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J Urban Health. Feb 2011; 88(Suppl 1): 176–183.
Published online Feb 8, 2011. doi:  10.1007/s11524-010-9523-8
PMCID: PMC3042073

Appendix B: CAAC Program Resources

New York: Link

Asthma Basics for Children—This program is designed to help early childhood educators and parents of children (newborn through age 6) learn to manage asthma.

ABC Early Childhood Educators Handbook:

Table of Contents for the ABC Early Childhood Educators Handbook:

  1. Be Aware: What is Asthma?
    Introducing asthma as a chronic disease of the lungs.
  2. Be Prepared: Make a Plan:
    Taking control of your child’s asthma
  3. Reduce asthma triggers:
    Taking control of your child’s asthma is to reduce your child’s asthma triggers in and around the home
  4. Stay Connected:
    It takes a village to control asthma and parents and caregivers need each other, working as a team, in order to control asthma.
  5. City & Community Asthma Resources:
    Resources available in the community to help families of children with asthma

ABC Club Card:

An educational tool to help remind parent of things they should be aware of and also to increase their confidence in managing their children’s asthma

Northern Manhattan Asthma Basics for Children-Sticker AAP-Medication Schedule Form:

A friendlier picture-sticker form that helps children and parents understand the different types of asthma medication. It also reminds them to take their asthma medication whether they have symptoms or not.

Please contact Sally Findley at the Mailman School of Public Health, Columbia University to request these materials

Phone: 212-304-5790 Email: findley.se@gmail.com



Kickin’ Asthma—Kickin’ Asthma addresses the unique needs of kids ages 11 to 16 with asthma who are too old for our Open Airways for Schools program but not yet adults.

Open Airways—Elementary school children can learn to manage their own asthma through this interactive school program.


Please contact Dolores Weems at the University of Illinois at Chicago to request these materials

Phone: 312-413-5317 Email: weemsjr@uic.edu

Materials supporting the community health worker home based-intervention

Asthma Knowledge Assessment—Questionnaire used to assess what participants know about asthma (pre and post)

Health Intervention Visit Checklist—Forms used by educators to detail level of education or service provided to participants.

Quality of Life—Participant perception of risk and impairment and effects of disease on child’s life.

Coover Home Environment Assessment Survey Tool—this is a 14 page document that covers innumerable triggers for a person with asthma. Everything from peeling paint, birds, smoking in home and by who, number of rooms, door, etc. and age of the home, radon and lead are covered by this tool.

Home Survey, Interventions and Education Evaluation (HSIEE)—this form is a very condensed tool in relation to the Coover tool home assessment tool, which was used as a contract with the families for environmental changes to be made in and around the home.

Health Assessment Form—This form is an in-depth intake form. It includes a stop and end time to determine how long the questionnaire takes, and was done at 6 month intervals (ideally), identifies gender and age of participant children, helps collect control indicators of risk and impairment such as the number of ED, hospitalizations, episodes of wheezing, coughing, shortness of breath, etc. Also information regarding allergies is collected with this form.

Referral Form—Form to refer patients to physicians and other services. The form also includes space for receiving follow-up from the referred to physicians and service providers.

End of Participation Form—to assess if participants completed all phases of the interventions

Richmond: Link

Please contact LuAnne Grimes at CARMA to request these materials

Phone: 804-213-0917 Email: LuAnn_Grimes@bshsi.org

Asthma FIT Program (an after school program to promote physical activity and provide nutrition and asthma education)

  1. Talking Points (PDF) on water drinking and asthma
    Reminder Cards—Water Drinking
    Importance of Water (PDF)
  2. Talking Points (PDF) on exercise and asthma
  3. Talking Points (PDF) on fruits and vegetables
    Reminder Cards—Fruits and Vegetables
    Importance of Fruits and Vegetables (PDF)
    Put a Rainbow on Your Plate Handout
    Challenge Form
  4. Talking Points (PDF) on asthma signs and healthy snacks
    Reminder Cards—Healthy Snacks
    Healthy Snacks Pyramid (PDF)
  5. Talking Points (PDF) on asthma triggers and TV turn off
    Fitting in Fitness (PDF)
    Turning off the TV (PDF)
    Challenge Form
    Reminder Cards—Turning off the TV
  6. Talking Points (PDF) on asthma overview and family factors
    Fit and Fun Handout (PDF)

Philadelphia: Link

Home Visiting Program assessment forms

Intake Questionnaire (PDF)

Assessment Tool (PDF)—Used to assess the condition of the family’s home at initial visit

Medication Update Form (PDF)—Used at each visit to document all asthma medicines that are in the home, their use, and enrolled child’s symptoms in the past two weeks

