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The
following is an example of the evaluation form that can be created
using this system. This form includes 5 indicator statements taken
from the indicator list found at View
Life Skills.
SAMPLE
4-H
Science Camp Evaluation
We
want to know how well 4-H Science Camp works. We are asking you
to answer the following questions about what you may have learned
from being in 4-H Science Camp. It should take about 10 minutes
of your time to complete the survey. You do not have to fill out
this survey. If you decide not to fill out the survey, it will
not affect your participation in future U of I Extension
programs. Your answers will be anonymous and will not be identified
in any way. This means that no one will know how you have answered
any of the questions. Answering the questions means you have agreed
to participate in this evaluation. If you have any questions about
this survey or the evaluation, please contact Local Extension Office at (***) 555-1212
| Because
of my participation in 4-H Science Camp I am able to: |
Back
. . . before I
participated in 4-H Science Camp
|
Now
. . . after I have participated in 4-H Science Camp
|
| |
Circle
one number
for each statement
|
Circle
one number
for each statement
|
| |
No
|
Sometimes
|
Usually
|
Yes
|
No
|
Sometimes
|
Usually
|
Yes
|
| 1.
Wisely use the natural resources in my environment. |
1
|
2
|
3
|
4
|
1
|
2
|
3
|
4
|
|
2. Listen carefully to what others say. |
1
|
2
|
3
|
4
|
1
|
2
|
3
|
4
|
|
3. Treat people who are different from me with respect. |
1
|
2
|
3
|
4
|
1
|
2
|
3
|
4
|
|
4. Work out problems that are presented to me. |
1
|
2
|
3
|
4
|
1
|
2
|
3
|
4
|
|
5. Follow instructions as they are given me. |
1
|
2
|
3
|
4
|
1
|
2
|
3
|
4
|
| 6.
Follow instructions as they are given me. |
1
|
2
|
3
|
4
|
1
|
2
|
3
|
4
|
|
Tell
us about yourself.
(Check one response to each question). |
|
1.
My age falls in the following group:
___11-13
___14-17
___18-25
___26-35
___36-45
___46-55
___55+
|
2.
I am:
___female
___male
|
3.
My current home is:
___farm
___rural non-farm
___town under 50,000
___city over 50,000
|
4.
I would describe myself as:
___African
American
___American Indian
___Asian American
___Hispanic
___White/Caucasian
___Racially mixed
|
1.
The most important thing I have gained from attending 4-H Science
Camp is...
2.
The one thing, if anything, I would change about 4-H Science Camp
is...
3.
Other comments I would like to make...
|
