Sangamon County Excellence in School Wellness Award
Application for Middle schools & High Schools
School Information Form
School District: _______________________________________________________
School Name: ______________________________________ Grades: __________________
Address: ______________________________________________________________________
City: ____________________________________ Zip: _______________________
Main Phone: ___________________________ Main Fax: ___________________________
Percentage free/reduced lunch: ____________ %
Principal Name & Email: __________________________________________________________
Physical Education Teacher Name & Email: ___________________________________________
Food Service Director/Manager Name & Email: _______________________________________
**School contact person for Award: ________________________________________________
**Contact phone: ____________________ **Contact email: ___________________________
Best way to be reached (choose one): Phone Email
Additional questions:
1. Is this the first year that your school is applying for the Sangamon County Excellence in School Wellness Award?
□ Yes □ No
2. How did you hear about the award? _____________________________________________
______________________________________________________________________________
3. Do you give permission to the awards council to share any of your submitted policies, activities, programs, and/or documentation for future outreach or educational purposes (e.g. resource guides, best practices, success stories, etc.)?
□ Yes □ No
4. Do you give permission for supporting partners of the award to contact you regarding school wellness opportunities, resources, programs, and/or grants for your school?
□ Yes □ No
Excellence in School Wellness Award Application
* = Required question
1. *Do you have a district wellness policy as required by federal law?
□ Yes □ No □ Not applicable
2. *Do you have a district wellness committee or team?
□ Yes □ No □ Not applicable
3. *Do you have a school wellness committee or team? □ Yes □ No
4. *Who is involved on your school wellness committee or team? (Check all that apply)
□ Principal □ School nurse □ Health Teacher
□ Assistant Principal □ Parent(s) □ Community member(s)
□ PE teacher □ Student(s) □ Other teacher(s)
□ Food service manager/staff □ Maintenance/Janitorial staff
□ Other: ______________________________________
5. *How long have you had a school wellness committee/team?
□ ≤ 1 year □ 1-3 years □ 3-5 years □ ≥ 5 years
6. *How often does your school wellness committee/team meet during the school year?
□ 0-2 times per year □ 3-5 times per year □ 6 or more times per year
Food service
1. *Do you participate in the National School Breakfast and/or Lunch Program(s)?
□ Yes, National School Breakfast Program (Optional: ______% participation)
□ Yes, National School Lunch Program (Optional: ______% participation)
□ No, however our nutrition requirements/guidelines for breakfast and/or lunch are attached.
2. *Are your school meals currently in compliance with the current federal school meal standards?
□ Yes □ No □ Not applicable
3. *Are the a la carte and competitive food and beverage items in compliance with the federal Smart Snacks guidelines?
□ Yes □ No □ We don’t sell a la carte/competitive food/beverages(s)
□ Not applicable
4. Does your school have a salad bar or fruit/vegetable bar? □ Yes □ No
5. Do you purchase any local foods to be served in your school meals? □ Yes □ No
If yes, what do you purchase?
□ Milk □ Meat/meat alternatives □ Bread/grains □ Fruit
□ Vegetables
□ Other: ______________________________________
6. If you have a school garden, is any of its produce served as part of school meals?
□ Yes □ No □ Not applicable
7. Have you implemented any alternative breakfast models in your school to increase breakfast participation, i.e. Grab & go breakfast, Second chance breakfast?
□ Yes □ No □ Tried, but it wasn’t sustained
8. Have you completed a USDA Smarter Lunchrooms assessment? □ Yes □ No
9. If yes, have you implemented any improvements or changes recommended by the USDA Smarter Lunchrooms Movement?
□ Yes □ No
10. If yes, what changes did you make? ______________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
11. Does your school provide an afterschool meal program? □ Yes □ No
12. Is your school a summer meal site? □ Yes □ No
13. Does your school or district provide meals to summer meal sites? □ Yes □ No
14. *How much time do students have to eat breakfast? __________________ minutes
15. *How much time do students have to eat lunch? _____________________ minutes
16. *How many days per week is a fresh fruit or vegetable served at breakfast?
□ 1 □ 2 □ 3 □ 4 □ 5
17. *How many days per week is a fresh fruit or vegetable served at lunch?
□ 1 □ 2 □ 3 □ 4 □ 5
18. *Is non-fat flavored milk served daily? □ Yes □ No
19. If not, how often is it served? _______ days/week (breakfast) ________ days/week (lunch)
20. Have you provided taste tests in your lunchroom for items on the school menu?
□ Yes □ No
21. What percentage of your school food items are made “from scratch,” “semi-scratch,” or “made in house” rather than pre-packaged or “heat & serve”?
