Title IV, Part A
Safe
and
of the No Child Left Behind
Act (formerly IASA)
Contact Name: _______________________________________
Contact Title: _______________________________________
Contact e-mail address:
_____________________________________
Contact Phone
(_______):___________________________________
Q1a. Schools and
Students Served by School Type. Please count only those schools at which services
were funded in whole or in part by SDFSCA.
1)
During the
school year, how many public schools in your district provided
prevention services/activities to students, categorized by elementary schools,
middle schools, and senior high schools?
See the Glossary for definitions of school type.
2) Of the students
enrolled in these public schools, how many students received services that were funded in whole or
in part by SDFSCA?
|
School Type[1] |
# of Schools Providing
Services funded by SDFSCA |
2) # of Students Receiving
Services funded by SDFSCA |
|
Public elementary schools[2] |
|
|
|
Public middle schools |
|
|
|
Public senior high schools |
|
|
Q1b. Services
at nonpublic schools receiving Title IV (
1)
How many nonpublic schools provided services/activities
to students?
2) Of the students enrolled in these nonpublic
schools, how many students received services that were funded in whole or in
part by SDFSCA?
|
|
1) # of Schools Providing
Services funded by SDFSCA |
2) # of Students Receiving
Services funded by SDFSCA |
|
Nonpublic schools
receiving funds |
|
|
Section 2. ATOD prevention strategies, Services
and Activities Funded (Inactive)
Q6 Check if, during
the school year, your district involved community agencies or organizations in implementing
its
____
Yes, community agencies or
organizations involved
If
No, Skip to Q8
Q7 Check if the district involved schools
and one or more community agencies or organizations in:
|
|
Type of Community Involvement |
Check |
|
a |
Joint
service delivery, including referrals |
|
|
b |
Teacher/staff training
|
|
|
c |
Public
awareness activities |
|
|
d |
Fundraising |
|
Q8 During the school year, did students in your district participate in: a)
designing; b) delivering; and/or c) critiquing ATOD or violence prevention
programming? (Check as many as
apply. If your district did not involve
students, do not check any of the responses.)
___ a) Yes, designing
___ b) Yes, delivering
___ c) Yes, critiquing
Section
4. Principles of Effectiveness
Q9 Since
the United States Department of Education is keenly interested in district
implementation of the Principles
of Effectiveness, the New Jersey
Department of Education wants to learn the status of all districts with regard
to designing and executing ATOD prevention programs based upon the four
principles. See the Glossary for a
description of the principles.
Indicate below the status of your district
with regard to the principles: (Check only one.)
___ Would appreciate
technical assistance
___ Making satisfactory progress in
implementing the principles
___ Have experienced success in using the
principles to design and execute our ATOD prevention program. Would be willing to discuss serving as a
model for other LEAs.
Q10 Indicate below the areas or topics in which your
district would appreciate technical assistance: (Please check all that apply)
Ø
___ Data analysis
Ø
___ Data collection
Ø
___ Program/Service/Activity selection
Ø
___ Establishment of performance measures
Ø
___ Organization and selection of the planning team
for Title IV-A funds
Ø
___ Strategies to incorporate the consultation
of parents
Ø ___ Strategies for obtaining active parental consent
Ø ___ Comprehensive program planning
Ø
___ Other
_____________________________________________
Ø
___ None
Q11 Intentionally left blank.
Q12 Steroid Use: Number of students identified and referred to
a school-based or outside service for steroid use.
K-8 9-12
School-Based
Service ____ ____
Outside
Service ____ ____
Q13 Smoking Cessation. Number of students referred to a smoking
cessation program.
K-8 9-12
School-Based
Service ____ ____
Outside
Service ____ ____
Q14 Alcohol
and/or drug use by self or others. Number
of students referred to an alcohol or other drug school-based or outside
service for reasons related to the use of alcohol or other drugs (exclude
smoking cessation and steroid treatment/programs)[3]:
K-8 9-12
School-Based
Service ____ ____
Outside
Service
Private Physician ____ ____
Clinic, Outpatient or Residential
Treatment Facility ____ ____
Group, e.g., Alcoholics Anonymous,
Al-Anon-Al-A-Teen ____ ____
Q15
During the school year, how did your
district use data related to youth drug use and violence to manage youth ATOD
and violence prevention programs? (Please check all that apply.)
Ø
___ Assess needs
Ø
___ Develop performance measures for the
district’s
Ø
___ Select school and/or community-based
interventions
Ø ___ Monitor
the success of interventions in reducing ATOD use and violence
Ø
___ Inform the public
Ø
___ Improve program outcome measures
Ø
___ None of the above
Q16 Indicate below the types of data your
district used in its needs assessment process to develop priority problems
and/or select target populations in violence and ATOD prevention: (Please check all that apply.)
Ø
___ Truancy data
Ø
___ Discipline data
Ø
___ Academic data
Ø
___ Program, activity or curricula data
Ø
___ Perception of social disapproval, perception
of health risks or other perception data
Ø
___ Data on age of onset of use of alcohol,
tobacco and other drugs
Ø
___ Data on use of alcohol, tobacco and other
drugs (e.g., 30-day, annual, lifetime use)
Ø
___ Other
Ø
___ None
Q17 During the school
year, did staff in your district receive
training in a) collecting data; b) analyzing data; and/or c) using data for
other aspects of ATOD and Violence prevention planning? (Check as many as
apply.)
___ No ___ Yes
If Yes, please indicate type of training
___ Collecting data
___ Analyzing data
___ Using
data for other aspects of prevention planning
Thank you!
Do not mail or fax this form. Use it only as a worksheet.