Appendix A. Example of an SHN School Summary Questionnaire

Appendix A. Example of an SHN school summary questionnaire

Program Coordinator:The shaded text in italics are aimed at the person responsible for developing the questionnaire and should not to be included in the final questionnaire.

SHN questionnaire

Program Coordinator:Teachers need to see and understand the value of collecting and reporting information, otherwise they will find it tedious and may do a bad job. A training course on how to complete all these tools is essential and should explain why this information is needed and explain how it will be useful to them too, as well as giving some basic instructions (see Training and supervision section in main document). Please adapt the questionnaire as needed

Why should we complete this questionnaire?

This questionnaire is to help you summarize all information related to School Health and Nutrition activities in your school over the last year. It will help you see which activities worked well and which didn’t and will help you track changes over the years. You can use this questionnaire share the program achievements and challenges with the other teachers, parents, club leaders and community members and try and resolve issues that have arisen. For example, one finding might be thatmost children took the deworming tablet but many refused to take the iron. Why not? What can the school, community and clubs do to change this? Another finding might be that there is no soap or water to wash hands. Why and what can be done to make sure there is? Sharing the program results provides an opportunity to raise people’s awareness around SHN issues and the importance of iron or hand-washing with soap in this case.

A copy of the questionnaire should be sent to the program coordinator who will aggregate the information from all the schools and see if the program overall is doing what it should do, identify schools which are doing well and schools which are doing less well and help resolve issues and share lessons learned so that the program can be improved and sustained across all schools. However, it relies on the data being recorded accurately and consistently and the questionnaire being completed correctly, in full, and sent in on time.

Instructions:

Please complete these questionnaires once a year at the end of the school year. Return one copy to your nearest health facility by end of the school year and keep one copy for your school records.

A- General information

(1)Name of the school:______

(2)District:______

Name of the Head teacher:______

Date:!__!__!-!__!__!-!__!__!__!__!

day month year

B – Education information

1.How many children were ENROLLED in each grade at the beginning and end of the school year? Add the number of classes for each grade

# enrolled at beginning of school year
# boys / # girls / Total
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
TOTAL
# enrolled at end of school year
# boys / # girls / Total
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
TOTAL

2.How many children DROPPED OUT of school before the end of the school year?

Note for Program Coordinator:Add a definition of what dropped out means in your country e.g. how long does a child need to be absent from school to be classified as having dropped out

# dropped out before end of school year
# boys / # girls / Total
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
TOTAL

3.Add the reasons children dropped out in your school? (list most important first)

Note for Program Coordinator: Add most common known reasons for dropping out and leave 1-2 columns for additional reasons to be added. This table can only be included if reasons for dropping out are recorded at the classroom level

labor / Marriage / Death of child / Other:______
# boys / # girls / # boys / # girls / # boys / # girls / # boys / # girls
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
TOTAL

4.How many children will be REPEATING their class in the next school year?

Note for program manager: If the questionnaires have to be completed before the teachers know which children will repeat the next school year, then repetition of the current school year could be used. But the same definition should be used every year in all schools

# of students repeating their current grade
# boys / # girls / Total
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
TOTAL

5.How many school days attended have there been during this last school year? (add all days attended for girls and boys, by month for each grade)

Note for program manager: Mean actual attendance should only be calculated if you think attendance registers are recorded correctly and in the same way by all teachers and over time. If not, estimated attendance (counting the number of children present on random days in a sample of schools may be a more accurate assessment of attendance.

Total # of school days in school year / # school days attended by boys / # school days attended by girls / Total
MONTH / 1 / 2 / 3 / 4 / 5 / 6 / 1 / 2 / 3 / 4 / 5 / 6 / 1 / 2 / 3 / 4 / 5 / 6 / 1 / 2 / 3 / 4 / 5 / 6
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
TOTAL

Comments: ______

C – Deworming and micronutrients

6.How many children received a DEWORMING tablet on the first and second round of treatment?

# dewormed on first round
# boys / # girls / Total
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
TOTAL
# dewormed on second round
# boys / # girls / Total
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
TOTAL

7.How many children received a VITAMIN A capsule on the first and second round of treatment?

# received vitamin A capsule on first round
# boys / # girls / Total
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
TOTAL
# received vitamin A capsule on second round
# boys / # girls / Total
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
TOTAL

8.How many children received at least 12 tablets of IRON in each grade

Note to Program Manager: the number of iron tablets will depend on the course of iron tablets which the program decides to provide. For example if the program is providing one iron tablet per child for 15 weeks, then the minimum number of iron tablets might be 10 or 12 tablets. There are no recommended guidelines for the frequency and length of preventative (mass) iron supplementation in schools. This should be decided on a case by case basis, depending on need and funding availability

# received at least 12 tablets of iron
# boys / # girls / Total
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
TOTAL

Comments:______

D – Vision (or hearing) tests

9.How many children had their VISION TESTED ? How many had POOR VISION? How many were MOVED TO THE FRONT of the class? How many were REFERRED to health center? How many RECEIVED GLASSES? (please complete tables below)

# who had their vision tested
# boys / # girls / Total
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
TOTAL
# with a vision problem
# boys / # girls / Total
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
TOTAL
# who were moved to front of class
# boys / # girls / Total
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
TOTAL
# who were referred to health center
# boys / # girls / Total
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
TOTAL

# who received eye glasses
# boys / # girls / Total
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
TOTAL

E – School level health treatments

10.Are other health treatments provided in the school besides routine ones? Yes / No (circle correct answer).

