School Wellness Team Final Report Form 2015-2016 School Year
Team Name:
School:
Reporter:
Date:
Principal Signature:
Date:
□ Included in SCEP Plan (check box to indicate “yes”)
1. Was your wellness team chairperson given an assigned “duty” to run the wellness team?
YES
NO
If yes, how many days per 6 day cycle? ___________ and how long was the duty in minutes each day? __________
2. Please indicate the category that best describes your school wellness team chairperson. If you have co-chairs,
please complete both sections to indicate the roles of each.
Chairperson (or Co-chair)
Chairperson (Co-chair)
□ A teacher assigned a duty
□ A teacher assigned a duty
□ A teacher – not assigned a duty
□ A teacher – not assigned a duty
□ A parent
□ A parent
□ A student
□ A student
□ An administrator
□ An administrator
□ Other ____________
□ Other ____________
2.
TEAM CHARTER:
Date established:
Established by:
Date shared with SDMT:
Date shared school-wide:
3. What were your 2015-2016 wellness goals for your school:
4. What feedback, input, or data helped you identify a need for the above goal(s)? (this might include hearing about
an issue from parents, students, or teachers, or it may be data that you generated from completing the School
Health Index. It also could include information from the Youth Risk Behavior Survey, Employee Wellness data,
BMI/weight data, other student health data (e.g. rates of diabetes, asthma, etc.)
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5. When did you hold meetings during the 2015-2016 school year?
Month
Date
Day of the week
Agenda/Focus
6. Please provide your TENTATIVE MEETING SCHEDULE for the 2016-2017 school year (refer to the calendar on
last page and enter dates). *We recognize this may change at the start of the school year. Please estimate the
dates and times here and then send an updated schedule following your first wellness team meeting.
Month
Date
Day of the week
7. SUCCESSES FROM THIS YEAR: Please describe at least two successes of your wellness team this school year.
8. CHALLENGES FROM THIS YEAR: Please list and describe at least two challenges your team experienced this
year.
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ABOUT YOUR TEAM’S USE OF DATA AND TECHNOLOGY:
9. Please reflect on the information that has helped you PLAN your wellness team goals and activities. Place a check
in the boxes that correspond to your team’s perceptions about each data source.
Data Source
We do not know
about this data
We know about
this data, but not
how to use it
We know about
this data and
received some
guidance on how
to use it
We would like to
schedule a session
with someone to
assist with the use
of this
Youth Risk Behavior Survey (YRBS)
Employee Wellness
Interest/Assessment Report
Body Mass Index (BMI)/Weight
status data
EdVantage Data Dashboard
(demographics, academics, etc.)
NYS Heart Check
Student Health Data (e.g. rates of
asthma, ADHD, diabetes, etc.)
School level surveys of students,
teachers, and/or parents
Trauma Informed School
information
Restorative Practices
Community Health Workers
Other- please type in comment
box below
Comment:
10. Please reflect on the types of SCHOOL-PROVIDED RESOURCES that have helped you IMPLEMENT your wellness
team goals and activities. Place a check in the boxes that correspond to your team’s perceptions about each data
source.
We know about
Technology/Other Assistance Type
We would like to
We know about
this, but not how
to use it/them
BPS Survey Tool
Data dashboard
Body Mass Index (BMI)/Weight status data
Blogs
Google Docs (mid-year report tool)
District Health Related Services Whole Child website
Schoology
Web Ex
Infinite Campus
District level committees (e.g. Nutrition, Employee
Wellness, Physical Activity, etc. See below for a full list)
Other- please type in comment box below
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this and received
some guidance on
how to use
it/them
schedule a session
with someone to
assist with the use
Comments:
ABOUT YOUR TEAM’S USE OF DISTRICT HEALTH COMMITTEES
11. Please characterize your team’s knowledge of and interaction with THE DISTRICT HEALTH COMMITTEES. Place
a check in the boxes corresponding to your team’s responses.
We don’t know
about it
We know
about it,
though have
not had need
to contact
We know
about it and
plan to contact
related to our
goals
We know
about it and
have contacted
them for
assistance/
information
Nutrition Committee
Garden Committee
Physical Activity Committee
Healthy School Environment Committee
Faculty/Staff Health Promotion
Mental Emotional Social Health Committee
Family & Community Involvement Committee
Health Education Committee
Health Services Committee
Dental Health Committee
School Wellness Advisory Team (SWAT)
Sexual Education Committee
Project ACT (Assisting Care-giving Teens)
12. If you did contact one or more health committees, how did they help support the work of the wellness team?
13. What suggestions do you have for improving communication between the district committees and the
wellness teams at each school building?
ABOUT YOUR TEAM’S PARTICIPATION IN SHARED DECISION MAKING AT THE BUILDING LEVEL
14. Has your School Wellness Team aligned with the School-Based Management Team (SBMT) and/or Community
Engagement Team (CET) (receivership schools have these)?
Yes
No
Please describe.
15. Are the goals of your School Wellness Team included in the School Comprehensive Education Plan (SCEP)?
Yes
No
Please describe.
16. Is there ANYTHING ELSE you would like to add?
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17. ACTION PLAN/PLAN FOR IMPROVEMENT: Please attach your draft/complete action plan to this report. Below,
please summarize any work that you have accomplished on your prioritized actions/objectives.
Please provide an update on at least two ACTIONS that your school wellness team plans for next school year.
Action 1:
Plans to Address:
Action 2:
Plans to Address:
Action 3 (optional):
Plans to Address:
Action 4 (optional):
Plans to Address:
18. What are your current training NEEDS from the District for next school year? (This will drive the professional
development plan for the 2016-2017 school year)
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HOW WOULD YOU EVALUATE YOUR TEAM AT THIS POINT IN TIME?
19. Thinking specifically of the abilities of your team members as related to their work for the school wellness team
(SWT), please indicate your level of agreement with the following statements.
Member of this team:


