Massachusetts Department of Public Health, Center for Environmental Health
Pediatric Asthma Surveillance Form
 2003-2004 School Year

Thank you for participating in the 2003-2004 Pediatric Asthma Surveillance Program!  Please provide the following information for K-8 students in your school building that have asthma of any type or severity as indicated by parent, student, or health care provider communications, direct observation, emergency cards, or other reliable means.  The school nurse should complete this form.  

Below are some guidelines to aid you in successfully completing the surveillance form:

•	
•	Include students in grades K-8 only.  Do not include pre-K or high school students.
•	Provide information for one school only. If you are responsible for students in another school, please complete a separate form for those students.
•	Answer questions for the current school year, 2003-2004, only.
•	Please contact the pediatric asthma surveillance program with any questions (contact information listed below).
•	Please answer every question.
•	Please return competed survey via email or fax by April 30, 2004 to:

Massachusetts Department of Public Health
Center for Environmental Health 
Pediatric Asthma Surveillance Program
FAX: (617) 624-5560, PHONE: (617) 624-5757
EMAIL: Ped.Asthma@dph.state.ma.us

1. Full Name of School  	3. City/Town	5. Name of Person Completing Form	
                                                                                                

(office use only)

(office use only)

     	         	
2. Street Address of School 	4. Phone Number	6. Email Address	
     	     	     	
7. Is this school (select only one):	8. (If this is a public school) Which school district is this school a part of?	
	 1.) part of the local public school    
     district	 3.) a charter school	

(office use only)

     	
	 2.) part of a regional public school 
     district	 4.) a nonpublic 
     school		
9. Number of K-8 Students With Asthma By Grade
•	‘0’= no students with asthma
•	‘NA’ = not applicable, grade not present	10. Number of K-8 Students with Asthma By Gender
•	‘0’= no students with asthma
•	‘NA’ = not applicable, gender not present	12. How else did the school nurse know these students had asthma?   (check all that apply)	
		emergency cards	student communication	
Grade	Number	Don’t Know	Gender	Number	Don’t Know	parent resource   
    center	direct observation of asthma 
    attack	
Kindergarten	     		Male	     				
Grade 1	     		Female	     		parent 
    communication
	other	
Grade 2	     		Total
(should equal  total by grade)	     			(Explain:                                       )	
Grade 3	     							
Grade 4	     					13. Please estimate the number of students from item number 9 for which you have an Asthma Action Plan on file.	
Grade 5	     		11. Please estimate the number of students from item number 9 for which you have documentation of a provider diagnosis of asthma and/or asthma medication orders?		
Grade 6	     			
Number:

	                     	
Grade 7	     			14. How did you collect the data for this survey? (select only one)
	
Grade 8	     			 1.) computerized records	 3.) paper records	
Total
(should equal total by gender)	     			
  
          	 2.) combination of 
      computerized and     
      paper records	 4.) other	
						
Number:

(Explain:                                )	

Please return by April 30th, 2004 to the MDPH Center for Environmental Health.
Phone: (617) 624-5560, Fax: (617) 624-5777, Email: Ped.Asthma@dph.state.ma.us.

Massachusetts Department of Public Health, Center for Environmental Health
Pediatric Asthma Surveillance Form, 2003-2004

Location Code: