1. I like coming to this program
please choose
5. Agree Strongly
4. Agree
3. Neutral
2. Disagree
1. Disagree Strongly
2. The adults in this program treat all youth fairly.
please choose
5. Strongly Agree
4. Agree
3. Neutral
2. Disagree
1. Strongly Disagree
3. I feel safe when I am at this program.
please choose
5. Strongly Agree
4. Agree
3. Neutral
2. Disagree
1. Strongly Disagree
4. Youth at this program respect each other.
please choose
5. Strongly Agree
4. Agree
3. Neutral
2. Disagree
1. Strongly Disagree
5. The people who work at this program understand my familyâs culture.
please choose
5. Strongly Agree
4. Agree
3. Neutral
2. Disagree
1. Strongly Disagree
6. When I need help, I find someone to talk with.
please choose
5. Strongly Agree
4. Agree
3. Neutral
2. Disagree
1. Strongly Disagree
7. There is an adult in this program who notices when I am upset about something.
please choose
5. Strongly Agree
4. Agree
3. Neutral
2. Disagree
1. Strongly Disagree
8. I do interesting activities at this program.
please choose
5. Strongly Agree
4. Agree
3. Neutral
2. Disagree
1. Strongly Disagree
9. At this program, I get the opportunity to talk about what Iâm learning.
please choose
5. Strongly Agree
4. Agree
3. Neutral
2. Disagree
1. Strongly Disagree
10. At this program, I make choices about what I will do when I am here.
please choose
5. Strongly Agree
4. Agree
3. Neutral
2. Disagree
1. Strongly Disagree
11. The adults in this program tell me when I do a good job.
please choose
5. Strongly Agree
4. Agree
3. Neutral
2. Disagree
1. Strongly Disagree
12. The adults in this program believe I will become a success.
please choose
5. Strongly Agree
4. Agree
3. Neutral
2. Disagree
1. Strongly Disagree
13. I have been asked for my opinion about how to make this program better.
please choose
5. Strongly Agree
4. Agree
3. Neutral
2. Disagree
1. Strongly Disagree
14. The adults in this program listen to me when I need to talk.
please choose
5. Strongly Agree
4. Agree
3. Neutral
2. Disagree
1. Strongly Disagree
15. This program helps me feel more confident about my school work.
please choose
5. Strongly Agree
4. Agree
3. Neutral
2. Disagree
1. Strongly Disagree
16. In this program, I do things that really make me think.
please choose
5. Strongly Agree
4. Agree
3. Neutral
2. Disagree
1. Strongly Disagree
17. I am asked to help lead activities at this program.
please choose
5. Strongly Agree
4. Agree
3. Neutral
2. Disagree
1. Strongly Disagree
18. There is an adult at this program that really cares about me.
please choose
5. Strongly Agree
4. Agree
3. Neutral
2. Disagree
1. Strongly Disagree
19. What would you be doing if you did not come to this program? (please check all that may apply):
(please check all that may apply):
(1) Go home or to another home (such as a friend, relative or neighborâs house, with an adult there)
(2) Go home or another home, without an adult there
(3) Go to a park or recreation program
(4) Go to participate in a community, volunteer, or church group
(5) Go to another after school program
(6) Go somewhere not on my school campus to take a class or lessons in something like art, music, or dance
(7) Go somewhere not on my school campus to play or practice a sport
(8) Go to my job
(9) Go some other place
(10) Stay at school for an extra class, tutoring, or activity such as band, sports, or a club
(11) Other (specify below)
19 cont: Explain, if you listed "other" or need to provide more explanation:
20. What do you think is the most important thing that should be done to improve the program? Please be as specific as you can.
21. How old are you?
22. What is your home ZIP Code?
23. Please indicate your gender
please choose
1. Male
2. Female
3. Transgender
24. Please check all the boxes that describe your race or ethnicity.
please choose all that apply:
(1) African American
(2) Other Black (specify below)
3) Asian - Chinese
(4) Asian - Filipino
(5) Asian - Indian
(6) Asian - Japanese
(7) Asian - Korean
(8) Asian - Laotian
(9) Asian - Thai
(10) Asian - Vietnamese
(11) Asian - Other (specify below)
(12) Hispanic/Latino - Mexican/Mexican
(13) Hispanic/Latino - Central American
(14) Hispanic/Latino - South American
(15) Hispanic/Latino - Caribbean
(16) Hispanic/Latino - Other
(17) Middle Eastern - Arab
(18) Middle Eastern - Iranian
(19) Middle Eastern - Other
(20) Native American
(21) Native Alaskan
(22) Pacific Islander - Guamanian
(23) Pacific Islander - Hawaiian
(24) Pacific Islander - Tongan
(25) Pacific Islander - Samoan
(26) Pacific Islander - Other
(27) White
(28) Multiracial/Multiethnic
(29) Other (specify)
30) Decline to state
24 cont. Explain "other" or mixed ethnicities, etc (optional)