get along with each other very well.
all really value being members of this team.


have excellent skills for our team projects.
are good at planning how to reach team
goals.

are good at coordinating everyone's activities
to reach team goals.
anticipate problems and figure out good
solutions.
are able to reach consensus on most issues.
help each other get the job done.
some cannot do their jobs well
share leadership roles and responsibilities in
ways that help the entire team.
discussed and agreed to norms (team
charter) for how we should work as a team.






Strongly
Agree
Agree
Neither
Agree nor
Disagree
Disagree
Strongly
Disagree
20. Please think about your school wellness team (SWT) in answering the following questions. To what extent to you
agree with the following statements?
This Team:

so far has met or exceeded its goals



completes its tasks on time.
makes sure that the work it does is of high
quality.
is not very effective.


takes action when problems come up.
is not able to perform as well as it should

solves problems that might slow down its
work.
is poor compared to other teams doing
similar work
is a productive team.


Strongly
Agree
21. Is there ANYTHING ELSE you would like to add?
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Agree
Neither
Agree nor
Disagree
Disagree
Strongly
Disagree
BPS School Wellness Team Roster
School Number and School Name:
Committee Positions
Committee Member Name
Phone Number
Email
Chairperson (s)
(May have co- or trichairpersons)
Health Teacher
Phys. Ed. Teacher
Nurse
Social Work
School Counselor
Engineer
Assistant Principal
Student Leaders
(Minimum of 2: male
and female)
Parent Leaders
(Minimum of 1)
Site Facilitator (Say Yes)
Nutrition Services
Teachers (Special Ed. Or
General Ed.)
Principal
Resource Officer (High
School)
Please Note: Co- or Tri-chairpersons need to be on the wellness committee and fulfill a position listed above (ex.
Health Teacher). The school nurse cannot be one of the co-advisors/leaders.
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