Who should complete this form?
This form is designed to be completed by the school nurse or school health contact for the school listed on the top of the surveillance form.
When should this form be returned?
The form should be completed and returned via fax to 617-624-5560 as soon as possible, preferably no later than 2 weeks from the day it is received by the school nurse or school health contact.
Which students should I include on this form?
Please include students with asthma (those that a doctor, nurse, or other health professional ever identified to have asthma) and diabetes in grades kindergarten through 8 only. Do not include pre-kindergarten or high school students on this form. Students are to be reported by the city/town in which they reside. If your school does not serve any of grades K-8, please state so on the form and send it back by fax to 617-624-5560.
What if this school does not have any students with asthma and/or diabetes?
Please complete the form with zeros and send it back by fax to 617-624-5560.
How should I report numbers by grade in the case of ungraded students?
Students younger than 5 or older than 14 should not be reported on this surveillance form. For students with asthma and/or diabetes who are not assigned to a particular grade, use the following guideline:
How do I report the number of students with asthma and/or diabetes by city/town of residence?
Some students may commute from towns other than that in which the school is located, therefore please report the number of students with asthma and/or diabetes by the city/town they live in. If your school serves students from multiple cities/towns, please photocopy the surveillance form and fax back all copies to the Department of Public Health. If your school has students with asthma and/or diabetes who do not live in the state of Massachusetts, please group these students together on one survey form and label “out of state”.
How do I report the race/ethnicity data?
For asthma and for diabetes, please fill in the tables for RACE/ETHNICITY by marking the number of males and females in each category. Contact the business office for accurate RACE/ETHNICITY information. Do not guess. If your school has students that fall into more than one racial category, for example students that are Black and Asian Non-Hispanic, please use the “multi-racial, non-hispanic” category. If you do not know the race/ethnicity of certain students, please record them in the “unknown” category.
What if the school name, address, or district information printed on the form is not correct?
If the information printed on the form for your school is not correct, please check the box provided on the surveillance form. Then cross out the incorrect information and write in the correct information in any blank space that is available. The information will be updated in our database upon receipt of the form.
Is there an online or electronic version of this form?
Yes, the online version of the form can be completed electronically and emailed to MDPH. The online form and instructions for completing it can be found at www.mass.gov/dph/asthma by clicking on 2012-2013 Asthma Survey.
Who should I contact with questions or comments regarding this form or the pediatric asthma/diabetes surveillance project?
Questions may be directed via email to the project mailbox at firstname.lastname@example.org or via telephone to 617-624-5757. Please ask for the Pediatric Asthma Coordinator.