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Schools and terrorism: a supplement to the report of the national advisory committee on children and terrorism.

Schools may or may not be the targets of terrorism, but they are certain to be affected by terrorism, whether directly or indirectly. The likelihood that one or more schools will be in the vicinity of terrorist targets is demonstrated by the events of September 11, 2001. When the first airplane hit the north tower of the World Trade Center, four elementary schools and three high schools were beginning classes within six blocks of the site of the attack. (1) Thousands of children were exposed to the dust cloud from the collapsing buildings. Even those children not in the immediate vicinity experienced a great deal of anxiety. Children in at least three states (New York, New Jersey, and Connecticut) had parents working in or around the World Trade Center that day. Their schools were forced to consider whether to allow students to watch the events unfold, whether family members would be able to return from lower Manhattan to retrieve their children at all that day, and whether some students might have lost family members in the attack. In the Washington, DC, area schools faced similar questions after the Pentagon was attacked. Gridlocked streets and parents desperate to get to their children compounded problems. In fact, all across the country, schools were inundated by parents rushing in to pick up their children.

The US Department of Education strongly encourages every school, public and private, to have an emergency management plan. (2) In addition, many states require districts and public schools to develop such plans. Schools do not need new plans to address terrorism-related issues. The basic components of most plans (ie, crisis response team, communications, emergency organizational chart, operations plans, evacuation, shelter-in-place, transportation, emergency care, short- and long-term mental health care) apply whether an emergency is caused by terrorism, tornado, or school shooting. However, few plans address how the school fits in with the larger public health (including mental health) and emergency management response to a community-wide event, such as a terrorist attack. Fewer still address foodborne or other infectious disease outbreaks or contaminated food recalls. Some parts of existing plans might need to be expanded or revised to address terrorism-specific issues (eg, terrorism may arouse different fears and anxieties than natural disasters). Schools also might be required to engage in some unique tasks to respond to a terrorism event (eg, administering potassium iodide in the event of radiation exposure or atropine for nerve gas). School health services vary by state and community. Some schools have full-service school-based health centers providing primary care and mental health services, some have full-time school nursing staff, and some have only part-time nursing and fragmented mental health and other services. Food service, physical education staff, and health education staff are also school health personnel and should be included in preparedness, response, recovery, and mitigation activities.

In order to adequately address the special needs of children, public and mental health agencies, and other emergency responders, must involve education agencies and schools in their planning processes. Local level coordination is essential, but a good deal of planning occurs at the state and national levels. Collaboration at these levels is also necessary. The best way to address the needs of schools is through collaboration between public health, mental health, medical care, education, emergency management, law enforcement, fire, homeland security, and transportation.

The recent TOPOFF 2 exercises provide a good example. Chicago used a vacant school as a medical center for plague victims. Seattle conducted drills, such as sheltering-in-place, after schools hours. Although school officials were involved in the planning and enactment of the drills, there were many questions that were not considered during the planning and evaluation phases of the exercises, including: Can classes continue to be held? Are school and community plans well-integrated, or in conflict with one another? How would parents, students, and staff respond to the idea that their building was being used to triage or treat infected people? How could authorities and emergency responders let parents, students, and staff know whether or not the disease or condition was not one that spreads person-to-person? How would the medical needs of children with chronic or disabling conditions be met? How would alternative education be provided until students are able to return to school? How would parents, students, and staff be given assurance that they could safety return to the school building? How would students be returned to their normal routine as quickly as possible?

Preparation is the responsibility of every school, community, and state. No one can afford to subscribe to an "It won't happen here" mentality. As the fall 2002 sniper attacks in the Washington, DC, Maryland, and Virginia, area showed, no region of the country is safe from the impact of terror.

Why Schools?

Schools are integral parts of their communities, but they also have special needs that must be given consideration when integrating schools into community plans, including the lack of dedicated fiscal and staffing resources to support activities and services beyond the normal role of schools. Schools are different from most other community settings in a number of important ways.

Schools are places where large numbers of children are gathered on a daily basis. Every day 53 million young people attend more than 119,000 public and private schools where 6 million adults work as teachers or staff. (3) Counting students and staff, on any given weekday more than one-fifth of the US population can be found in schools. Nearly all--98%--of young people aged 5 to 17 are students. The needs of schools to protect these young people in their care in a terrorist event are critical to address. In addition, if a disaster occurs during school hours, parents will go to schools, which will serve as a point of reunification of children with their families--yet another reason for schools to be involved in community planning.

Schools are in loco parentis. School officials have a special responsibility for the children in their care. They are responsible for their safety, and their safe return to their families. If an event occurs in or near even a single school, the health care system will need to collaborate with these school officials in order to triage and treat many children at once. Because of their responsibilities towards children with special needs, schools often have permission to dispense medications, and access to health records of students documenting medical history and requirements (eg, medications available at school, allergies, etc.). Schools are also responsible for children at times and in ways that are not traditionally considered. These include, for example: traveling to or from school via school or public transportation; before or after school programs at school sites; sporting events; field trips; Head Start programs; infants of teen mothers attending high schools; and even students who are dropped off before school hours for unofficial child care. Schools are places with a cadre of individuals trained in the care, education, and supervision of children. This is a key resource for children requiring supervision and temporary guardianship.

Schools are resources for response for their communities. In times of crisis, schools are often called upon to act as shelters, food distribution centers, community meeting places, and even command centers. Communities place extra, unfunded burdens on schools in this situation. On September 11, for example, Stuyvesant High School's evacuation was prompted by an FBI agent who wanted the building for a command center close to the site of the attack. (1)

Schools are places of learning. Communities can work with schools to build upon their inherent educational mission to teach children the skills they need to be alert and respond to potential dangers in their schools and communities, prepare for possible disasters that might strike while they are at home, in the community, or at school, and even emergency first aid skills they can use in response to a disaster. Schools can also be a source of education for families and community members.

Schools are places of health care delivery. In some communities, schools may be the only health care provider for disadvantaged children. In addition, schools maintain medical records for children. This is especially important for children with special health care needs. In many cases, the only other location besides home where a child with special health care needs may have their medications, medical supplies, and individuals who know about their medical history, medications, and needs is at school.

Schools are food service settings. In addition to breakfasts, snacks, potlucks, and food served at after-school events, 28 million school lunches are served to students every day. (4) Schools have a responsibility to ensure that foods provided to students and staff are safe and free from intentional contamination.

Schools are also places where recovery services can be delivered. Schools provide access to people in the neighborhoods in which they live. No place else in the community has access to such a high percentage of children and adolescents, and, through them, adult family members. After past community crises, mental health, and other recovery services have often been offered through or at schools. As microcosms of their communities, anxieties, tensions, and intolerance will be played out in schools. A basic capacity, or partnerships with community agencies to deliver health and mental health services is a necessity for schools.

