Wellness Policy Assessment Tool and Report Template

Background

Federal regulations at 7 CFR 210.31 require local education agencies (LEAs) participating in the National School Lunch Program to complete an assessment of their local school wellness policy at least once every three years and make the results available to the public. This triennial assessment must measure the implementation of the local school wellness policy and include:
•	The extent to which schools under the jurisdiction of the LEA are in compliance with the local school wellness policy;
•	The extent to which the LEA’s local school wellness policy compares to model local school wellness policies; and
•	A description of the progress made in attaining the goals of the local school wellness policy.

LEAs may use a variety of methods to assess compliance and determine progress of their goals and objectives. Action planning documents that contain timelines, goals, and key tasks may assist in assessing changes over time. For example, the School Health Index (SHI) is a comprehensive self-assessment tool that helps with action planning and recordkeeping (a shorter version of the SHI is available from Alliance for a Healthier Generation), and the WellSAT 2.0 is an online tool that indicates the strengths and weaknesses of your written policy.

Triennial Assessment Tool and Report Template

When completed in full, this form may serve as both an assessment tool and triennial assessment report template to meet the requirements in federal regulations and prepare for the Administrative Review by the Pennsylvania Department of Education (PDE), Division of Food and Nutrition. This document is intended to be completed using LEA-level information; however, the LEA may determine that a report from each school site, or alternatively, each school level (i.e., elementary, middle, high school) works better in assessing compliance and progress over time. For larger school districts, reporting on a district level may be challenging due to variation in sites’ programs and progress in attaining wellness goals. If completing this report for the entire LEA, answer questions using the best available information and consider noting individual building variations or concerns in the “notes” sections.

In the left columns, indicate whether the listed goal or practice is included in your local school wellness policy. Bolded policy elements are required by federal regulation to be included in the written policy. When bolded items are not in the local policy, include an explanation. This tool uses the Pennsylvania School Board Association’s school wellness policy template (#246) as the model wellness policy for comparison purposes, but it can be used regardless of the template used to develop your local policy.

In the right columns, indicate implementation of the goal or practice at schools within the LEA. LEAs are always encouraged to develop additional policy elements and goals for schools under their jurisdiction to create a supportive environment for student nutrition and physical activity.

Space is provided at the bottom of the form for the LEA to describe the progress made in attaining the goals of the local school wellness policy as required.

July 2018	This institution is an equal opportunity provider

Wellness Policy Assessment Tool and Report Template

LEA / District Name:

Name(s) of Reviewer(s):

Reporting Timeframe (month/year to month/year):

School Name (if applicable):

Select grades:

PK	K	1	2	3	4	5	6	7	8	9	10	11	12

Included in the written policy?

Yes	No

Implemented in the school building(s)? Fully in	Partially	Not in Place	in Place	Place

Public Involvement, Notification, and Assessment

We have LEA official(s)/designee(s) in charge of wellness policy compliance.
Name(s)/Title(s):
We complete an assessment of the local school wellness policy at least every three years (“triennial assessment”).
Triennial assessment results are made available to the public in an easily accessible manner.
Website address and/or description of how to access copy:

At least every three years we use the results of the triennial assessment to update or modify the wellness policy as needed.
The LEA informs and updates the public about the contents, updates, and implementation of the wellness policy at least annually and the policy is accessible to the public.
Website address for policy and/or description of how to access copy:

We retain records as required by federal regulations including: The written school wellness policy,
Documentation of making the wellness policy publicly available, Documentation of outreach efforts inviting stakeholders to participate in the wellness committee / wellness policy process, and
Copy of triennial assessment and documentation of reporting results to public. The LEA utilizes a wellness committee that includes these community stakeholders in the development, implementation, review, and update of the wellness policy:

Administrators Food service staff School health professionals Parents School board members	PE teachers	Students Public

Other stakeholders (describe):

Notes on public involvement, notification, and assessment:

Nutrition Education*

Nutrition education is provided within PDE’s sequential, comprehensive health education standards.
We teach, model, encourage, and support healthy eating through nutrition education.

July 2018	This institution is an equal opportunity provider	1

Wellness Policy Assessment Tool and Report Template

Included in the written policy?

Yes	No
We provide all students with knowledge and skills for healthy lives via nutrition education.
We offer age-appropriate nutrition education and activities to students in: Elementary School	Middle School	High School
Our nutrition education curriculum teaches behavior-focused skills such as menu-planning, reading nutrition labels, and media awareness.
School food service and nutrition education classes work together to create a learning laboratory.
In addition to meeting academic standards for nutrition education, we integrate nutrition education into a variety of subjects (e.g., math, science, language arts). We reinforce lifelong lifestyle balance by linking nutrition and physical activity. Staff providing nutrition education receive standards-based training and professional development.
We engage and involve families and the community in nutrition education efforts. Other goal (describe):

Implemented in the school building(s)? Fully in	Partially	Not in Place	in Place	Place

Notes on goals for nutrition education:

Nutrition Promotion*

We use evidence-based techniques and nutrition messages in school and encourage participation in school meal programs.

We participate in Farm to School activities such as having a school garden, taste-testing local products, incorporating local foods into school meals, and educating students in the classroom and on field trips about local agriculture.
We cooperate with community agencies and organizations to provide opportunities for student projects related to nutrition.
We implement behavioral economics techniques in the cafeteria to encourage consumption of whole grains, fruits, and vegetables and to decrease plate waste. We display and disseminate consistent nutrition messages in schools, classrooms, cafeterias, homes, community, and media.
Our staff model healthy eating in front of students and avoid using unhealthy foods in classroom lesson plans.
We offer health and nutrition resources to parents to help them provide healthy meals for their children.
Other goal (describe):

Notes on goals for nutrition promotion:

Physical Activity*

We provide a variety of developmentally appropriate opportunities for physical activity during the school day for all students.
We contribute to the effort to provide students daily opportunities to accumulate at least sixty minutes of age-appropriate physical activity daily as recommended by the CDC.

July 2018	This institution is an equal opportunity provider	2

Wellness Policy Assessment Tool and Report Template

Included in the written policy?

Yes	No
In addition to planned physical education, we offer activities such as indoor and outdoor recess, before and after school programs, intramurals, interscholastic athletics, and clubs to meet the needs and interests of our students.
We maintain a physical and social environment that encourages safe and enjoyable activity for all students.
We discourage extended periods of inactivity (two hours or more) for students. We provide physical activity breaks in the classroom.
We offer before and/or after-school programs that include physical activity for participating children.
We partner with parents/guardians and community members and organizations (e.g., YMCA, Boys & Girls Clubs, local parks, hospitals, etc.) to offer programs supporting lifelong physical activity.
We do not use physical activity as a punishment (e.g., running laps).
We do not withhold physical activity as a punishment (e.g., taking away recess). We encourage walking and biking to school.
We encourage students and families to use our physical activity facilities, such as playgrounds and ball fields, outside of school hours in accordance with school rules.
Other goal (describe):

Implemented in the school building(s)? Fully in	Partially	Not in Place	in Place	Place

Notes on goals for physical activity:

Physical Education (PE)

We implement a PE program consistent with state academic standards. All students participate in PE.
PE instruction promotes skills and knowledge necessary for lifelong physical activity.
PE classes provide the means for students to learn, practice, and be assessed on developmentally appropriate skills.
Our curriculum promotes both team and individual activities.
We offer a comprehensive PE course of study with planned instruction time for students to meet standards at the proficient level.
We use a local assessment system to track student progress on state standards. Students are moderately to vigorously active as much time as possible during PE class. Accommodations are made in class for documented medical conditions and disabilities.
We provide safe and adequate equipment, facilities, and resources for PE class. Certified health and PE teachers teach our classes.
We provide professional development for PE staff.
PE classes have a teacher-student ratio similar to other courses for safe and effective instruction.
We do not use or withhold physical activity as a form of punishment in PE class. Other goal (describe):

Notes on goals for physical education:

July 2018	This institution is an equal opportunity provider	3

Wellness Policy Assessment Tool and Report Template

Included in the written policy?

Yes	No

Implemented in the school building(s)? Fully in	Partially	Not in Place	in Place	Place

Other School-Based Wellness Activities*

Free drinking water is available and accessible to students during meal periods and throughout the school day.
School nutrition staff meet local hiring criteria and in compliance with federal regulations.
We provide continuing education to school nutrition staff as required by federal regulations.
We provide adequate space for eating and serving school meals. We provide a safe and clean meal environment for students.
We offer students enough time to eat (10 minutes sit down time for breakfast; 20 minutes sit down time for lunch) and schedule meal periods at appropriate hours. We implement alternate school breakfast service models to increase participation, such as “grab & go,” breakfast served in the classroom, and breakfast after first period.
Students have access to hand washing or sanitizing before meals. Only authorized staff have access to the food service operation.
We provide the nutrition content of school meals to the school community. We include students/parents in menu selections through taste-testing and surveys.
We utilize outside funding and programs to enhance school wellness. We train all staff on the components of the school wellness policy. School based activities are planned with wellness policy goals in mind.
Fundraising projects submitted for approval are supportive of healthy eating and student wellness.
We encourage administrators, teachers, school nutrition professionals, students, parents/guardians, and community members to serve as positive role models through district programs, communications, and outreach.
We communicate information to parents/guardians to support their efforts to provide a healthy diet and daily physical activity for their children.
Indoor air quality is in accordance with our healthy learning environment program and applicable laws and regulations.
Other goal (describe):

Notes on goals for other school-based activities:

Nutrition Guidelines for All Foods and Beverages at School

We consider promoting student health and reducing obesity when offering foods and beverages to students at school.

Foods and beverages provided through the National School Lunch and School Breakfast Programs comply with federal meal standards.
We offer healthy food and beverage options at school-sponsored events, such as dances and sporting events.
Foods and beverages outside of the school meal, which are sold to students at school during the school day, meet or exceed the established federal competitive food standards (USDA Smart Snacks in School). Venues include vending, school stores, non-exempt fundraisers, and a la carte items.

July 2018	This institution is an equal opportunity provider	4

Wellness Policy Assessment Tool and Report Template

Included in the written policy?

Yes	No
We limit the number of food fundraisers at school and have procedures in place for requesting a fundraiser exemption (i.e., selling foods that do not meet Smart Snacks) in accordance with limits set by PDE.
We have local standards in our written policy for foods and beverages offered for free to students at school, including food rewards, items offered at classroom parties and celebrations, and foods/beverages provided to the class as shared classroom snacks.
We provide a list of nonfood ideas and healthy food/beverage alternatives to staff and parents/guardians.
Only foods and beverages that meet or exceed federal nutrition standards (USDA Smart Snacks in School) are permitted to be marketed or promoted to students during the school day. Examples: posters, vending machines, menu boards, cups for beverage dispensing, coolers, trash cans.
Notes on nutrition guidelines for foods and beverages at school:

Implemented in the school building(s)? Fully in	Partially	Not in Place	in Place	Place

* At least one goal for these categories must be included in the written policy per federal regulations.

Report on the progress made in attaining the goals of the wellness policy (REQUIRED):

July 2018	This institution is an equal opportunity provider	5