TABLE II-2.	2005-06 Schools / Enrollment.  Complete for each community in your county (make additional copies as needed).

Community	School District	School Name	What Grades?	Enrollment	

					

					

					

					
					
	Total Elementary School Enrollment:		
	Total Middle School Enrollment:		
	Total High School Enrollment:		
	Total Enrollment:		

If there have been recent changes of enrollment, please note these changes here:

TABLE II-3.	Schools with Tobacco-free Policy (make additional copies as needed)

School Name	How are students informed about the policy?	How are staff informed about the policy?	To what extent is the policy enforced (students / staff)?	Consequences for violation
and/or Cessation/Advocacy Opportunities
(students / staff)	

					

					

					

					

					

					

					

TABLE II-4.	Schools without Tobacco-free Policy (make additional copies as needed)

School Name	Any Policy?
(Yes/No)	Describe the Tobacco-Related* Policy 
 (if applicable)	List possible barriers to implementing
a tobacco-free policy in the school**	

				

				

				

				

*	E.g., smoke-free only, only applies to school hours, only applies to students, student use only (no provision for possession of tobacco), no enforcement provision.
**	Barriers can include current policy, lack of support by administration, open campus, lack of enforcement, community culture, use of school for community events, etc.

Table II-5.	Tobacco Health Education and Prevention Curricula  (make additional copies as needed)

School District	Name of Prevention Curriculum*	Grades Targeted 
	Hours per Grade**	% of Students Participating
(by grade level)	

					

					

					

					

					

					

*	Programs might include LifeSkills, TNT, Project Alert, TEG/TAP, DARE, non-health classes, health classes, local curricula, etc.

**	Pertaining specifically to tobacco/tobacco use prevention.

Table II-7.	School Student / Staff Cessation Referral (make additional copies as needed)

School Name	Student Cessation Program Name &
Program Coordinator / Phone number	# Students Referred
(1999-2000)
(2000-2001)	School Staff Cessation Program Name &
Program Coordinator / Phone number	# Staff 
Referred
(1999-2000)
(2000-2001)	
	’ Onsite		’ Onsite
		
	’ Offsite
		’ Offsite		
	’ Onsite		’ Onsite
		
	’ Offsite
		’ Offsite		
	’ Onsite		’ Onsite
		
	’ Offsite
		’ Offsite		
	’ Onsite		’ Onsite
		
	’ Offsite
		’ Offsite		
	’ Onsite		’ Onsite
		
	’ Offsite
		’ Offsite		
	’ Onsite		’ Onsite
		
	’ Offsite
		’ Offsite		

Table II-11.	Current Number of Tobacco Retailers in Each Community that are near schools  (make additional copies as needed)

Community	# of Retailers	# of Retailers within 2 Blocks of School Grounds	Community	# of Retailers	# of Retailers within 2 Blocks of School Grounds