Student health has a profound effect upon student academic performance. In 1994, with a focus on increasing student achievement, the Public Education Network (PEN) began working with the Centers for Disease Control and Prevention, Division of Adolescent and School Health (CDC/DASH) to integrate coordinated school health programs (CSHPs) into a larger, systemic school reform effort at the local and national levels. PEN provided funding and technical assistance to five local education funds (LEFs) to implement projects that would create, enhance, and/or institutionalize school health programs within their districts. This report -- the last of a four-part series -- looks at the process of institutionalization based on a model developed by PEN in collaboration with the five LEFs. A major component of this work involved engaging public support by clearly articulating the need for, and value of, comprehensive school health programs. Through the Comprehensive School Health Initiative (CSHI), PEN and LEFs are linking school health and school reform through the critical issue of school and adolescent health which includes HIV prevention as a major focus. This report looks at some of the indicators for institutionalization used by the LEFs in order to sustain their activities in establishing and enhancing comprehensive school health programs in their schools and communities.