Connecticut State Department of Education

Health Services Program Information
2009

Please take a moment to answer the following questions regarding the Health Services Programs in your district.  Some questions require separate responses for public school districts and for private, non-profit schools.  In these cases, IF YOUR DISTRICT DOES NOT PROVIDE SERVICES TO PRIVATE, NON-PROFIT SCHOOLS, PLEASE LEAVE QUESTIONS SPECIFIC TO THESE SCHOOLS BLANK.

THERE IS ONE EXCEPTION.  QUESTIONS 10 AND 20 ON THIS PAGE MUST BE COMPLETED OR THE SURVEY SOFTWARE WILL NOT ALLOW YOU TO PROCEED TO THE NEXT PAGE OF THE SURVEY.  FOR QUESTION 20, IF YOU DO NOT PROVIDE SERVICES TO PRIVATE, NON-PROFIT SCHOOLS, PLEASE PUT A "0" IN THE BOX.

I. Services Provided

For sections A and B, in the left hand column, please type the number of students  receiving each service.  In the right hand column, please type the number of students referred to an outside provider for treatment as a result of receiving the service.   In Section A, please consider students receiving services ONLY in your PUBLIC school district.  In Section B, please consider students receiving services ONLY in your PRIVATE, NON-PROFIT schools.

A. Public School District

Number of students receiving service annually

Number of students referred to outside provider as a result of service

Service provided:

1.  Body Mass Index Screening

2.  Pediculosis (Head Check)

3.  Nutrition Screening

4.  Mental Health Consultation/Screening

5.  Dental Screening

Of students receiving each of the following mandated screenings, how many are referred to an outside provider as a result of these screenings?

Number of students referred to outside provider as a result of service

6.  Vision

7.  Scoliosis

8.  Hearing

9.  Mandated Health Assessments

To assist us to calculate percentages, please type the total number of students in your PUBLIC schools in the box provided.  Do not include students in private, non-profit schools.  THIS QUESTION MUST BE COMPLETED OR THE SOFTWARE WILL NOT ALLOW YOU TO PROCEED TO THE NEXT PAGE OF THE SURVEY.

10.  Total Number of Students in PUBLIC Schools

B.  Private, Non-Profit Schools

Number of students receiving service annually

Number of students referred to outside provider as a result of service

Service provided:

11.  Body Mass Index Screening

12.  Pediculosis (Head Check)

13.  Nutrition Screening

14.  Mental Health Consultation/Screening

15.  Dental Screening

Of students receiving each of the following mandated screenings, how many are referred to an outside provider as a result?

Number of students referred to outside provider as a result of service

16.  Vision

17.  Scoliosis

18.  Hearing

19.  Mandated Health Assessments

To assist us to calculate percentages, please type the total number of students in your PRIVATE, NON-PROFIT schools in the box provided.  Do not include students in public schools.  IF YOUR DISTRICT DOES NOT PROVIDE SERVICES TO PRIVATE, NON-PROFIT SCHOOLS, PLEASE PUT A "0" IN THE BOX.  THIS QUESTION MUST BE COMPLETED OR THE SOFTWARE WILL NOT ALLOW YOU TO PROCEED TO THE NEXT PAGE OF THE SURVEY.

20.  Total Number of Students in PRIVATE,     NON-PROFIT schools

21.  Is there anything you would like the State Department of Education to know about the health services provided to students in your public or private, non-profit schools?

Please answer by typing your response in the box below.

22.  Is there anything you would like from the State Department of Education to better provide services to students in your public or private non-profit schools?

Please answer by typing your response in the box below.

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