2015 AFSI CHAMPION AWARD APPLICATION
1. Application Contact
Name:
Title:
School:
Address:
Telephone:
Email:
2. School Profile
School Name:
School District:
Address:
Telephone:
Email:
Total # of students:
Total # of students identified with asthma:
Total # staff:
Does your school have a full-time nurse on site, all day every day?
Yes
No
What policies related to asthma management has your school, district or state
implemented? Please list those policies that impact your school.
3. Community Partners or Organizations
Please list the community partners and organizations and give examples of ways they have
helped your school address asthma management.
4. School-Based Programs
What type of school-based programs has your school implemented to support a safe and
healthy school environment for students with asthma? Please mark all that apply.
American Lung Association’s Asthma-Friendly Schools Initiative (AFSI)
American Lung Association’s Open Airways For Schools® (OAS)
American Lung Association’s Asthma Basics
American Lung Association’s Not On Tobacco® (NOT)
American Lung Association’s Asthma 101: What You Need to Know™
EPA’s Indoor Air Quality Tools for Schools
EPA’s Healthy School Environmental Assessment Tool (HealthySEAT)
CDC’s School Health Index
U.S. Green Building Council’s LEED for Schools
U.S. Department of Education’s Green Ribbon Schools
Other(s):
5. Asthma Program Successes
Please provide three examples that illustrate your school’s success in implementing a
comprehensive, long-term asthma management program.
1.
2.
3.
6. Description of Program Master Planning
Briefly describe (350 words or less) the school’s commitment to sustainable asthma
management programs, specifically address the type of planning work conducted to design a
comprehensive, long-term asthma management program. Please refer to the AFSI Toolkit
Master Planning Action Steps to help describe the type of planning your school has conducted.
7. Description of Program Evaluation
Briefly describe (350 words or less) how the school measures success of the asthma
management program. How does the school evaluate the program long-term and allow for
modifications/updates of program components as needed. Please refer to AFSI Toolkit, Master
Planning, Action Step 4, “Create a Year 1 Work Plan”.
8. Components of a Comprehensive Asthma Management Program
Based on the AFSI Champion Award guidelines, school activities must include minimally the
select components in each of the strategies of the Asthma-Friendly Schools Initiative. Those with
an asterisks signify components that must be implemented in order to be considered.
Applicants are required to provide supporting documentation for all the components (i.e.
asthma medication policy, emergency management protocol, tobacco-free campus policy,
fragrance-free policy). Please mark all that apply, including a description of activities and
supporting materials, if needed.
I. Maximizing School Health Services
A supportive environment from the school health services can help to promote asthma selfmanagement among students, prevent asthma-related emergencies, and establish the
protocols to create a safer learning environment for everyone. Examples may include an
asthma action plan policy used by a school, asthma emergency protocol, a wellness policy
that includes the management of chronic conditions like asthma.
To best answer the following questions, please refer to the Maximizing School
Health Services section of your toolkit. Mark all that apply and provide a detail description
as to the type of programs or policies that are offered.
Identification and tracking of all students with asthma (i.e. How does your school identify
and track the students who suffer from asthma?)
Description:
Use of an Asthma Action Plan for all student with asthma* (Does your school currently
have a policy requiring an Asthma Action Plan for students with Asthma?)
Description:
Immediate access to medications as prescribed*
Description:
Standardization of emergency protocols
Description:
Special services provided for students with asthma in school (i.e. case management)
Description:
Facilitation of connecting students to medical providers (i.e. referrals to community
clinics or school-based health clinics)
Description:
Full-time registered school nurse all day, every day for each school
Description:
Access to consulting physician/healthcare provider for each school
Description:
II. Building Asthma Education
Education is the cornerstone in establishing a comprehensive asthma management program
that is adopted, implemented, and communicated to the school community. Providing
education can build confidence in a student’s ability to self-manage their asthma, in a
teacher or staff member’s ability to handle an emergency, or in a parent’s/guardian’s ability
help manage their child’s asthma. The types of educational techniques that are mentioned
should be recognized and proven as effective asthma educational programs. Examples may
include but are not limited to Asthma Basics, Open Airways For Schools, Asthma 101: What
You Need to Know, Kickin’ Asthma, or Winning with Asthma, just to name a few.
To best answer the following questions, please refer to the Building Asthma
Education section of your toolkit. Mark all that apply and provide detail as to the type of
education programs and events that are offered.
Education for all school staff* (Have you provided your staff with information that
prepares them to give the necessary care to students with asthma?)
Description:
Education for all students (Have you educated your students on how to effectively
manage their asthma?)
Description:
Education for all parents of students with asthma
Description:
(Have you provided parents with information that prepares them to
give the necessary care to their child with asthma?)
III. Providing a Healthy School Environment
The majority of a child’s life is spent on school grounds and in school buildings. Indoor and
outdoor pollutants can be potential asthma triggers that bring on asthma symptoms for a
student. Establishing a healthy school environment can keep students healthy, reduce
absences, and decrease the chances of an asthma emergency. A few examples may include
the participation in the EPA’s IAQ Tools for Schools program, an adopted fragrance-free
policy, or the School Flag Program. Learn more about AFSI’s Providing a Healthy School
Environment strategy.
To best answer the following questions, please refer to the Providing a Healthy School
Environment section of your toolkit. Mark all that apply and give a detailed description of
the types of environmental programs and activities that are offered in your school.
Proactively maintain healthy indoor air quality (IAQ)*
Description:
Assure tobacco-free buildings and grounds*
Description:
Provide smoking cessation services for students and staff
Description:
Use integrated pest management (IPM) techniques to control pests
Description:
Manage students’ exposure on high outdoor air pollution days (On high outdoor air
pollution days, does your school have a plan in place to reduce students’ exposure to
outdoor air pollution?) (I.e. indoor recess, etc.)
Description:
IV. Managing Physical Education and Activity
Staying active helps students stay physically and mentally fit. Many students with asthma
have exercise-induced asthma, which is brought on by vigorous activity. With the right
education, activity modifications, and proper asthma management, children with wellcontrolled asthma should be encouraged to participate in physical education and activity.
Examples can include the process for students to self-carry their asthma medicine or the
types of support offered to physical education instructors and coaches to ensure they are
prepared to help manage activity for students with asthma.
To best answer the following questions, please refer to the Managing Physical Education
and Activity section of your toolkit. Mark all that apply and provide detail as to how your
school ensures full participation in physical education and activity for student with asthma,
when they are able.
Encourage full participation when students are well
Description:
Manage physical activity for students with asthma* (Do your educators monitor and
modify the physical activity of students who have asthma when they are not well?)
Description:
Ensure ready access to pre-medication as prescribed and immediate access to quick
relief medication*
Description:
Provide examples for modified activity as indicated in a students’ Asthma Action Plan
Description:
I agree that the information provided in this application is accurate and am willing to coordinate a
site visit with an American Lung Association representative. In addition, I acknowledge that this program
does not designate my schools as ‘Asthma-Friendly’ but recognizes the efforts made in a particular year
to ensure a healthier learning environment for all.
Please submit application, commitment letter, and supplemental materials to
AFSIChampion@Lung.org by September 30, 2015.