Integration is Key

Recovery services and schools are a natural fit. Nonetheless, all phases of emergency management can and should be addressed in conjunction with local education agencies (also known as "districts") and schools. Many different federal, state, and local agencies are developing plans and resources to address potential terrorist events. In order to adequately address the special needs of children, public health agencies (including mental health), and other emergency responders, must involve education agencies, schools, and parents in their planning processes. Working together at the federal level will model collaborative approaches for states and locals. For example, the Federal Response Plan is a system for bringing together multiple federal agencies. However, the US Department of Education (ED) is included in only one component of the multifaceted plan. The same is true for the involvement of state education agencies in state plans. For schools and education agencies to be effective partners, they should be included in all components of the planning process. What happens in schools in a disaster situation does not happen in a vacuum.

Similarly, large amounts of funds have been made available to the states. For example, the Centers for Disease Control and Prevention (CDC) Public Health Preparedness and Response for Bioterrorism funding provided $940 million to the states to upgrade state and local public health jurisdictions' preparedness for and response to bioterrorism and other public health threats and emergencies. States were not directed to work with state or local education agencies to address the special needs of children. In addition, the CDC has funded several Centers for Public Health Preparedness, but working with local education agencies and schools is not an integral part of their activities.

In other cases, funding is directed locally and statewide coordination or collaboration is limited. Multiple resources might be directed to only one or two large cities while other parts of a state are not provided resources. State agencies can play an important role in conducting broad-based efforts, including the allocation of resources and training to local agencies to ensure a coordinated and seamless statewide effort.

Schools and local education agencies need to be an integral part of communitywide plans. Comprehensive, multi-hazard emergency management plans must be developed and implemented by local public health, law enforcement, emergency response, and education agencies together. Joint trainings are one way to build partnerships across multidisciplinary trainings. For example, in October 2002, the City of Memphis, Tenn., provided multi-hazard emergency planning training to 500 planning team members representing all of the Memphis public schools and at least one private school. The purpose of this training was to assist schools to implement a comprehensive emergency planning process in coordination with their local fire, police, EMS, and emergency management personnel.

A partnership between public health and education has many potential benefits for all involved. Public health can provide, for example, expert health guidance on appropriate school responses to specific hazards, and plans for triaging injured students. Schools can provide health and mental health services onsite and ensure the safety of students in their care. Together public health and education can provide for the safety and health of children.

PREPAREDNESS

Preparedness involves planning how to respond when an emergency or disaster occurs and working to marshal the resources needed to respond effectively. Just as schools and education agencies cannot prevent natural disasters, they may not be able to prevent a terrorist event. But, they can plan how to respond when an emergency does take place, either in school or the community. Federal and state education agencies urge every school to have an emergency management plan, but do not require school plans to be integrated with statewide planning efforts. Most preparedness efforts originating from the education arena are targeted at, or take place at the local level. Most public health preparedness efforts do not fully engage local education agencies and schools.

What Is Currently Being Done?

In March 2003, the US Department of Education revealed a new web site, www.ed.gov/emergencyplan, to provide school leaders with more information about emergency preparedness. The website includes crisis planning resources and links to other federal, state, local, and nongovernmental resources.

In addition to the website, ED is making $38 million available in FY 2003 to help school districts improve and strengthen emergency response and crisis management plans. Funds can be used to train school personnel, parents and students in crisis response; coordinate with local emergency responders including fire and police; purchase equipment; and coordinate with groups and organizations responsible for recovery issues, such as health and mental health agencies. An additional $30 million is included in the proposed FY 2004 budget.

ED recently released Practical Information on Crisis Planning: A Guide for Schools and Communities (May 2003). The Guide is intended to guide schools and school districts through crisis planning. The plan describes key components and action steps to address mitigation, preparedness, response, and recovery.

In April of 2002, ED and the Harvard School of Public Health sponsored a teleconference, titled The Three R's to Dealing with Trauma in Schools: Readiness, Response, and Recovery. The purpose of this teleconference was to provide educators and community workers with the most current information on effective steps for dealing with crises such as school shootings or attacks like those of September 11.

The National Clearinghouse for Educational Facilities website, www.edfacilities.org, includes an extensive resource list on Disaster Preparedness for Schools. The list includes links, books, and journal articles on building or retrofitting schools to withstand natural disasters and terrorism, developing emergency preparedness plans, and using school buildings to shelter community members during emergencies.

CDC funds education and health agencies in 18 states to strengthen their capacity to plan and implement Coordinated School Health Programs. The coordinated school health program model holds that all components of the school health program must interact, support, and reinforce each other to ensure student health. A coordinated school health program goes beyond the health education curriculum to include physical education; health services (including mental health and counseling); food services; a healthy and safe school environment; staff health promotion and training; and family and community involvement. The CDC-funded states build partnerships between education and health agencies to address school health, but have not yet focused on terrorism or disaster preparedness through coordinated school health programs.

In May 2002, CDC, ED, Federal Emergency Management Agency (FEMA), and the FBI hosted a teleconference, titled CDC and US Department of Education Collaborate to Help Schools Prepare for Possible Terrorism, to provide state and local education, health, emergency management, law enforcement and homeland security agencies with updated information on biological, chemical, and radiological threats; answer questions about school preparedness and response; and describe roles of partnering agencies in the case of a terrorist threat. This teleconference is available as an archived webcast or on videotape. The website, http://www.phppo.cdc.gov/PHTN/schools/default.asp, also includes frequently asked questions and a state team discussion guide.

CDC's School Health Guidelines to Prevent Unintentional Injuries and Violence, published in December 2001, include recommendations for establishing mechanisms for short-and long-term responses to crises, disasters, and injuries that affect the school community as part of a coordinated school health program. Recommendations address written response plans, preparations for response, and short- and long-term responses and services after a crisis. In addition, the CDC funds Centers for Public Health Preparedness throughout the country with the goal of linking schools of public health, state and local health agencies, and other academic and community health partners to prepare the nation's public health and healthcare workforce to respond to terrorist incidents and other emerging health threats. Working with schools is not an integral part of their activities.

The Agency for Healthcare Research and Quality (AHRQ) has provided the American Academy of Pediatrics with one year of funding for the development of a Pediatric Terrorism Preparedness Resource. This resource will include information such as equipment lists, medication dosages, protocols, and training packages that could improve the ability of all health care professionals to undertake preparation and planning activities for schools. The resource also will include educational and training material that could be used by pediatricians and other health care professionals to guide school disaster preparedness efforts.

In February 2003, AHRQ and Emergency Medical Services for Children (EMS-C) co-sponsored a National Consensus Conference which developed guidelines for Pediatric Disaster and Terrorism Preparedness. In addition to the multitude of recommendations that apply to children, there is a specific section providing recommendations and guidelines for children in schools.