___________ % Breakfast items ___________ % Lunch items
Open response: In the space provided below, please type your open response further explaining or illustrating your school’s wellness efforts in the area of Food Service, especially about the questions to which you answered ‘yes’.
Nutrition/Nutrition Education
1. *Do you have a written policy or rule that decreases or prohibits unhealthy food(s) during school celebrations, e.g. classroom celebrations, birthdays, student of the month, etc.?
□ Yes □ No
2. *Do you have a written policy or rule that decreases or prohibits unhealthy food(s) or candy as a classroom reward?
□ Yes □ No
3. Have you had external people or organizations provide nutrition education in the classroom, e.g. Ag in the Classroom (Sangamon County Farm Bureau), OrganWise Guys (UI Extension), Brain Breaks (genHkids), Doctors, Dietitians, Health Educators, etc.?
□ Yes □ No
4. Have you had internal staff provide nutrition education in different classrooms, e.g. school nurse, food service, PE teacher, health teacher, etc.?
□ Yes □ No
5. Has the school or any classrooms participated in Farm to School programs or education?
□ Yes □ No
6. *Does your school have a school garden? □ Yes □ No
7. *If yes, are you using a garden curriculum to teach students about nutrition?
□ Yes □ No
8. *If not, is the garden used by classroom teachers (including PE/Health teachers) to enhance any parts of their standard curriculum?
□ Yes □ No
9. *Do students have unrestricted access to free, safe, unflavored water at all times during the school day, e.g. water bottles allowed in classrooms, water fountain or cups of water accessible during class/breakfast/lunch/recess, etc.?
□ Yes □ No
10. Have you organized, or do you offer, any healthy fundraisers? □ Yes □ No
11. If yes, how many? □ 1-2 □ 3-4 □ 5-6 □ 7+
12. *Did you ask for any fundraising exemptions in the current school year?
□ Yes □ No □ N/A
13. If yes, how many? □ 1-2 □ 3-4 □ 5-6 □ 7+
14. Have you offered healthy options during school sporting events or concession stands outside of the school day?
□ Yes □ No
15. If yes, what options? _________________________________________________________
_____________________________________________________________________________
16. Have you offered healthy options in vending machines for students or staff?
□ Yes □ No
17. If yes, what options? _________________________________________________________
______________________________________________________________________________
18. Have you organized a health fair or wellness day for students or families?
□ Yes □ No
19. *Have you provided healthy food choices and/or opportunities for physical activity during student and/or family events at your school?
□ Yes □ No
Open response: In the space provided below, please type your open response further explaining or illustrating your school’s wellness efforts in the area of Nutrition/Nutrition Education, especially about the questions to which you answered ‘yes’.
Physical Education/Activity
1. *Are you compliant with the state requirements for daily Physical Education?
□ Yes □ No □ Not applicable
2. If not, why not? _____________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
3. Did your school or district request a Physical Education waiver or waiver extension from the state for the current school year?
□ Yes □ No □ Not applicable
4. Do you have a certified PE teacher on staff? □ Yes □ No
5. Do you have use agreement allowing the general public to use your physical activity area outside of school hours?
□ Yes □ No
6. What percentage of classroom teachers uses brain breaks or activity breaks on a regular basis? __________ %
7. (Middle schools) How many minutes of PE do students receive each week?
_______________ minutes
8. (High schools) How many semesters or credits of PE are required in your school?
___________ semesters or ____________ credits
9. Are students moderately to vigorously active at least 50% of the time during PE?
□ Yes □ No
10. Do you have a written policy or rule prohibiting the withholding of PE as punishment?
□ Yes □ No
11. Do you offer additional opportunities for physical activity during, before or after school, e.g. genHkids Jump Start, Girls on the Run, a walking or running club, garden club, etc.?
□ Yes □ No
12. Do you have, or have you offered, a walk/bike to school program, e.g. Safe Routes to Schools, walking school bus, or another similar program supporting active transportation?
□ Yes □ No
Open response: In the space provided below, please type your open response further explaining or illustrating your school’s wellness efforts in the area of Physical Education/Activity, especially about the questions to which you answered ‘yes’.