Follow-up Visit Form (PDF)—Documents intervention maintenance

Asthma Quiz (PDF)—Given pre- and post-intervention

Asthma Quality of Life Survey (PDF)—Given at initial visit, at six months, and at 12 months

Asthma Control Survey (PDF)

St. Louis: Link

Community Asthma Program

Asthma Pocket Card

Buffet Pocket Card

CAP Survey

Follow-Up Telephone Call Form


PCP Office Visit Form

You Have Asthma Flyer

Asthma Friendly Pharmacies

AFP Fax Template

Bag Tag

RX Interventions 7 Day Log

Asthma 411

Absence Tracking Form

Monthly Nurse Activity Tracking Form

PCP Fax Form

Student Asthma Record

Minneapolis/St. Paul: Link

Systems change intervention logic model

Health Plan Policy

Documents Detailing Health Plan Coverage for Asthma Services:

2007 Minnesota Health Plan Coverage for Additional Controller Medications

Prescription Benefit Coverage Grid for Minnesota Health Plans

Other Asthma Services & Benefits Covered By Minnesota Health Plans

Asthma Programs Offered by Minnesota Health Plans

Surveys Used to Assess Health Plan Coverage for Asthma Services:

Health Plan Survey Questions about Pharmacy Billing

Health Plan Survey Questions about Asthma Programs

Health Plan Survey Questions about Asthma Services Billing

Pharmacy Intervention Tools

Asthma Educator Certification Course

Setting the PACE (Provider Asthma Care Education) for Asthma in Minnesota

Pharmacy Intervention

Curriculum Guide

Improving the Lives of Our Patients with Asthma: a Power Point presentation

Minnesota Asthma Information Center

Educational Resources Evaluation Tool

Annual Website Evaluation

Professional Skill Validation Tools

Asthma and Allergy FAQ

Emergency Department follow-up in Primary Care summary

Emergency Department follow-up in Primary Care concept paper

Asthma Education in the Emergency Department

Asthma Education in the Emergency Department Evaluation Plan.

Children’s Hospital Emergency Department Patient Education Poster.

Primary Care Appointment Following an ED/UC Visit (short version).

Primary Care Appointment Following an ED/UC Visit (detailed version).

Childcare Provider Education Tools

Caring for Kids with Asthma Curriculum Guide

Caring for Kids with Asthma—Asthma Training for Childcare Providers: Power Point presentation

Participant handouts:

  • Asthma Quiz
  • Asthma Triggers List
  • Care and Cleaning of Spacers
  • How to use an MDI
  • How to use a Nebulizer
  • Medication Sheet

Family Asthma Education Forum Tools

Managing Your Child’s Asthma Curriculum (Hmong, Somali, Spanish)

Managing Your Child’s Asthma Curriculum Guide

Participant Handouts:

Table thumbnail

Medication Device Instruction Sheets

How to use a compressor driven nebulizer (Hmong, Somali, Spanish)

How to use the Diskus (Hmong, Somali, Spanish)

How to use the Foradil Aerolizer

How to use an Inhaler with a Spacer (Hmong, Somali, Spanish)

How to use the Maxair Autohaler

How to use a Metered Dose Inhaler

How to use your Peak Flow Meter (Hmong, Somali, Spanish)

How to use the Turbuhaler

Proven Pathways

Albuterol Refill


Living with Asthma Survey

Planned Visits

Pre-completed Asthma Action Plans



Environmental Assessment and Modification Tools

Environmental Focus Group Findings

Home Environmental Assessment Tool

EACH Project Evaluation Plan

Asthma Clinical Assessment, Symptom, and Quality of Life Baseline Survey

Home Environmental Baseline Assessment

Home Modification Sustainability Survey

Simple Steps to Remove Asthma Triggers in Your Home (Hmong, Somali, Spanish)

School Intervention Tools

Work Plan for Before and After School Training Pilot

Healthy Learners Asthma Initiative Year 2 Pilot—Evaluation Plan

Healthy Learners Asthma Initiative Year 3 Pilot—Evaluation Plan

St Paul Public Schools—Asthma Action Plan

Clinic-based Systems Change Initiative

Assessment of Current Asthma Care Worksheet

Chart Audit Form

Living with Asthma Survey (Spanish, Somali, Hmong)

Monthly Reporting Form

Clinic-based Systems Change Evaluation Plan

Primary Care Appointment Following an ED/UC Visit (short version)

Primary Care Appointment Following an ED/UC Visit (detailed version)

Asthma Billing Codes

Asthma Self Management Goals (developed by Hennipen County Healthcare for the Homeless)

Articles from Journal of Urban Health : Bulletin of the New York Academy of Medicine are provided here courtesy of New York Academy of Medicine
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