Jeffco Healthy Schools Checklist 2020-21
Thank you for taking the time to share this important information!

This checklist helps Jeffco Healthy Schools by:
-- Gauging wellness at the school-level
-- Identifying needs so we can best support and fund wellness in schools
-- Abiding by Federal Rule to track progress toward District Wellness Goals
-- Driving the long-term work of the Jeffco District Health Advisory Council

PLEASE REFERENCE the CURRENT SCHOOL YEAR when responding and seek input if you don't know the answer.

PLEASE answer honestly and to the best of your ability. There is NO PENALTY for how your school responds to any question. The information will help with identifying overall needs in the district.

Complete only ONE form per school (To See if your school has participated view: https://docs.google.com/spreadsheets/d/14BdNhJXfsxXLxTCZFFGTjy3uO4zGVYbjUffnVdI-LkM/edit?usp=sharing)
School *
Email address (to send a report with your responses) *
In what city is your school located? *
General Culture of Health
1. Does this school have a health and wellness/healthy schools TEAM? *
Can include a PTA Health and Wellness team
2. Does this school have an identified person that leads/coordinates school health efforts? *
3. Does this school have and implement health and wellness GOALS? *
Nutrition
4. Are students permitted to have a drinking water bottle during the school day? *
5. Has this school adopted a written policy or guideline (school and/or district-created) that… *
The district does have a written policy and guideline on these topics. Learn more here: https://goo.gl/S9JfZw
Yes
No
Prohibits using food as a reward (e.g., candy for positive behavior)?
Prohibits the advertising of unhealthy food/beverages on school grounds (e.g., banners, student newspaper)
Requires predominantly healthy food/beverages for celebrations
Requires non-food or healthy food school-sponsored fundraisers
Prohibits food for birthdays (e.g. food brought in by families for students to share, such as cupcakes)
6. Does this school do the following to promote healthy eating? *
Yes
No
NA
Placed fruits and vegetables near the cafeteria cashier, where they are easy to access
Used attractive displays for fruits and vegetables in the cafeteria
Conducted taste tests to determine food preferences for nutritious items
Labeled healthful foods with appealing names (e.g., crunchy carrots)
Prohibited less nutritious foods and beverages (e.g., candy, baked goods) from being sold for fundraising purposes
7. How many total MINUTES, on average, is your school's lunch period? *
(i.e., the sum of line, serving, and seated time)
8. Does your school prohibit advertisements for candy, fast food restaurants, or soft drinks in each of the following locations? *
Yes
No
In school buildings
On school grounds (e.g., fields)
In school publications (e.g., newsletters, web sites, other)
Physical Activity/P.E.
9. ELEMENTARY and MIDDLE ONLY: Has your school adopted a written policy (school and/or district-created) that prohibits taking away all or part of recess for the following reasons?
Yes
No
NA
Punishment for misbehavior
Make up for lost instructional time or testing
Clear selection
10. ELEMENTARY and MIDDLE ONLY: How many minutes, on average, do students have for recess during the school day? Please include all recess after the morning bell rings (e.g., morning, lunch, afternoon recess).
11. ELEMENTARY and MIDDLE ONLY: How many recess periods does your school have for the MAJORITY of your students?
Clear selection
12. ELEMENTARY and MIDDLE ONLY: In the case of implement weather, has your school adopted a written policy that requires an indoor recess with comparable physical activity to outdoor recess.
Clear selection
13. ELEMENTARY and MIDDLE ONLY: Does this school schedule recess BEFORE lunch? *
14. During PE courses, what percentage of the time, on average, are students engaged in moderate to vigorous physical activity (equivalent to brisk walking, bicycling, aerobic dance, etc.)? *
please estimate % of time
15. How many teachers/classrooms in your school, on average, offer physical activity breaks in their classrooms? *
16. Does this school offer opportunities for students to participate in the following? *
Yes
No
NA
Interscholastic sports (e.g. competition between schools) [Note: elementary schools answer NA]
Intramural sports programs (regardless of physical ability)
Before or after school physical activity (i.e. clubs, access to physical activity equipment inside, etc.)
Health Education
17. Elementary ONLY: Outside of PE- are the following health education topics taught at this school?
Yes
No
Healthy eating
Physical activity
Personal hygiene
Oral Health
Mental and emotional wellness  (i.e. Second Step, Brainwise, etc)
Alcohol, tobacco and other drug use prevention
Unintentional injury prevention/Safety
Violence prevention (e.g., bullying, fighting, homicide)
Suicide prevention
Human sexuality/sexual health education
Stress Management
Clear selection
18. Does your school’s health education program include information that is specific to the experiences and needs of students who identify as the following? *
Yes
No
Lesbian, gay, bisexual, queer or questioning
Transgender
Intersex (i.e., people born with reproductive or sexual anatomy that does not fit the typical definitions of 'female' or 'male.')
People with physical or intellectual disabilities
People who have experienced sexual assault
Mental/Emotional Wellness
19. How many teachers/classrooms in your school, on average, practice mindfulness with students in their classrooms?
Clear selection