Marketing/Promotion
1. Does your school participate in any of the following healthy school challenge programs/school wellness programs?
□ USDA Team Nutrition □ USDA Healthier US Challenge
□ US Alliance for Healthier Generation □ Fuel Up to Play 60
□ Action for Healthy Kids □ Let’s Move! Active Schools
□ CATCH school
□ Other: ___________________________________________________________
2. Do you publicize information about your school’s wellness efforts? □ Yes □ No
3. If yes, where do you publicize? Check all that apply.
□ School website □ School online newsletter □ School Facebook page
□ School mailed newsletter □ School TV □ Local TV
□ Local newspaper □ Twitter □ Pinterest □ Instagram
□ School events
□ Other: ___________________________________________________________
4. Do you provide information about health, nutrition, or physical activity to your parents/families on a regular basis?
□ Yes □ No
5. If yes, where do you publicize? Check all that apply.
□ School website □ School online newsletter □ School Facebook page
□ School mailed newsletter □ School TV □ Local TV
□ Local newspaper □ Twitter □ Pinterest □ Instagram
□ School events
□ Other: ___________________________________________________________
6. Did you have posters, billboards, marquees, or other promotional materials that advertise for food or beverages that were not in compliance with the Smart Snacks guidelines, e.g. Pepsi, Coca Cola, M&M’s, etc.?
□ Yes □ No
7. Where do you have posters or promotional materials about obesity prevention, drinking water, nutrition/healthy eating, or physical activity?
□ Food service line □ On salad bar □ In cafeteria/sitting area
□ Hallways □ Bathroom □ Gym □ Admin Office
□ Locker room □ Playground □ Outside of school, on building
□ Nurse’s Office □ Classrooms
□ Other: ___________________________________________________________
8. Have you organized contests focusing on nutrition, physical activity, or wellness-related themes for students and/or families, e.g. coloring/art/poster contests, walking contests, jump rope contests, video/picture contests, 5K, etc.?
□ Yes □ No
9. Have you celebrated as a school any nutrition/wellness-related holidays (either nationally recognized, state, local, or created by the school), e.g. National Nutrition Month, National School Lunch Week, National Childhood Obesity Awareness Month, National Strawberry Day, Diabetes Awareness Month, Heart Month, Rethink Your Drink, etc.?
□ Yes □ No
10. How often do you present feedback to your district and/or superintendent about your school’s wellness progress?
□ Never □ 1x per year □ 2x per year □ > 3x per year
Open response: In the space provided below, please type your open response further explaining or illustrating your school’s wellness efforts in the area of Marketing/Promotion, especially about the questions to which you answered ‘yes’.
Family/Community Involvement
1. Do you have external people or organizations providing nutrition or physical activity education/programs at your school during, before, or after school? E.g. cooking club, UI Extension 4-H,, genHkids Jump Start, Girls on the Run, etc.
□ Yes □ No
*If yes, please complete the Extracurricular Program Form and submit it with your completed application.
2. If you have a school garden, are parents or community members involved in maintaining the garden?
□ Yes □ No
3. If you have a school garden, are students involved in maintaining the garden?
□ Yes □ No
4. How often do parents volunteer for wellness events/programs?
□ Never □ Rarely □ Sometimes □ Often □ Always
5. Have family or community members been actively engaged in planning or implementing one or more wellness events/programs?
□ Yes □ No
6. Have you involved your PTO/PTA committee in helping you meet your school’s wellness goals?
□ Yes □ No □ We don’t have a PTO/PTA
7. Do you have community organizations or community members working as partners or sponsors helping you achieve your school’s wellness goals?
□ Yes □ No
8. Are parents or family members advised as to when school wellness meetings are held?
□ Yes □ No
9. *Have you applied for any grants or awards to help you achieve your school’s wellness goals?
□ Yes □ No
10. If yes, which grants/awards? ___________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Open response: In the space provided below, please type your open response further explaining or illustrating your school’s wellness efforts in the area of Family/Community Involvement, especially about the questions to which you answered ‘yes’.
Staff Wellness
1. Has the administration or staff organized staff wellness opportunities?
□ Yes □ No
2. If yes, How often?
□ > 3x per week □ 1-2x per week □ < 4x per month □ Quarterly
□ 2x per year □ Other: _____________________________________________
3. What staff wellness topics or issues have you covered in your events/programs?
□ Nutrition □ Physical Activity □ Stress □ Diabetes
□ Weight Loss □ Heart Disease/High Blood Pressure □ Cooking
□ Other: __________________________________________________________________
________________________________________________________________________
4. Does the staff receive information about how to improve their own health on a regular basis, either from school administration or from the school wellness team?
□ Yes □ No
5. Have health assessments for staff been offered for free or low-cost through the school at least once this school year?