The Health Resources and Services Administration (HRSA) and EMS-C jointly published the Basic Emergency Lifesaving Skills (BELS) framework for teaching emergency lifesaving skills to children and adolescents. The framework includes information on the sequence of basic emergency lifesaving skills performance and K-12 developmental principles and teaching strategies for learning basic emergency lifesaving skills. The BELSS Initiative is designed to increase the number of school-aged youth who are competent in safety, first aid, cardiopulmonary resuscitation, and automatic external defibrillator skills by training their teachers as instructors and providing curricula to promote the development of these skills. Trainings currently are planned for Wisconsin, Minnesota, North Dakota and South Dakota. FEMA has numerous resources for school disaster preparedness. The Multi-Hazard Emergency Planning for Schools Train-the-Trainer Course trains state and local multi- disciplinary teams representing education, police, fire, emergency management, EMS, and public health. These teams return to their communities and conduct additional training for education personnel. The Multi-Hazard Emergency Planning for Schools Independent Study Course provides the basic information and tools needed to develop effective all-hazard emergency operation plans for the wide array of potential emergencies that schools may face. Course components include understanding emergency management, team recruitment, hazard assessment, and plan development and testing.

FEMA for Kids, www.fema.gov/kids, was created to help children cope with disasters and to educate them about mitigation strategies. Highlights include "The Disaster Area," which teaches children disaster-specific information about what to do in each disaster, including a national security emergency and "Get Ready, Get Set" that teaches children preparedness and mitigation measures to protect their homes and families before disaster strikes. The FEMA website, www.fema.gov includes resources on community and family preparedness.

What Are The Gaps?

Clearly, there are many preparedness activities underway. However, there is no coordination between these activities. Few activities, notably the CDC and ED teleconference and the FEMA multi-hazards training course, are designed to foster collaboration between education, public health, and other emergency responders at the state or local level, or across levels.

Although schools are urged to plan, and the recent ED emergency planning grants will help the process, school plans are often treated as a separate plan rather than as part of the community plan. When collaboration with other community agencies is discussed, it is usually with law enforcement, fire, and homeland security, not with public health and mental health preparedness efforts. School plans tend not be practiced as part of larger community preparedness exercises. By working together, education and health agencies could:
   * Address preparedness as part of a coordinated school
   health program;

   * Provide for baseline school health services, including
   mental health;

   * Integrate existing school-based health services into
   plans to coordinate health care service delivery in
   schools;

   * Give schools the information they need to prepare for
   the possibility of chemical, biological, and radiological
   threats as well as the terror generated by these threats;

   * Plan for students with special health needs;

   * Plan for the needs of schools and students outside
   mainstream educational settings, eg, schools for the
   deal juvenile justice facilities;

   * Understand issues around bioterrorism and mass
   trauma events of particular importance to children and
   schools (eg, developmentally appropriate responses);

   * Establish mechanisms for reviewing outside offers for
   help after an event;

   * Train first responders about the special needs of
   schools and children;

   * Train teachers, other school personnel, and parents to
   triage injured and sick children, manage trauma reactions
   in children, and take care of their own needs;

   * Involve schools, parents, and students in the planning
   process;

   * Measure the level of preparedness at state, district, and
   school levels;

   * Conduct practice exercises for biological, chemical,
   radiological, and mass casualty events where public
   health will have the lead in response (in ways that do
   not increase fears among children, or where such fears
   can be addressed); and

   * Address mental health issues that arise around doing
   practices.


Recommendations

1. Ensure that every major DHHS-funded terrorism initiative, and other federal terrorism initiatives, appropriately addresses the role and needs of schools by providing regulatory requirements, oversight and funding to result in effective linkages between state and local education agencies, schools, public health agencies and other emergency preparedness entities.
   a. Establish an ongoing schools workgroup within
   homeland security efforts (eg, Operation Liberty
   Shield) in order to ensure that all relevant federal
   agencies plan together for the safety of schools
   and students and the integration of schools into
   community plans.


2. Expand CDC's School Health Program by supporting a high-level staff position in every state education agency and health department to coordinate policies and programs focused on the physical and mental health needs of students. As a central part of their mission, these staff should collaborate to ensure that schools are prepared to protect the lives and health of students and staff in emergencies. State school health leads, in education and health agencies, should work closely with state mental health, law enforcement, emergency management, and homeland security agencies and should receive at least a one-week course on the essentials of terrorism preparedness and risk communication.

3. Develop a plan and mechanism for flow of models of cooperation between the federal, state, and local levels. Some local communities and states have been very successful at developing collaborative planning relationships between public health, education, law enforcement, and homeland security. Reviewing these models could help improve other state and local, as well as federal, efforts at collaboration. Federal collaborations can also be models for states and locals.

4. Develop and disseminate information and measurement instruments to assess and improve the capacity of schools to prepare for and respond to chemical, biological, radiological, and mass trauma (physical and psychological) terrorism including:
   a. materials on the handling, identification, response,
   and decontamination for acts of chemical, biological,
   and radiological terrorism and related to
   specific hazards;

   b. psychosocial preparedness interventions for
   students and school personnel to increase
   resilience;

   c. mechanisms for addressing the needs and concerns
   of students and family members in preparedness
   and planning activities;

   d. instruments schools and education agencies can use
   to establish baseline mental "wellness" as well as
   the impact of school violence and other crises; and

   e. protocol templates for working with outside individuals
   or groups to provide mental health services
   after an event.


5. Build the capacity of education and public health agencies to work together on preparedness by:
   a. developing additional collaborative efforts built
   upon the May 2002 teleconference developed by
   the US Department of Education (ED), Centers for
   Disease Control and Prevention (CDC), Federal
   Emergency Management Agency (FEMA) and
   Federal Bureau of Investigation (FBI) to provide
   state and local education, public health, mental
   health, emergency management, law enforcement,
   and homeland security agencies with updated
   information on the agents of terrorism, provide
   technical assistance on school and community
   preparedness and response, and serve as a model
   for state-based collaborations.

   b. developing and disseminating resources on how
   schools work and on working with schools to the
   public health community;

   c. providing technical assistance to schools to assist
   them in joining community planning activities;

   d. developing and disseminating guidance for
   schools on how to establish agreements with local
   medical facilities and health departments and what
   such agreements should contain;

   e. developing expertise on the school-based management
   of emergency response for children with
   special healthcare needs, including medically fragile
   children;

   f. funding mechanisms to provide the minimum
   necessary number of health professional staff in
   schools to provide planning leadership and technical
   expertise if an event occurs; and

   g. ensuring that existing school health and school-based
   health services have necessary equipment
   and support the acquisition and upkeep of such
   equipment, and staff development on its operation.


6. Conduct and support research addressing preparedness of schools and their ability to respond to terrorism by:
   a. identifying "best practices" related to preparedness
   and recovery mental health services;

   b. determining the impact of preparedness activities
   on student mental health and wellness;

   c. studying whether schools are getting adequate
   information on chemical, biological, radiological,
   and mass trauma threats; whether they are satisfied
   with the information they are receiving; what
   types of information they would like to receive;
   and how they would like to receive it;

   d. describing the ability of school staff to balance the
   needs of their own children and families with
   those of the children in their care; and

   e. expanding the CDC School Health Policies and
   Programs Study to gauge state, district, and school
   preparedness, particularly in the areas of mental
   health services and availability and preparation of
   school health personnel to triage and respond to
   chemical, biological, radiological, or mass trauma
   events.


