CDC-RFA-DP-23-0002 Form Approved OMB No. 0920-xxxx
Expiration Date: XX/XX/XXXX
Public reporting burden of this collection of information is estimated to average 30 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).
DP23-0002 CDC Healthy Schools Program: Monthly Reporting Form
Key: Blue text – survey question type, piping logic, and other survey additions in Qualtrics
SECTION I: INTRODUCTION
Thank you for submitting the monthly indicator report. Please submit this form by the 15th of each month, following the reporting period (e.g., submit January report by February 15).
1. Select the period you are reporting on. [select one. Please see the table at the end of this document for a list of all reporting periods.]
SECTION II: PROFESSIONAL DEVELOPMENT
Professional development (PD) events include training, workshops, communities of practice, presentations, and information sessions designed to help individual participants obtain or develop new and existing knowledge and skills needed to put expected practices into action.
How many PD events were delivered in {reporting period}?
Please include PD events provided statewide and to your PLEA. [write in #, min 0, max 30- for each write in # option in the form, Qualtrics data validation ensures the field accepts numeric answers only]
Display Q3-17 if Q2>0
SUB-SECTION FOR EACH PD EVENT
The following questions pertain to the {1st, 2nd, 3rd, …, 30th} PD event.
What was the name of the PD event? [write in]
For each the following questions, please select all the topics that were a major theme or focus of the PD event. A theme or focus is major if it has a learning objective or another meaningful result attached to it.
Which of the following school health infrastructure building processes did the PD event focus on (if any)? (Select all that apply) [multiple selection]
Establishing and/or operating school health/wellness teams, councils, or committees
Conducting and/or using the School Health Index (SHI)
Conducting other CDC school health assessments (e.g., Wellness Policy in Action Tool (WPAT), Health Education Curriculum Assessment Tool (HECAT), or Physical Education Curriculum Assessment Tool (PECAT))
Conducting non-CDC school health assessments (e.g., Thriving School’s Integrated Assessment by the Alliance for a Healthier Generation, Health services Assessment Tool for Schools (HATS) by the American Academy of Pediatrics (AAP), or the Healthy Eating and Physical Activity (HEPA) Standards 2.0 Self-Assessment Tool by The National Afterschool Association (NAA))
Developing and/or implementing school health action plans
Developing and/or implementing local wellness policies
Evaluating programs and initiatives
Other infrastructure building process(es) [write in]
No school health infrastructure building processes were a focus of the PD event [exclusive]
Which of the following DP23-0002 priority topics did the PD event focus on (if any)? (Select all that apply) [multiple selection]
Health equity and/or health disparities
Management of chronic health conditions
Nutrition environment and services
Physical activity/Physical education (PA/PE) or Comprehensive School Physical Activity Program (CSPAP)
None of the above priority topics were a focus of the PD event [exclusive]
Which of the following additional topics did the PD event focus on (if any)? (Select all that apply) [multiple selection]
Community involvement
Counseling, psychological, and social services
Employee wellness
Family engagement
Health education
Health services
Out-of-school time
Physical environment
Social and emotional climate
Whole School Whole Community, Whole Child (WSCC) model
Other topic(s) [write in]
No additional topics were a focus of the PD event [exclusive]
How many total participants (i.e., individuals) attended the PD event?
Include only intended PD recipients. Exclude PD event staff or partner observers who are not intended to receive the PD to increase their knowledge and/or skills. [write in #, default 0]
How many of your state’s unique local education agencies and/or schools were directly represented by one or more participants at the PD event?
a. Local education agencies [write in #, default 0]
b. Schools [write in #, default 0]
[Display if 9a > 0] Was the PLEA represented by one or more participants at the PD event?
Select ‘yes’ if the PLEA or corresponding schools within the PLEA were represented at the event. [select one]
Yes
No
[Display if 9b > 0] Of the schools represented at the PD event, how many were located within your PLEA (if any)? [write in #, default 0]
Please select the types of school participants that attended the PD event. (Select all that apply) [multiple selection]
School administrators
School student support staff (i.e., counselors, psychologists, social workers)
School health/physical education teachers
School health coordinators
School nurses
School nutrition staff
Other school teachers
Other school staff
[Display if “Other school staff”] What other categories of school staff attended the PD event? [write in]
Please select the types of district (or LEA) participants that attended the PD event. (Select all that apply) [multiple selection]
District family or community engagement staff
District health coordinators
District health/physical education staff
District nurses or health services staff
District nutrition staff
District superintendent
Other district staff
[Display if “Other district staff”] What other categories of district staff attended the PD event? [write in]
Please select the types of non-school and non-district participants that attended the PD event. (Select all that apply) [multiple selection]
State education agency (SEA) staff
Other state government staff (e.g., health department staff)
Local government staff (e.g., local health department staff)
Out-of-school-time staff (e.g., administrators of out-of-school time programs, intermediary organizations, front line staff)
Community-based organization staff
Community members
Parents/family members
Students
[Display if “Other non-school or district participants”] What other categories of non-school and non-district participants attended the PD event? [write in]
SECTION III: TECHNICAL ASSISTANCE
Technical assistance (TA) is the process of providing direct, tailored support to an organization or individual(s). A TA instance is a collaborative (two-way) exchange between a provider (specialist) and one or more site(s) to address a need or problem. TA instances may occur by phone, e-mail, and virtual or in-person meetings and may include routine (e.g., monthly) and ad hoc communications. Multiple email exchanges or phone calls around one or more topics or issues should be counted as a single TA instance. Only report TA instances delivered as part of the DP23-0002 program.
