First Post-Test Survey

Form Approved OMB No. 0990-XXXX Exp. Date XX/XX/XX11

AGENCY POST-SURVEY

Instructions: Please complete this survey at the end of each eight-week program.
Thank you for your help!
1.

What types of things did you do to disseminate information about the program?
(Please check all that apply.)
❏ Distributed written information (flyers, brochures, etc.)
❏ Out information on the agency website or other websites
❏ Set up tables or booths at agency or other events
❏ Spoke at meetings
❏ Sent e-mails to colleagues
❏ Other (please describe): ______________________________________________________________________

2.

What methods did you use to recruit youth with disabilities to the program? Please briefly
describe each method and then, looking back, give us your opinion on how effective it was —
how well it worked.
A.

________________________________________________________________________
________________________________________________________________________

B.

❏ Not Effective
❏ Somewhat Effective
❏ Very Effective
________________________________________________________________________
________________________________________________________________________
❏ Not Effective

C.

❏ Somewhat Effective

❏ Very Effective

________________________________________________________________________
________________________________________________________________________
❏ Not Effective

D.

❏ Somewhat Effective

❏ Very Effective

________________________________________________________________________
________________________________________________________________________
❏ Not Effective

❏ Somewhat Effective

❏ Very Effective

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0990- XXXX. The time required to complete this information
collection is estimated to average XX hours or xx minutes per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s)
or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, ASRT/OCIO/PRA, 200 Independence Ave.,
S.W., Suite 531-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.

3.

What methods did you use to recruit mentors to the program? Please briefly describe each
method and then, looking back, give us your opinion on how effective it was - how well it worked.
A.

_________________________________________________________________________
_________________________________________________________________________
❏ Not Effective
❏ Somewhat Effective
❏ Very Effective

B

_________________________________________________________________________
_________________________________________________________________________
❏ Not Effective
❏ Somewhat Effective
❏ Very Effective

C.

_________________________________________________________________________
_________________________________________________________________________
❏ Not Effective
❏ Somewhat Effective
❏ Very Effective

D.

_________________________________________________________________________
_________________________________________________________________________
❏ Not Effective
❏ Somewhat Effective
❏ Very Effective

4.

How much of a problem was each of the following in the planning and implementation of
this eight-week implementation of the program?
No problem

A little bit of a
problem

A major
problem

Recruiting youth with disabilities (mentees)

❏

❏

❏

Disseminating information about the program

❏

❏

❏

Recruiting mentors
Keeping in touch with mentors on a regular basis

❏

❏

❏

Transportation for mentors or participants

❏

❏

❏

Lack of good resources on physical activities

❏

❏

❏

Lack of good resources on nutrition`

❏

❏

❏

Keeping mentors motivated

❏

❏

❏

Keeping mentees motivated

❏

❏

❏

Keeping track of program forms (registration
forms, surveys, etc.)
Completing background checks on mentors

❏

❏

❏

❏

❏

❏

❏

❏

Other:

❏ Not useful

❏ Somewhat Useful

❏ Very Useful

5.

How useful was the program
(agency) manual?

6.

What is the one thing we could do to improve the program manual?

7.

How useful was the program
Web site?

8.

What is the one thing we could do to improve the program web site?

9.

How well did the agency coordinator orientation prepare you for your role?
❏ Not at all well

10.

❏ Not useful

❏ Somewhat Well

❏ Well

❏ Somewhat Useful

❏ Very Well

What is the one thing we could do to improve the orientation?

❏ Very Useful

11.

In general, how much of a change would you say there has been in your knowledge of the
things listed below based on your involvement in the program?
No Change

I Know More

I Know Much
More

The importance of physical activity

❏

❏

❏

Activities youth with disabilities can do to become
more physically active
The importance of good nutritional habits
What good nutrition means in terms of eating
habits
Other:

❏

❏

❏

❏

❏

❏

❏

❏

12.

Overall, how would you describe your experience as an agency coordinator? (e.g. what
did you like about it? Would you do it again?)

13.

What is the one essential thing that we could do to improve this Program in the future?

THANK YOU FOR COMPLETING THIS FORM!