RESPONSE

Schools have a key role to play in the response phase. The response phase involves providing emergency assistance and trying to reduce the likelihood of further damage during and immediately following a disaster. If any type of disaster happens in the community during a school day, schools will be either safe havens for students or will be responsible for safely reuniting them with their families. If an event directly impacts a school, school personnel will be the first responders on the scene, with responsibility for safeguarding students' physical and mental health. However, few schools have nurses or other health professionals on-site or available in sufficient numbers to recognize an outbreak in progress or to handle a disaster situation without assistance from other school staff or community responders. For example, a recent California State PTA survey (5) found that 25.8% of California public schools (which educate more than 6.2 million students) never have a school nurse on campus. School personnel will also have concerns about the well-being of their own children and families. During community-wide events, schools are also often emergency assistance sites or staging areas for community response.

What Is Currently Being Done?

The Federal Response Plan (FRP) "establishes a process and structure for the systematic, coordinated, and effective delivery of Federal assistance to address the consequences of any major disaster or emergency." (FRP, p. 1) The Basic FRP, its 21 Annexes, and 4 Appendices contain only three mentions of the term "school"--once each in the Information and Planning Annex, Mass Care Annex, and Food Annex. ED is a party only to the Information and Planning Annex as a support agency. In this capacity, ED should identify a staff liaison or a point of contact at both the regional and headquarters levels to provide technical expertise, data, advice, and staff support for disaster operations and situation assessment activities that relate to schools (ESF #5, p.94). The Mass Care Annex description of a likely disaster condition states that "Thousands of family members may be separated immediately following a sudden-impact disaster, such as children in school and parents at work" (ESF #6, p.102). The Food Annex points out that "on the fringes of the geographic areas affected will be schools and small institutions having large inventories estimated to be sufficient to feed up to 10,000 people for three days and supply their fluid needs for one day" (ESF #11, p. 173).

CDC's Public Health Preparedness and Response for Bioterrorism funding has provided $940 million to the states to upgrade state and local public health jurisdictions' preparedness for and response to bioterrorism, other outbreaks of infectious disease, and other public health threats and emergencies. The funding addresses preparedness planning and readiness assessment, surveillance and epidemiology capacity, laboratory capacity, communications and information technology, health information dissemination, and education and training. Schools are mentioned twice in the Budget Year Four Continuation Guidance: recipients might establish the capacity to conduct public outreach campaigns which could include presentations to schools; and recipients are to develop communications materials regarding smallpox for local stakeholders such as school representatives.

The Bioterrorism Hospital Preparedness Program (BHPP) program is administered by HRSA in collaboration with the Assistant Secretary for Public Health and Emergency Preparedness and coordinated with other entities that assist state and local health agencies with bioterrorism preparedness. The mission of the BHPP is to ready hospitals and supporting health care systems to deliver coordinated and effective care to victims of terrorism and other public health emergencies. The program will also allow state and regional planning among local hospitals, emergency medical services systems, community health centers, poison control centers, and other health care facilities to improve their preparedness to combat a terrorist attack. BHPP recipients are directed to establish a Healthcare System Terrorism Preparedness Planning Committee that meets at least quarterly to provide guidance, direction and oversight to the state health department in planning for the state's terrorism response. Recent guidance directs recipients to create a joint advisory committee for both the CDC and HRSA cooperative agreements. Recipients have not been directed to include state and local education agencies or schools on these committees.

The Metropolitan Medical Response System (MMRS) operates at the local level to respond to a mass casualty event. The primary focus of the MMRS program is to develop or enhance existing emergency preparedness systems to effectively respond to a public health crisis, until state or federal resources are mobilized. Through preparation and coordination, local law enforcement, fire, hazmat, EMS, hospital, public health, and other first responders plan to more effectively respond in the first 48 hours of a public health crisis. Currently, more than 120 metropolitan areas have developed, or begun to develop MMRS. Although communities are directed to create a steering committee, state or local education agencies are not suggested as members. In addition, MMRS does not address special medical responses that might be needed if a terrorist event were to occur in the vicinity of a school, potentially impacting hundreds or thousands of children simultaneously. On March 1, 2003, MMRS moved from HHS to the Department of Homeland Security.

ED, in partnership with the American Red Cross, has created a program to certify teachers and other school staff in first aid. The first pilot training program occurred in May 2003 in Montgomery County, Maryland. ED will be conducting pilot training programs around the country in upcoming months to train school staff and provide students basic first aid and emergency preparedness information that they can take home to their families.

What Are The Gaps?

As was clear in the Preparedness phase, lack of coordination and communication between public health, education, and other first responders, remains a concern in the Response phase. State and local education agencies are not included on terrorism response planning committees mandated by various funding mechanisms. State and local agencies are not given meaningful information on how to involve education agencies and schools in the planning process. Although school nurses, where available, and other school personnel will likely be heavily involved in triaging and treating injured students in the event of a terrorist attack at or near a school, school personnel have not typically been included in emergency response plans or trained in handling medical emergencies. Neither are mental health concerns typically addressed in the response phase.

Little attention has been given to the possibility that students might need to be quarantined at school, which could include being separated from parents. Communication with parents should be effective and efficient. Schools and other first responders must be able to immediately address parent concerns about their children's health and safety. Students with special health care needs need particular consideration if sheltering-in-place or quarantine becomes necessary. Schools need an adequate supply of medications and special medical equipment to care for these students for up to 72 hours, as well as staff who are trained in their care.

In the aftermath of a terrorist event, schools will be called upon to provide services typically not within their realm of expertise. By working together, health and education agencies can ensure that schools:
   * Coordinate their response with that of public health,
   emergency management, law enforcement, and homeland
   security agencies;

   * Communicate effectively with these agencies;

   * Are prepared to look after student physical health,
   triage injured and exposed students, provide emergency
   medical assistance, and engage in quarantine;

   * Are prepared to immediately address student mental
   health concerns;

   * Have an adequate supply of medications, medical
   equipment, and trained staff to care for students with
   special health care needs for an extended period of
   time;

   * Provide staff with the training necessary to identify
   foodborne and other disease outbreaks and methods for
   preventing their spread;

   * Address the needs of school personnel to ensure that
   their own children and families are safe in order to
   effectively care for their students;

   * Can work with public health officials to administer to
   all students potassium iodide within two hours of exposure
   to radioactive iodine from a nuclear plant catastrophe
   or "dirty bomb" explosion;

   * Have recommendations on hand related to specific
   biological, chemical, and radiological hazards;

   * Know when it is appropriate to shelter-in-place or
   evacuate the school, and have the means to do both;

   * Know what activities are appropriate when sheltering-in-place
    (eg, whether classes should continue, whether
   other activities are appropriate, how to feed and shelter
   students);

   * Plan for the possibility of quarantining classrooms or
   schools;

   * Address the needs of students who are in transit to or
   from school when an event takes place; and

   * Are prepared for the possibility of serving as either a
   staging area for community response or as a community
   shelter.


