

28.

29.

30.

31.

32.

Digestive Disorder

Eating Disorder

Encopresis Disorder

Endocrine Disorder (except Diabetes)

Excretory Disorder

Genetic Disorder

Hematologic Disorder

Hepatic Disorder

33.

34.

35.

36.

37.

38.

39.

40.

Hypertension

Immunological Disorder

Inflammatory Disorder

Malabsorption Disorder

Malignant Disorder

Neurodevelopmental Disorder

Neurological Disorder

Neuromuscular Disorder

41.

42.

43.

44.

45.

46.

47.

48.

Neurovascular Disorder

Non Life-Threatening Allergy Disorder

Orthopedic Disorder (permanent)

Psychiatric Disorder (except eating disorder)

Renal Disorder

Reproductive Disorder

Respiratory Disorder (except asthma)

Skeletal System Disorder

49.

50.

51.

52.

53.

54.

Health ProceduresEnter the number of students on your campus requiring each of the following specialized procedures this school year:

Substance Abuse

Traumatic Brain Injury

Enter the number of students on your campus which received scheduled medications daily at school on a long-term basis for this school year (>3 weeks):

Enter the number of students on your campus which received medications at school on a short-term basis (<3 weeks):

Enter the number of students on your campus with a healthcare provider order for a PRN Over the Counter (OTC) medication:

Enter the number of students on your campus with parental consent only for a PRN Over the Counter (OTC) medication:

55.

56.

57.

58.

59.

60.

61.

62.

Blood Glucose Monitoring

Carbohydrate Counting

Catherization by Nurse or Unlicensed Assistive Personnel (UAP)

Peritoneal Dialysis

Updraft/Nebulizer Treatment

Postural Drainage

Tracheostomy Care

Other Stoma Care

63.

64.

65.

66.

67.

68.

69.

70.

Suctioning

Tube Feedings

Subcutaneous Medications

Intramuscular Medications

Intravascular Medications

Insulin Pump

CGM (contiuous glucose monitoring)

Urine Ketones

71.

72.

Care Coordination/Quality Improvement

Student PrescriptionsEnter the number of students with prescriptions for the following:

73.

74.

75.

76.

Wound Care

Enter the number of students receiving assistance by either a nurse or UAP with Activities of Daily Living (ADL's) due to disability (i.e. diapering, toileting, hygiene, ambulation, transfers, assistance with eating, meal preparation):

Albuterol/Xopenex or Fast acting Beta Agonist *

Glucagon *

Rectal Diazepam *

Intranasal Midazolam *

77.

78.

IHP-ECPEnter the number of students with an individualized health care plan or emergency action plan for the chronic conditions with the following prescriptions:

79.

80.

81.

82.

Sublingual or Buccal Benzodiazepine (i.e. lorazepam, clonazepam, valium) *

Epinephrine *

Albuterol/Xopenex or Fast acting Beta Agonist *

Glucagon *

Rectal Diazepam *

Intranasal Midazolam *

83.

84.

Emergency Doses: NurseEnter the number of "emergency" doses (not maintenance or preventive doses) administered by a licensed nurse:

85.

86.

87.

88.

Sublingual or Buccal Benzodiazepine (i.e. lorazepam, clonazepam, valium) *

Epinephrine *

Albuterol/Xopenex or Fast acting Beta Agonist *

Glucagon *

Rectal Diazepam *

Intranasal Midazolam *

89.

90.

Emergency Doses: UAPEnter the number of "emergency" doses (not maintenance or preventive doses) administered by a UAP:

91.

92.

93.

94.

95.

Sublingual or Buccal Benzodiazepine (i.e. lorazepam, clonazepam, valium) *

Epinephrine *

Albuterol/Xopenex or Fast acting Beta Agonist *

Glucagon *

Rectal Diazepam *

Intranasal Midazolam *

Sublingual or Buccal Benzodiazepine (i.e. lorazepam, clonazepam, valium) *

96.

Follow-up 911Enter the number of times 911 was called in relation to the administration of the following medications:

97.

98.

99.

100.

101.

102.