17. How many TA instances were provided in {reporting period}?
Please include TA provided statewide and/or to your PLEA and corresponding schools. [write in #]
For Q19 - 24, display if Q18 > 0
TA Topics of Focus
Select up to 3 school health infrastructure building processes most commonly addressed by TA instances in {reporting period}. [multiple choice, min 1, max 3]
Establishing and/or operating school health/wellness teams, councils, or committees
Conducting and/or using the School Health Index (SHI)
Conducting other CDC school health assessments (e.g., WPAT, HECAT, PECAT)
Conducting non-CDC school health assessments (e.g., Healthy Generation’s Healthy Schools Assessment)
Developing and/or implementing school health action plans
Developing and/or implementing local wellness policies
Evaluating programs and initiatives
No school health infrastructure building processes were the focus of TA [exclusive]
Select up
to 5 additional topics most commonly addressed by TA
instances in {reporting period}. [multiple
choice, min 1, max 5]
Community involvement
Counseling, psychological, and social services
Employee wellness
Family engagement
Health education
Health equity and/or health disparities
Health services
Management of chronic health conditions
Nutrition environment and services
Out-of-school time
Physical activity/physical education (PA/PE) or Comprehensive School Physical Activity Program (CSPAP)
Physical environment
Social and emotional climate
Whole School Whole Community, Whole Child (WSCC) model
Other topic(s) [write in]
No topics were the focus of TA [exclusive]
TA Participants
How many of your state’s unique local education agencies, schools, and/or other organizations did you provide TA to in {reporting period}?
Local education agencies [write in #, default 0]
Schools [write in #, default 0]
Other organizations (e.g., community-based organizations, out-of-school providers) [write in #, default 0]
[Display if “Other organizations”>0] What types of other organizations did you provide TA to in {reporting period}?
For example, community-based organizations, out-of-school time providers, local health departments. [write in]
Of the {Q18} TA instances provided in {reporting period}, how many were provided to the PLEA and/or PLEA corresponding schools? [write in #, default 0]
SECTION IV: PLEA CORRESPONDING SCHOOLS
This section pertains only to corresponding schools within your priority local education agency (PLEA). The maximum number of schools you may enter for any question is {#ofPLEAschools}.
How many PLEA corresponding schools completed new school health assessments of each type in {reporting period}?
Only report schools that completed the entire assessment during this period. Do not include schools that started or are in progress of completing an assessment or schools who had completed the assessment before this period.
School Health Index (SHI) (CDC) [write in #, default 0, max {#ofPLEAschools}]
Wellness Policy in Action Tool (WPAT) (CDC) [write in #, default 0, max {#ofPLEAschools}]
Health Education Curriculum Assessment Tool (HECAT) (CDC) [write in #, default 0, max {#ofPLEAschools}]
Physical Education Curriculum Assessment Tool (PECAT) (CDC) [write in #, default 0, max {#ofPLEAschools}]
Thriving School’s Integrated Assessment (Alliance for a Healthier Generation) [write in #, default 0, max {#ofPLEAschools}]
Health services Assessment Tool for Schools (HATS) (American Academy of Pediatrics) [write in #, default 0, max {#ofPLEAschools}]
Healthy Eating and Physical Activity (HEPA) Standards 2.0 Self-Assessment Tool (The National Afterschool Association) [write in #, default 0, max {#ofPLEAschools}]
Other assessment(s) [write in #, default 0, max {#ofPLEAschools}]
How many PLEA corresponding schools submitted a new fully developed DP23-0002 action plan in {reporting period}? [write in #, default 0, max {#ofPLEAschools}]
How many PLEA corresponding schools did you assist in implementing their action plans in {reporting period}? [write in #, default 0, max {#ofPLEAschools}]
[Display if Q28 > 0] In 1-2 sentences, describe how you assisted PLEA corresponding schools to implement their action plans. [write in]
27. You may provide any additional relevant notes on school health assessments and/or action plans here. (Optional) [write in]
SECTION V: WINS AND LESSONS LEARNED
Please share any wins and/or lessons learned in {reporting period}. (Optional)
For example, a state or district adopting a policy you have been advocating for, a partner you helped write a grant proposal secured funding, a new collaboration has kicked off due to your network weaving efforts. [write in]
Please share any other information that is important to understand your report this month (e.g., challenges, barriers, etc.). [write in]
SECTION VI: CERTIFICATION
I certify to the best of my knowledge and belief that this report is correct and complete for performance of activities for the purposes set forth in the award documents.
Name and title of person who completed this form [write in]
Email address [write in, validated]
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Chuvileva, Yulia (CDC/NCCDPHP/DASH) |
| File Modified | 0000-00-00 |
| File Created | 2025-05-19 |