Recommendations

1. Ensure that each major content area in DHHS-funded terrorism initiatives, and in other federal initiatives, addresses the role and needs of schools by providing dedicated fiscal resources and regulatory oversight to ensure that state and local health departments, and other agencies involved in this work, truly build partnerships with state and local education agencies and schools.
   a. Revise the Federal Response Plan, indicating the
   need for schools to be an integral part of preparedness,
   response, recovery, and mitigation efforts.

      * The Department of Health and Human Services
      is responsible for the Health and Medical
      Services Annex to the FRP (ESF #8). The
      Secretary should request that the Department of
      Education sign on as a Support Agency.
      Support responsibilities might include: (a)
      assist in providing emergency health services,
      including quarantine, to children in schools at
      the time of a disaster; (b) assist in identifying
      and addressing special needs of children in
      regards to reuniting with families, communication,
      and transportation; (c) assist in providing
      mental health services for children affected by
      the disaster; and (d) communicate to
      constituents that providing healthcare and
      mental health services are key roles of schools.

      * The American Red Cross has the lead for the
      Mass Care Annex of the FRP. The Secretary
      should suggest that the Department of
      Education sign on as a Support Agency to assist
      in addressing the special needs of schools and
      students. This could include management and
      coordination of sheltering, feeding, evacuating,
      and providing emergency first aid services to
      children in school at the time of a disaster, or
      otherwise separated from their families; providing
      logistical guidance and support for reuniting
      students with their families; identifying
      schools that can serve as community shelter
      locations; and planning for the use of schools
      as alternative health care sites for triage and/or
      treatment by identifying specific schools and
      ensuring that they are equipped with pediatric
      equipment and supplies.

      * The Department of Agriculture, Food and
      Nutrition Service (FNS) has the lead for the
      Food Annex of the FRP. Suggest to FNS that
      schools be considered not only as potential
      sources of food and fluids on the fringes of the
      affected area, but that the special needs of
      schools within a disaster area also be
      addressed. Suggest that the Department of
      Education sign on as a Support Agency to assist
      in this regard.

   b. In renewed and future Requests for
   Applications/Cooperative Agreement Awards for
   Public Health Preparedness and Response for
   Bioterrorism, and in associated guidance documents,
   add the following language:

      * In the Introduction, add School Health
      Programs to the list of CDC programs with
      which recipients should "augment, complement,
      and closely coordinate."

      *In Attachment X, Cross-Cutting Benchmark #2,
      add state and local education agencies to the
      list of required members of the Advisory
      Committee.

      * In Focus Area A, Critical Benchmark #2,
      require the recipients to work with the advisory
      committee to develop or enhance their response
      plans.

      * In Focus Area A, Critical Capacity #3, Item 5,
      add education agencies to the list of agencies
      recipients should work with to identify vulnerabilities
      in terms of human health outcomes.

      * In Focus Area B, Critical Capacity #5, Item 5,
      add school health professionals to the list of
      healthcare professionals for whom ongoing
      disease surveillance and epidemiology training
      should be provided.

      * In Focus Area B, Enhanced Capacity #6, Item
      6, add state and local education agencies to the
      list of organizations with whom recipients
      should establish designated points of contact
      and cross-training.

      * In Focus Area E, Critical Capacity #11, add
      state and local education agencies to the list of
      entities with whom recipients should ensure
      effective communications connectivity.

      * In Focus Area G, Critical Capacity #16, add
      school health personnel to the list of public
      health professionals to be educated and trained
      in preparedness for and response to bioterrorism.

   c. CDC conducts site visits to states to provide technical
   assistance in implementing Cooperative
   Agreement Awards for Public Health Preparedness
   and Response for Bioterrorism. The
   Secretary should direct CDC to specifically review
   efforts to include educational agencies in the planning
   process and to meet the needs of schools.
   Funding should also be provided to bring educational
   agencies into the planning process.


2. Add language to the "Model Public Health Act" indicating the need for schools to be an integral part of bioterrorism planning.

3. Conduct and support research addressing issues affecting the ability of schools to respond to terrorism including:
   a. what constitutes an adequate supply of potassium
   iodide, antitoxins, and other medical supplies and
   equipment necessary to treat students in schools.
   Make these supplies available to schools and train
   school personnel to use them; and

   b. availability and preparation of school health and
   mental health personnel to triage and respond to
   chemical, biological, radiological, nuclear or mass
   trauma events, as well as the terror generated
   before, during and after an event.


RECOVERY

Schools are uniquely positioned to provide normalization and security to children and should be a part of recovery efforts. The recovery phase includes engaging in short-term efforts to restore people to physical and mental health and vital systems to minimum operating conditions; and long-term efforts to restore entire disaster areas to previous conditions or better. Schools should remain open whenever possible. Keeping students engaged in their regular routine, including attending school, is a key to maintaining their resiliency. However, school buildings may be damaged or contaminated and in need of repair before classes can resume and services can be offered. Alternate locations may be needed if school buildings need extensive repairs or rebuilding. Transportation systems to and from school also may be damaged. The mental health of students is an essential ingredient for meeting schools' academic mission: Students suffering from anxiety, PTSD, or grieving the loss of friends or loved ones will have difficulty learning. Mental health services can be delivered through schools, particularly in underserved areas, in order to efficiently reach a large number of children. Schools provide an optimal location for discussion, peer, and adult support. In order for schools to support children who are having difficulty coping with a traumatic event, staff must be supported and be aware of their own responses to the traumatic event.

What Is Currently Being Done?

Immediately following the events of September 11th, ED made $8.9 million of Project School Emergency Response to Violence (Project SERV) funds available to the New York City Board of Education, and state educational agencies in New York, New Jersey, Connecticut, Virginia, Maryland, and Washington, DC. Funds awarded to the state educational agencies were distributed to school districts that were impacted by September 11th. Funds awarded to the New York City Board of Education were distributed to various school districts within the city. Funds from Project SERV were used by school districts to help restore the learning environment and for a variety of mental health services. Project SERV funds also supported a study conducted by Columbia University to assess the mental health effects of September 11th on children in over 8,000 school children in NYC public schools. CDC provided technical assistance to this study.

The Substance Abuse and Mental Health Administration (SAMHSA), in collaboration with Project SERV, has developed a Guide for Intermediate and Long-Term Mental Health Services after School-Related Violent Events. This document provides guidelines for school staff and community mental health personnel to establish and maintain immediate, intermediate, and longer-term mental health recovery services necessary to restore the social and emotional equilibrium and well-being of students and staff after violent events. SAMHSA also developed a guide on Coping with Traumatic Events, Tips for Teachers which provides tools to assist teachers to develop students' emotional and psychological coping and resilience skills during times of crisis.