Epinephrine *

Albuterol/Xopenex or Fast acting Beta Agonist *

Glucagon *

Rectal Diazepam *

Intranasal Midazolam *

Sublingual or Buccal Benzodiazepine (i.e. lorazepam, clonazepam, valium) *

Epinephrine *

InjuriesEnter the number of students having experienced an injury or emergency with post incident follow-up by 911 or health care provider:

103.

104.

105.

106.

107.

108.

109.

Head Injury

Eye Injury

Fracture Injury

Strain/Sprain Injury

Dental Injury

Psychiatric Emergency

Heat Related Injury

110.

111.

112.

113.

Sexual HealthEnter the number of students impacted by teen pregnancy and/or sexually transmitted diseases (STD) this school year:

114.

115.

116.

Respiratory Emergency

Anaphylactic Reaction Emergency

Sudden Cardiac Arrest

Adrenal Crisis

Pregnancies

Pregnant adolescents receiving homebound services

Pregnant adolescents who dropped out of school permanently

117.

118.

Mental HealthEnter the number of known students receiving professional mental health services (contact your school counselor for this information):

119.

120.

121.

122.

Pregnant adolescents diagnosed as high risk (i.e. Gestational DM, Preeclampsia)

Referral to health care provider for symptoms of STD's

On your campus

Or off campus if known

List all the mental health agencies (i.e. Ozark Guidance, Youthbridge, SW Arkansas Counseling, Mid-South Behavioral Health) providing mental health services to your campus and/or district:

List the name of any school employed clinician (i.e. LCSW, LPC, LPE) providing mental health services to your campus and/or district:

123.

124.

Mark only one oval.

Yes

No

125.

126.

127.

Mark only one oval.

Yes

No

Enter the number of times you and the school counselor provided a team approach to assist a student with a mental health need:

Does your district or campus have a School Based Health Center (SBHC)?

If "Yes", what are the other services or duties you provide for the SBHC?

Enter the number of students on your campus having had an overdose this school year:

Was an opioid antagonist (i.e. Naloxone, Narcan) available?

128.

Mark only one oval.

Yes

No

Quality Improvement

OutcomesEnter the number of student encounters/health office visits resulting in the following outcome referred by the nurse:

129.

130.

131.

132.

133.

If yes, was the opioid antagonist administered?

Students Sent Back to Class *

Students Sent for Medical Attention *

Students Sent Home *

Students sent to ER *

Students sent to the SBHC (School-Based Health Center)

134.

135.

Community/Public Health

136.

Mark only one oval.

Yes

No

137.

Enter the number of students with a Do Not Resuscitate Order (DNR) for your campus/campuses:

Number of students missing at least 10% or more of school year including excused and unexcused absences (may need to get from attendance person at your school or access from APSCN coordinator): *

Have you contacted your Community Health Nurse Specialist (CHNS) or Community Health Promotion Specialist (CHPS) for support services such as education, resources, and/or technical assistance this school year? *

If yes, what type of assistance was provided to you or your school?

138.

Mark only one oval.

Yes

No

School Personnel

Enter the number of services provided or the use of the nurse office resources to school personnel this school year:

139.

140.

141.

142.

143.

Are you assisting your district or campus with Stop the Bleed training for your school personnel or students directly or indirectly?

Blood pressure check

Blood glucose check

Height/Weight

Injections

Rescue Medications

144.

145.

146.

147.

148.

LeadershipCOVID-19 Support

149.

First Aid Treatment

Workers' Compensation-Nursing only

Education Regarding Medications

Education Regarding Treatments

Education Regarding Diseases

Share any opportunities or activities you have provided to your schools during COVID-19:

150.

Mark only one oval.

School

Home

Both

151.

Mark only one oval.

Yes

No

152.

Standards of PracticeThank You! Please review your answers before submitting.

Have you worked from home, school, or both?

Have you thought about re-entry for when school begins for the 2020-2021?

Whether yes or no, do you have any suggestions to help support the needs of the students especially those with chronic health needs or how the role of the school nurse can help guide schools with re-entry:

153. Comments: