Life Skills Evaluation System

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 Life Skills, Jr.
We want to know how well Sample Junior works. We are asking you to tell us some things about yourself, now and then after you participate in Sample Junior. It should take about 10 minutes of your time to complete the survey. You do not have to fill out this survey. Your parents know we are going to ask you about these things, but you get to make the final choice. It is up to you if you want to answer the questions or not. There is no right or wrong answer to any of our questions. You don’t have to answer any question you don’t want to answer. If you decide not to fill out the survey, you can still be in ABC Program or any other program we have for you. Every answer will be private. We won’t tell your parents or anyone else how you answered the question. When we tell other people about what we learned, we won’t tell them your name or the name of anyone else who answered the questions. You can ask us questions anytime and you can talk to your parent any time you want. Thank you.

	Circle one number for each statement
	Never	Sometimes	Usually
DECISION MAKING
1. I think about my choices before making a decision.	1	2	3
2. I think about what might happen because of my choice.	1	2	3
WISE USE OF RESOURCES
3. I recycle at home or at school.	1	2	3
COMMUNICATION
4. I tell people how I feel when they hurt my feelings.	1	2	3
HEALTHY LIFESTYLE CHOICES
5. I wear a safety helmet when riding a bike, using a skateboard or roller blades.	1	2	3

Tell us about yourself.

I am _______ years old.

I am in   3rd grade   4th grade   5th grade

I am a   girl   boy

My current home is: ____ farm ____ rural non-farm ____ town under 50,000 ____ city over 50,000

I would describe myself as: ____ African American ____ American Indian ____ Asian/Pacific Islander ____ Hispanic ____ White/Caucasian ____ Multi-racial

THANK YOU!!!