SAMHSA funds the National Child Traumatic Stress Network (NCTSN) to raise the standard of care and improve access to services for traumatized children, their families, and communities throughout the United States. The NCTSN will work with established systems of care, including the educational system, to ensure that there is a comprehensive continuum of care available and accessible to all traumatized children and their families.

For more than 25 years, the FEMA/SAMHSA Interagency Agreement to Provide Crisis Counseling Assistance and Training Crisis Counseling Program has supported short-term interventions with individuals and groups experiencing psychological sequelae as a result of large-scale disasters. These interventions assist disaster survivors in understanding their current situation and reactions, assist survivors in reviewing their options, promote the use of coping strategies, provide emotional support, and encourage linkages with other people and services. Upon receiving a Presidential disaster declaration, if a state determines that state and local resources are insufficient to meet mental health service needs, the state mental health authority can request supplemental funds from FEMA.

The Trauma Psychiatry Program at UCLA, as part of the NCTSN, has produced a Trauma Information Pamphlet for Teachers. This pamphlet includes information on types of posttraumatic stress reactions, consequences of these reactions for adolescents, things that make these reactions worse, and information on how teachers can help.

What Are The Gaps?

Only a small percentage of children in the United States receive the mental health treatment they need. For those children who do receive needed mental health services, schools are the primary providers. However, short- and long-term mental health services in schools or tied to schools remain scarce. In addition, there is a lack of information on baseline mental health of children in the absence of a terrorist event.

Children who are displaced from their schools due to a terrorist event, disrupting their daily routines for an extended period of time, are likely to be at increased risk for post-event difficulties. In addition, anxious or ill children do not learn well, jeopardizing the school's academic mission. Most schools are not well-equipped to address the mental health needs of students and staff after a terrorist event. Funding to support school mental health services is scarce. Relationships between mental health providers and schools need to be established in advance of a crisis. School staff can be trained to identify and refer students who appear to be in need of mental health services. Mental health providers should develop working partnerships with schools in order to address the mental health impact of terrorism on children. Project SERV and FEMA/SAMHSA activities should be coordinated to prevent gaps in service provision. Schools may be inundated with outside proposals to provide services and conduct research. Schools must review these to determine their appropriateness for the setting and to balance the needs for supportive intervention and normalization.

School officials are responsible for ensuring the physical safety of school buildings and grounds. Little information is available to help school officials understand what remediation actions are needed to ensure the safety of school property after a terrorist event, especially an event involving biological, chemical, or radiological agents. Nor is there guidance for schools about when it is safe to reopen damaged school buildings, or those impacted by biological, chemical, or radiological agents.

Recommendations

1. Collaborate with the Secretary of Education to formalize partnerships at the federal, state and local levels, and coordinate activities to ensure that schools are fully integrated into preparedness, response, recovery, and mitigation efforts. Specific activities on which HHS and ED can work together are:
   * Add funds to the School Emergency Response to
   Violence Project (SERV) contingency fund,
   increasing the government's capacity to respond in
   a fast and flexible manner to meet the critical
   needs of schools and students after a crisis in the
   school or community.

   * Increase collaboration and linkages between
   Project SERV and SAMHSA crisis counseling
   services.

   * Fund demonstration projects that evaluate the
   effectiveness of school-based responses to past
   emergencies (eg, Columbine high school shootings,
   September 11th) and expand and evaluate
   existing emergency planning and response models
   (eg, New York City, Los Angeles) for involving
   education agencies and schools in a coordinated
   system of response and recovery.

   *  Train students, staff, and family members to be
   first responders.

   * Ensure that schools are part of community-based
   planning and training as both community
   resources and as places where large numbers of
   children and adolescents are congregated.

   * Ensure that schools place a high priority on returning
   students to school and their normal routines as
   quickly as possible after an event as one important
   method for supporting their resiliency.

   * Establish a school terrorism and disaster
   psychosocial preparedness and recovery technical
   assistance center.


2. Develop and disseminate materials and fund staff development for teachers and other school personnel about:
   a. symptoms of psychological disturbances
   among children and how to refer students to
   appropriate care;

   b. the importance of fostering resiliency among
   children and methods for doing so; and

   c. methods for managing the stress of on-going
   terrorism threats.


3. Develop and disseminate guidance for school officials regarding:
   a. remediation actions that might be necessary
   after different potential types of terrorist events;

   b. the importance of mental health screening and
   mechanisms for determining what should be
   permitted in an emergency setting; and

   c. when it might be safe to reopen damaged
   school buildings, or those contaminated by
   biological, chemical, or radiological agents.


MITIGATION

Public health and education agencies can work together to reduce the chance that terrorism will lead to a disaster in schools. Mitigation includes activities that eliminate or reduce the chance of occurrence or the effects of a disaster. Mitigation can include modification to policies and practices (eg, visitor policies, baggage checks, food biosecurity practices); to facilities (eg, physical barriers, air filtration systems, building design); and even to people (eg, students and staff can be taught to be alert to potential terrorist threats).

Schools cannot mitigate the chance of a terrorist event in isolation from public health and other state and local agencies. Partnerships between education and public health can benefit both schools and their communities. Schools could collect, compile, and report health data that might indicate a biological, chemical, or radiological terrorist event to appropriate health authorities. Likewise, schools could collect, compile, and report health data that might rule out terror events (ie, false positives). For example, data collection by schools was used to rule out last year's skin rash epidemic as terror-related. In addition to meals and snacks eaten throughout the school environment, 28 million school meals are served daily in cafeterias. Public health and agriculture officials could work with schools to ensure that this food supply remains safe.

What Is Currently Being Done?

The US Department of Agriculture (USDA) Food and Nutrition Service is developing School Food Biosecurity Guidelines. The USDA guidelines include suggestions on how to form a school foodservice biosecurity management team, how to identify and respond to intentional foodborne disease outbreaks, use a checklist to prioritize suggestions for strengthening biosecurity inside and outside the primary foodservice area, and create a school foodservice biosecurity management plan. CDC plans on working with USDA to integrate the school food biosecurity guidelines into a forthcoming Food-Safe Schools Action Guide.

FEMA is developing a Primer for Security Component for Safe Schools to provide comprehensive school security information with a focus on physical attack prevention, mitigation design, and renovation. Primary physical attack methods will include explosive, ballistic, sabotage, biological, chemical, and radiological. The primer will include threat, vulnerability, and criticality assessment; the relationships between design for building security and design for natural hazards; measures related to building sites and site planning, attack impacts on buildings and their contents; methods of resisting attack; development of risk management programs; and the relationship to emergency operations and disaster recovery plans. This document is targeted toward design professionals--architects and engineers--and school officials involved in the technical and financial decisions of school construction, repairs, and renovations.

