Monthly Activities Report

Comprehensive School Health Services Program

Massachusetts Department of Public Health

timestampstart

Month and year in which these health encounters occurred

Month

Year

Enter the month and calendar year that the services were provided. (Do not enter the date you submitted the report. Do not enter the fiscal year or the school year.)

Are you reporting for a public school district, school union, charter school, collaborative, or nonpublic school?

* must provide value

Public school district, school union, charter school, or collaborative

Nonpublic school

reset

School district

Select your school district, school union, charter school or collaborative.

Your school will not appear in the list unless you have selected the correct "Type of School or District". If your school is not in the list, go back and check that the "Type of School or District" is correct.

If your school is still not in the list, scroll to the bottom of the list, select "Other", and enter the name of your school in the box that will appear below.

Submit a single report for the entire school district rather than a separate report for each school. School Unions: Submit one report that includes all the schools in the union and any related regional schools.

*** means funded through the Model grant in FY24

** means funded through the Affiliate grant in FY24

* must provide value

Other public school (Specify)

Nonpublic school

If your school name is still not in the list, scroll to the bottom of the list, select "Other", and enter the school name and address in the box that will appear.

** means funded through the Affiliate grant in FY24

* means funded through the Nonpublic grant in FY24

* must provide value

Other nonpublic school (Enter name and complete address)

Name of person completing report

* must provide value

Email address

* must provide value

Type of encounter	Students	Staff
In-person
Remote (Virtual, telehealth)

Enter the number of encounters for nursing services this month.

Note: The number of in-person encounters is used to calculate the return to class rate which is the number of students returning to class divided by the total number of encounters. Each student visit to the health office or nursing assessment/intervention occurring outside health office (i.e. classroom, playground, cafeteria, etc.) counts as a SINGLE encounter, regardless of the number of procedures done or medications administered during that visit. Mandated screenings DO NOT count as visits. Students' seen more than once during the school day would be counted as a new encounter for every new visit.

1. Returned to class
2. Dismissed from school due to illness:
a. Non-emergency dismissal
b. 911 emergency dismissal
3. Dismissed from school due to injury:
a. Non-emergency dismissal
b. 911 emergency dismissal
4. Dismissed from school due to behavioral health:
a. Non-emergency dismissal
b. 911 emergency dismissal
c. Emergency Mobile Crisis Unit dismissal
5. Other disposition:
a. Stayed in health room
b. Referred to the counselor's office
c. Sent home to return later that day
d. Other
6. TOTAL (automatically calculated)*

*In this form, all numbers shown in red font are automatically calculated and do not indicate an error.

RTC - Student encounters (Calculated by the form)

View equation

The number of students returned to class cannot be greater than the total number of in-person student encounters. Please check your data.

Returned-to-class rate		%
Automatically calculated

Type of injury	Students	Staff
Unintentional
Intentional
Intent Unknown`

Type	Students	Staff
Occurring during school-sponsored activities
Occurring during out-of-school activities

Number of emergency doses administered to staff and visitors this month:

Type of Emergency Medications	Staff	Visitors
1. Epinephrine
2. Glucagon
3. Naloxone (Narcan)

A. Number of daily and PRN prescriptions kept on file this month:

	Students
Type of Medication Prescriptions on File	Number of Scheduled Prescriptions*	Number of PRN Prescriptions
1. Analgesics
2. Antibiotics
3. Anticonvulsants
4. Antihypertensives
5. Antihistamines
6. Asthma
7. Epinephrine (non-asthma related)
8. Glucagon
9. Insulin
10. Naloxone (Narcan)
11. Psychotropic
12. Other Prescriptions
Total**

*Scheduled medications are those that are ordered to be given on a scheduled basis (QD, bid, q4h, etc.).

**In this form, all numbers shown in red font are automatically calculated and do not indicate an error.

B. Number of doses administered or supervised by school nurses, this month, for each of the following types of medication, based on usage:

	Students
Type of Medication Administered	Scheduled Doses Administered*	PRN Doses Administered
1. Analgesics
2. Antibiotics
3. Anticonvulsants
4. Antihypertensives
5. Antihistamines
6. Asthma
7. Epinephrine (non-asthma related)
8. Glucagon
9. Insulin
10. Naloxone (Narcan)
11. Psychotropic
12. Other Prescription Medication
13. OTC
Total**

* Scheduled medications are those that are ordered to be given on a scheduled basis (QD, bid, q4h, etc.).

OTC: Count over the counter medications that do not fall into one of the above medication categories

**In this form, all numbers shown in red font are automatically calculated and do not indicate an error.

Type of Communication	Length of Time	# of Communications
Parent / Guardian	< 15 Minutes
	≥ 15 Minutes
School Staff	< 15 Minutes
	≥ 15 Minutes
Community Agencies	< 15 Minutes
	≥ 15 Minutes
Group Meetings (With 2 or more of the above participants)	< 15 Minutes
	≥ 15 Minutes

To save your report so you can finish it or edit it later, click Save & Return Later, and then bookmark this page and re-name the bookmark so it includes the date (For example: "Monthly report-September"). You can also have the Survey Link for this report sent to your email address. To do that, just follow the instructions on the screen that pops up after you click Save & Return Later. If you need to edit your report later but do not have the Survey Link and have not bookmarked the page, then you will not be able to edit your report and you will need to re-submit the report and re-enter all of your data. When we receive more than 1 report for the same month, we save only the more recently submitted report and discard any earlier reports.

Save a copy of your report before you submit it. We will not be able to retrieve your report and send it to you. You can download a pdf file after you click Submit, but to save a more readable copy, before you click Submit, print to a pdf file or print a hard copy of the page (right-click on the page and select Print).

When you have completed the report, click Submit. When you have successfully submitted a report. you will see a "Thank you" message on screen.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.