If yes, fill in the table below. If no, go to next section.

11. How many children reported the following health problems? How many were treated? How many were referred to the health center (please complete the table below)

# reported / # treated / # referred to health center
Malaria
Eye infection
Headache
Stomachache
Toothache
Others (list below)

Comments (continue on a separate sheet of paper if needed)______

______

F- Health education

Note to Program Manager:Only include these questions if a health education program is in place, and then tailor the questions to the type of activities expected to be carried out in each school. To monitor the approach used during health education sessions (if a new approach was introduced for example), regular classroom observations will be required.

12.How many HEALTH EDUCATION lessons have been delivered in each grade?

# lessons taught by subject
HIV/AIDS prevention / Nutrition / Hygiene
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
TOTAL

G – Other health promotion activities

13.How many HEALTH PROMOTION events have taken place in the school or the community?

# health promotion events
HIV/AIDS / Nutrition / Hygiene
Health campaigns at school
Health campaigns in the community
Other:
TOTAL

Comments (continue on a separate sheet of paper if needed)

______

H – School environment

Note to Program Manager: For an objective assessment of the school environment, it is best to have an outsider assess the situation by observation and other qualitative information can then be included to determine whether the latrines are clean and user friendly for example. This can be done by the program implementers during supervisory visits. A checklist should be developed to help program implementers make this assessment in an objective manner. The following questions provide a quick overview of the water and sanitation situation in schools.

14.How many functional LATRINES and URINALS are there in the school?

# latrines and urinals in the school (enter number)
Total / Boys / Girls / Teachers
Latrines
Urinals

15.Are there any HAND-WASHING FACILITIES and DRINKING WATERat the school today?(add yes or no)

Presence of … / Yes/ No
Hand-washing facility
Water to wash hands
Soap to wash hands
Drinking water at school

16.Where does the DRINKING WATER come from? (add yes or no)

Source of drinking water / Yes / No
Tap
Pump
Closed well
Other

17.Is the drinking water TREATED?Yes / No (circle correct answer).

If yes, how is it treated?

Type of Treatment / Yes/No
chlorine
iodine
filtering
Other:

18.Are there any repairs required to the latrines, water points or hand-washing facilities? Please list: (Damages and repairs should be reported straight away. They shouldn’t wait until the end of the year to be reported in this questionnaire).

______

I – Community support

Note to program Manager: These questions should be adapted to the program objectives and activities and only included when the trainings have been carried out and schools are expected to have the following committees and clubs in place.

19.Is there an active SHN committee at the school? Yes / No (circle correct answer)

20. What student led clubs are set up and functioning? (Add yes or no and list others)

Clubs / Yes / No
SHN club
Hygiene club
Anti-Aids club

Comments (continue on a separate sheet of paper if needed)

______

J – School health policies

Note to Program Manager:These need to be adapted to the program objectives. Only include policies that are expected to be enforced. Remove shaded cells. These are only examples.

21.What SCHOOL HEALTH POLICIES have been approved, publicized and are being enforced? (list the policies in table below and add ‘yes’ or ‘no’ if they have been approved, publicized and are being enforced)

Approved / Publicized / Enforced
Non violence policy (example)
Non smoking policy (example)

22.How many RESOURCES has the community given to support Health activities in the school?

Describe support / Cash
(amount) / Labor
(number of hours worked times number of people) / Materials/ food
(e.g. cement/ food) include quantity
5 women cooked food for health day for approximately 4 hours (example) / 5X4 =20 / 5 Kg maize
3 men spent a day building girls latrine (example) / 3 X7=21

K – Training of teachers (and/or school management committee)

Note to Program Manager: List all the trainings provided below. This information will tell youwhether each school has at least a minimum number of teachers trained as determined by the program objectives. For example, the target number of trained teachers in each school may be two. This data will tell you which schools do not have at least two trained teachers and which schools need additional teachers to be trained.

23.How many teachers in your school, have received the following training?

Trainings / Men / Women
Training on deworming and micronutrient supplementation (A)
Training on First Aid Kits (B)
Training on vision and hearing (C)
…
Total number of teachers in the school(Z)
Percent trained on Deworming and Micronutrient supplementation (A divided by Z times 100)

24.How many members of the SCHOOL MANAGEMENT COMITTEE (SMC) received the following TRAININGS?

Men / Women
General SHN training (A)
Training on management of SHN supplies (B)
…
Total number of SMC members (Z)
Percent of SMC members who received General SHN training (A divided by Z times 100)

L - School health supplies

25.List the quantities of SHN supplies received, distributed/used and stored for next distribution

Name and dose of medicine / Number IN
(received) / Number OUT
(used) / Balance / Number returned to Health center
Albendazole (400mg) / 260 (15/9/2003) / 236 (12/12/2004) / 24 / 24

THANK YOU VERY MUCH

Please return this questionnaire to your nearest Health facility