On February 13-14, 2002, ED, in partnership with the US Department of State and the Organization for Economic Cooperation and Development (OECD), held an International Forum on Response to Terrorism to discuss how schools could be protected from violence and terrorism. Key educators and law enforcement personnel from 10 countries (including Israel, Turkey, Northern Ireland and Spain which have experienced terrorist threats and attacks) attended the conference. A key finding from this conference was that while terrorists generally have not had a significant direct impact on education, they have had an indirect or collateral effect on education in many countries; students have been killed, injured, and experienced mental health problems even though they were not the primary targets. In Turkey, however, terrorists did attack schools directly. Over a period of 13 years (1984-1997), approximately 146 teachers were killed and 370 schools destroyed in terrorist incidents. There was also a consensus among all participants that security needs to be balanced with the need to maintain an environment that is conducive to learning; none of the participants wanted to see their schools become "bunkers."

ED is working with officials from the OECD to sponsor a Second International Meeting on the Prevention of School Violence and Terrorism with key education and law enforcement officials to share information on the extent and nature of school violence and terrorist threats and the best strategies for addressing them.

ED and the US Secret Service released a guide, Threat Assessment in Schools: a Guide to Managing Threatening Situations and to Creating a Safe School Climate, in May 2002. The guide is designed to help educators and others charged with responsibility for ensuring school safety identify youth who pose a threat to the school environment. ED and the US Secret Service trained state and local educators and law enforcement personnel on the principles of effective threat assessment. The threat assessment guide and its companion document, The Final Report and Findings of the Safe School Initiative: Implications for the Prevention of School Attacks in the United States, can be accessed at www.secretservice.gov/ntac_ssi.shtml.

ED has been working closely with the Bureau of Alcohol, Tobacco, and Firearms to develop and disseminate a Bomb Threat Guide, based upon the latest science, which will help school officials develop strategies for preventing and responding to bomb threats.

What Are The Gaps?

The challenge of mitigation is to make schools safer without turning them into places where children would not want to be and where learning would be more difficult. When schools look and act like prisons, students do not learn well. By building partnerships at the state and local level, schools can remain open to the community and still be safe.

Schools have the greatest chance of making improvements related to policies, practices, and people, rather than in facility design. By linking policies and practices to other areas of school health, school safety can be improved efficiently while also addressing ongoing health needs of children (eg, by revising indoor air quality policies schools can impact asthma and tobacco use in addition to terrorism, food biosecurity programs can be tied to school nutrition efforts, safe transportation systems might include ensuring the presence of sidewalks for students who walk between school and home.)

Schools do not routinely collect or analyze illness, injury, or absence data. By linking schools or districts with public health agencies to improve data collection and analysis, it might be possible to quickly detect health trends that could indicate the use of biological, chemical, or radiological agents.

Schools can infuse lessons throughout the educational curriculum that help students understand the root causes and history of terrorism, conflict, and violence in their communities and throughout the world. Schools can also teach students skills such as conflict resolution, prosocial behaviors, and problem-solving that might lead to a decrease in violence in their world.

Recommendations

1. Fund CDC to work with USDA and other federal agencies to integrate model food biosecurity programs into existing coordinated school health programs. As part of this effort, states should be funded to forge state and local partnerships among health, education, and agriculture agencies to develop and implement strategic plans for integrating and improving school food biosecurity efforts within FoodSafe Schools.

2. Integrate schools with public health surveillance programs that allow for trends in increased disease incidence and early detection of possible chemical, biological, or radiological terrorism.

3. Collaborate with the US Department of Education to develop and disseminate guidance for schools on effective modifications to policies, practices, facilities, and people that might mitigate the impact of terrorism on schools and students.

4. Support school-based violence prevention education and programs that help students understand the root causes and history of terrorism, conflict, and violence in their communities and throughout the world and teach them skills (eg, conflict resolution, problem-solving) that might lead to a decrease in violence in their world.

Appendix

Sample National, Nongovernmental Organization Resources and Activities

Preparedness
   * The American Academy of Pediatrics website, www.aap.org, includes
   a section on Children, Terrorism, and Disasters. Included in this
   section are links to other relevant resources and information for
   pediatric health care providers on chemical, biological,
   radiological, and other agents, psychological aspects of terror and
   disasters, disaster planning, and public policy.

   * The American Red Cross has a variety of materials and programs to
   help schools and students prepare for    disasters, including
   terrorism. They have developed a list of Recommended Emergency
   Supplies for Schools. Available from the American Red Cross website,
   the list includes information on what and how much to store, and
   where to store it. The Masters of Disaster[R] curriculum provides
   students with information to help them prepare for disasters and
   stay safe during and after a disaster in their home, school, or
   community. The Together We Prepare effort includes web-based tools
   for making a plan, building an emergency supply kit, getting trained
   in emergency preparedness, donating blood, and volunteering. The
   American Red Cross Homeland Security Advisory System Recommendations
   for Schools provides recommended actions that can be taken at the
   different color-coded threat levels, available for downloading in
   English and in Spanish.

   * The National Education Association Crisis Communications Guide and
   Toolkit provides resources for preparing for a crisis, responding
   during a crisis, and long-term actions to move beyond a crisis.

   * The National Association of School Nurses (NASN) published
   Disaster Preparedness Guidelines for School Nurses in 2002. The
   manual contains information for the school nurse regarding the
   nurse's role in each of phase of disaster preparedness. Forms,
   checklists, and planning tools are included. NASN also developed a
   full-day workshop on Disaster Preparedness for School Nurses.
   Developed through a partnership with EMS-C, the course addresses the
   four phases of disaster preparedness as well as emerging diseases.
   Skill development in triage and disaster response is included.


Response
   * An important effort of the National Association of School
   Psychologists (NASP) is the National Emergency Assistance Team
   (NEAT). The mission of NEAT is to "develop policies and procedures,
   disseminate information, provide consultation, and facilitate the
   training of school-based crisis teams in response to significant
   emergencies impacting children and adolescents." The team is
   composed of school psychologists with expertise in prevention,
   intervention, and postvention who can provide assistance in response
   to large-scale emergencies.

   * NEAT works in partnership with the National Organization for
   Victim Assistance (NOVA). NOVA helps local decision-makers identify
   all the groups at risk of experiencing trauma; trains local
   caregivers to reach out to those groups after NOVA has departed; and
   leads model crisis intervention sessions.


Recovery
   * The American Red Cross has added a supplement to the Masters of
   Disaster curriculum, Facing Fear: Helping Young People Deal with
   Terrorism and Other Tragic Events, to address dealing with feelings
   of loss, sadness and anger after a tragic event; provides
   information about understanding media coverage; and provides
   positive ways for children and their families to respond to past
   events and plan for future uncertain times. Also available for
   downloading from the Red Cross website, is a series of brochures
   that provide age-appropriate suggestions for how adults (parents
   and educators) can help children cope with disasters and terrorist
   attacks.

   * Many national organizations provide resources for teachers to
   help students cope with terrorism. A few are listed here:

      ** In addition to resources available an their website,
      helping.apa.org, the American Psychological Association has
      developed four pamphlets containing tips for parents and teachers
      of elementary school children and teens, day-care providers of
      preschool children, and tips for teens themselves.

