Sample Senior Evaluation Form
(download a Word copy)
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, Sr.
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 WSU 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. You may stop completing the survey at any time. If you have questions
you can ask the program coordinator at anytime. Thank you for your help.
|
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
|
|
Tell us about yourself. (Check one response to each question).
|
|
1. My age falls in the following group:
___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
___Multi-racial
|
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...
