The 2013-2014 MDPH Pediatric Asthma/Diabetes Survey can be completed electronically and emailed back to MDPH at  The form can also be completed, printed and faxed to MDPH at (617) 624-5560.  The form should be completed and returned as soon as possible before March 1, 2014.  Please provide data for the 2013-2014 school year.  If you submit an electronic copy to MDPH by email, you do not have to submit a paper copy.

Which students should I include on this form?

Include students with asthma and diabetes in grades K through 8 only. Do not report 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 have any students with asthma or diabetes or if your school does not serve any of the grades K-8, please state so on the form and send it back by email or fax.

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 or diabetes who are not assigned to a particular grade, use the following guideline:

5 years old = kindergarten
8 years old = Grade 3
11 years old = Grade 6

6 years old = Grade 1
9 years old = Grade 4
12 years old = Grade 7

7 years old = Grade 2
10 years old = Grade 5
13 & 14 years old = Grade 8

How do I complete the online form?

To begin, type the school name, address, city, state, zip code, and school code (if you know it). The school code is an 8 digit number assigned to each school by the Department of Elementary and Secondary Education. Please leave this field blank if you do not know the school code.  Next fill in the total number of cities/towns that you will be submitting for your school. As in previous years, MDPH is asking that you report students with asthma and diabetes by the town in which students live.  Determine the number of towns that have students with asthma/diabetes and place this total in the box “Total # city/towns being submitted.”  If your school has students with asthma and/or diabetes who do not live in the state of Massachusetts, please group all these students together on one survey form and label the city as “out of state.” Count this “out of state” town as one in your “Total # city/towns being submitted.”

Next, fill in the remaining information in the header of the form, being sure to include your name, phone number, and an email address where MDPH can reach you. Check those grades between K-8 that your school serves and provide the total K-8 enrollment at your school. Enrollment information is available in the school’s administrative/registrar office.

Once you have completed the header, you can begin to enter the information on students with asthma and diabetes. You will need to fill out one form for each city/town having any students with asthma and/or diabetes.  First, type in the city/town of residence at the top.  Please note that the city/town of residence for asthma should be the same city/town of residence for diabetes. Then type in the number of students with asthma and with diabetes by gender, grade, and race/ethnicity.  If there are no students with asthma or no students with diabetics from that town, please check the box indicating this at the top of the asthma or diabetes section.

How do I report the race/ethnicity data?

Complete the race/ethnicity section by entering the number of males and females with asthma/diabetes in each category. If your school has students with asthma/diabetes 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. For students with asthma/diabetes who do not fall into any of the categories or, if you do not know the race/ethnicity, please record as “unknown.”

How do I submit the form by email?

Once you have entered data for one town, click the “Step 1 Print” button (to keep a paper copy of your work).  Next, click “Step 2 Submit Town by Email” button.  Clicking this will bring up instructions on how to submit your form by email depending on your school’s email system.  Follow those instructions. If you are using an internet mail system (such as hotmail or gmail) you will have to save the form as a PDF and add as attachment(s) to your email. You must complete this step before proceeding to a new town/new form.   If you have students with asthma and/or diabetes from multiple towns, you should then proceed to Step 3 “Add Additional Town” and click yes. By clicking the “Yes” button, the header information you entered at the top of the form will remain, however all information you entered about students with asthma and/or diabetes from the previous town will be cleared. When you have no additional towns to submit, simply click “No” and the last survey will be sent to the MDPH.  The MDPH email address is

This information is provided by the Environmental Health within the Department of Public Health.