      ** The American Counseling Association, www.counseling.org, has
      developed a counselor's guide to preparing and responding to
      terrorism, trauma, and tragedies. The guide provides information
      on strategies to help students cope with a school tragedy.

      ** The American School Counselor Association,
      www.schoolcounselor.org, has a resource center on their
      website with links, information, suggested books, and sample
      documents on school safety and trauma. The ASCA also recently
      completed an on-line symposium entitled the Human Side of School
      Crisis in which more than 1900 people participated. The symposium
      addressed both short- and long-term effects of crisis on school
      staff and students.

      ** The Association for Supervision and Curriculum Development,
      www.ascd.org, has many resources for schools including How to
      Prepare for and Respond to a Crisis, and Quick Response: A
      Step-by-Step Guide to Crisis Management for Principals,
      Counselors, and Teachers.

      ** The UCLA School Mental Health Project Center for Mental Health
      in Schools offers a guide to school-based crisis intervention
      that can be used as an in-service session or self-tutorial. They
      also have materials on responding to a crisis at school.

      ** The National Center for Children Exposed to Violence,
      www.nccev.org, has a teachers' guide for talking to students
      about war and terrorism.

      ** The National Association of School Psychologists,
      www.nasponline.org, includes a wide range of materials on coping
      with crisis, children's fears, and memorial activity suggestions.

      ** The National Mental Health Association, www.nmha.org, has
      materials on coping with disaster and helping children cope
      with loss resulting from war or terrorism.

      ** The National PTA, www.pta.org, provides resources on coping
      with tragedy, addressing prejudice, and teaching children about
      empathy.

      ** The National Youth Violence Prevention Resource Center,
      www.safeyouth.org, provides information for educators on
      responding to terrorism.

      ** A number of national organizations (eg, Connect for Kids,
      School Social Work Association of America, and the International
      Society for Traumatic Stress Studies) have compiled lists of
      resources for helping children cope with trauma, terrorism, and
      war. Some include age-specific guidance and lesson plans.


Mitigation
   * The National Association of School Resource Officers (NASRO),
   www.nasro.org, conducted a national survey of school resource
   officers regarding their schools' vulnerability to terrorism and
   preparedness for such an attack. NASRO is calling for terrorism
   training for school police officers and teachers, and standards and
   funding for school security assessments, emergency planning, and
   security-related information sharing with public safety officials.

   * The National Food Service Management Institute recently released
   Emergency Readiness Plan: A Guide for the School Foodservice
   Operation. This document provides recommendations for developing an
   emergency readiness plan, assessing a situation that disrupts food
   service, and special requirements for serving as a designated relief
   shelter.


References

(1.) Bartlett S, Patrarca J. Schools of Ground Zero: Early Lessons Learned in Children's Environmental Health. Washington, DC: American Public Health Association and Healthy Schools Network; 2002.

(2.) US Dept of Education. Practical Information on Crisis Planning: A Guide for Schools and Communities. Washington, DC: Office of Safe and Drug-Free Schools; 2003.

(3.) US Dept of Education. Digest of Education Statistics, 2001. Washington, DC: National Center for Education Statistics; 2002.

(4.) US Dept of Agriculture, Food and Nutrition Service. Child Nutrition Tables. Washington, DC: Available at: http://www.fns.usda.gov/pd/cnpmain.htm, Accessed June 5, 2003.

(5.) California State PTA Healthcare Survey Statistics. Los Angeles, Calif: California State PTA; 2003.

(6.) US Dept of Health and Human Services. Mental Health: A Report of the Surgeon General. Washington, DC: US Government Printing Office; 1999.

RELATED ARTICLE: Schools and Terrorism.

A Supplement to the National Advisory Committee on Children and Terrorism Recommendations to the Secretary

This paper was prepared by: Brenda Greene National School Boards Association, and Member, National Advisory Committee on Children and Terrorism; and Lisa C. Barrios, DrPH; Joy Elizabeth Blair; and Lloyd Kolbe, PhD; Division of Adolescent and School Health, Centers for Disease Control and Prevention.

The paper and recommendations were developed through a process that involved the following representatives of federal and state agencies and nongovernmental organizations who reviewed drafts, participated in a conference calf, and submitted comments.

Nancy Birkhimer State Adolescent Health Coordinators Network Augusta, Maine

Evelyn Boeckler EMS-C National Resource Center Washington, DC

Jim Bogden National Association of State Boards of Education Washington, DC

Lorraine Brown USDHHS, Health Resources and Services Administration, Head Start, Rockville, MD

Stephanie Bryn USDHHS, Health Resources and Services Administration, Maternal and Child Health Bureau Rockville, MD

Cecilia Rivera Casale USDHHS, Substance Abuse and Mental Health Services Administration Rockville, MD

Cheryl Connelly National Association of City and County Health Officials Washington, DC

Jill Cook American School Counselors Association Alexandria, VA

Linda Davis-Alldritt California Dept. of Education Sacramento, CA

Kellie Dressler Dept. of Justice, Office of Juvenile Justice and Delinquency Prevention Washington, DC

Ted Feinberg National Association of School Psychologists Bethesda, MD

Sascha Fielding Centers for Disease Control and Prevention, National Center for Environmental Health Atlanta, GA

Stacey Gooding USDHHS, Health Resources and Services Administration, Maternal and Child Health Bureau Rockville, MD

Amy Greene Association of State and Territorial Health Officials Washington, DC

Isadora Hare USDHHS, Health Resources and Services Administration, Office of Adolescent Health Rockville, MD

Gabriella Hayes National PTA Chicago, IL

Molly Hicks American Academy of Pediatrics Chicago, IL

Nora Howley Council of Chief State School Officers Washington, DC

Moniquin Huggins USDHHS, Administration for Children and Families Washington, DC

Mary Grenz Jalloh New York State Center for School Safety New Paltz, NY

Mitzi Johnson National Association of School Nurses Denver, CO

Milagros Kennett Dept. of Homeland Security Federal Emergency Management Agency Washington, DC

Theresa Lewallen Association for Supervision and Curriculum Development Alexandria, VA

William Modzeleski Dept, of Education Office of Safe and Drug Free Schools Washington, DC

Sharon Murray Society of State Directors of Health, Physical Education and Recreation Reston, VA

Ron Palomares American Psychological Association Washington, DC

John Schlitt National Assembly for School-Based Health Care Washington, DC

Rick Smith USDHHS, Health Resources and Services Administration, Maternal and Child Health Bureau Rockville, MD

Allen Sosebee Dept. of Justice Federal Bureau of Investigation Atlanta, GA

Heidi Taylor American Red Cross Arlington, VA

Kenneth Trump National School Safety and Security Services Cleveland, OH

Farris Tuma USDHHS, NIH, National Institute of Mental Health Bethesda, MD

Eleanor Wagoner USDHHS, Administration for Children and Families Washington, DC

Dawn Warehime Dept. of Homeland Security Federal Emergency Management Agency Washington, DC
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Publication:Journal of School Health
Geographic Code:1USA
Date:Feb 1, 2004
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