20. Do the following staff members at this school regularly receive training on how to identify and support students with social, emotional, and behavioral health needs?
(e.g., Responsive Classroom, Youth Mental Health First Aid, Signs of Suicide)
Yes, most if not all receive training
Yes, some receive training
No
Teachers
Administrators
Coaches
Nurses, health aides, health paraprofessionals
Counselors, psychologists, social workers
Paraprofessionals 
Clear selection
21. With regard to ALL students (i.e., Tier 1)
Yes
No
Does your school conduct a universal screening? (e.g., DESSA-mini)
Does your school provide opportunities that develop the knowledge, attitudes, and skills (e.g., School Connect, Second Step, BrainWise) for social and emotional wellness?
Does your school provide school-wide student supports for modeling, practicing, and reinforcing pro-social behavior?
Clear selection
22. With regard to SOME students (i.e., Tier 2)
Yes
No
Does your school use a system (e.g., Check & Connect, Check-In/Check-Out) for weekly monitoring of the progress of select students toward identified goals?
Does your school have a class(es) or group(s) for identified students in need of social, emotional, and behavioral health supports?
Clear selection
23. With regard to a FEW students (i.e., Tier 3)
Yes, most if not all receive training
Yes, some receive training
No
Have teachers and other staff received training on how to respond to an individual student in crisis (i.e., threatening harm to self or others)
Clear selection
24. With regard to a FEW students (i.e., Tier 3)
Yes
No
Does your school have a re-entry plan for students after a prolonged absence or suspension that includes social and emotional support for re-integration into school?
Clear selection
25. With regard to a FEW students (i.e., Tier 3) does your school provide or refer for therapeutic services?
Yes
No
Individual counseling (in-school)
Group counseling (in-school)
Referrals to services (outside of school)
Clear selection
26. Does this school engage in the following practices to address positive school climate?…
Yes
No
Hold school-wide activities that give students opportunities to learn about diverse cultures and experiences
Use instructional materials that reflect the diversity of your student body and develop appreciation for the diversity of others
Consistently implement culturally responsive teaching techniques in the classroom
Have a student-led club that aims to create a safe and welcoming school environment for all youth, regardless of sexual orientation or gender identity (e.g., student voice, gay/straight alliances)
Clear selection
27. Does this school engage in the following practices to address harassment and bullying?…
Yes
No
Conduct trainings for school staff about how to respond to harassment and bullying
Provide information to parents/guardians about harassment and bullying
Provide information to students about the consequences of harassment and bullying
Implement strategies or programming to prevent harassment and bullying
Provide anonymous methods for students to report harassment and bullying
Institute corrective measures for students engaged in bullying (e.g., training in acceptable behavior, counseling, restorative justice, appropriate discipline)
Clear selection
28. Does this school engage in the following practices to support lesbian, gay, bisexual, transgender, or questioning (LGBTQ) youth?
Yes
No
Identify "safe spaces" where LGBTQ youth can receive support from administrators, teachers, or other school staff
Prohibit harassment based on student's perceived or actual sexual orientation or gender identity
Encourage staff to attend professional development on safe and supportive school environments for all students
Clear selection
Family, Community, and Student Involvement
29. In an effort to be culturally relevant, does your school engage students, families, and community members in developing communications about school health programs and activities? *
30. Does your school engage parents/guardians and families in school health programs and activities through the following?
Yes
No
Gathering feedback and input from families on school health and wellness activities
Meeting with a parent organization (e.g., PTA) to discuss school health needs and strategies
Providing families with information on school health policies, strategies, and services
Hosting school health activities for families (e.g., cooking classes, yoga or Zumba classes)
Clear selection
31. How does your school obtain input from students about the following components of school health?
Input from students is not solicited
Suggestions are collected from students
Programs or policies are co-created by students
Student health services
Health (including sexual health) education
Physical education
Counseling, psychological, and social services
Food served in school
The school’s physical environment
School culture and climate
Other (please specify below)
Clear selection
Other areas of health in which the school obtains input from students
Employee Wellness
32. Does this school: *
(including, educators, custodians, food service and administrative employees at your school)
Yes
No
Communicate employee wellness as a priority
Provide opportunities for staff wellness
Support staff wellness program participation
Allow a portion of staff meeting time to promote employee wellness and programs 
Conduct a school employee wellness needs assessment or interest survey
Have a prioritized lactation space that can be used by employees and families
33. Are there any supports you need in your school?
check all that apply
Submit
Never submit passwords through Google Forms.
This form was created inside of Jefferson County Public Schools. Report Abuse