1 LASSIE Survey K12 HED CBO

2010-2011 Program and Performance Measurement Report

K-12, HED, CBO Grants

Please fill out all relevant sections of this form completely.

The Grant Profile Information (pages 4-5 of this form) should be completed by any organization receiving Learn and Serve America funds (grantees, subgrantees, organizations receiving grants from subgrantees).

The Program Reporting Form (beginning on page 6) should be completed by Learn and Serve America grantees, subgrantees, and sub-subgrantees that directly operate Learn and Serve America supported service-learning programs and/or service-learning training and technical assistance activities. Respondents will be directed to the relevant sections of the Program Reporting Form based on their responses to the Grant Profile section.

The questions on this form refer to the July 1, 2010 – June 30, 2011 program year.

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Privacy Act Statement

AUTHORITY: In accordance with the Privacy Act of 1974 (5 U.S.C § 552a) the following information is provided.

PURPOSE: The primary purpose of the user account is to provide a means for the Corporation for National and Community Service to collect and report on the activities of Learn and Serve America funded-programs. The collection of this information is authorized by the National and Community Service Act, as amended by the National and Community Service Trust Act of 1993.

ROUTINE USES: These routine purposes may include disclosure of the information to federal, state, or local agencies pursuant to lawfully authorized requests.

• All information collected will be made available to the Corporation, any intermediary grantor of your Learn and Serve funds, if applicable, and federal, state, or local agencies pursuant to lawfully authorized requests;

• Used as a basis for summaries, briefings, or responses to Members of Congress or other agencies in the Executive Branch of the Federal Government;

• Provided to Congress or other Federal, State, and local agencies, when determined necessary.

MANDATORY OR VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL NOT PROVIDING INFORMATION:

All non-personally identifiable information may be provided to the public. Personally identifiable information will not be provided to any other organizations without your prior written permission.

Additionally, disclosure of LASSIE data through the Open Government Initiative will be available to the public.

ACKNOWLEDGMENT:

I understand the provisions of the Privacy Act of 1974 as related to me through the foregoing statement.

CONTENT

I.Grant Profile	3
II.Program Performance Report	5
A.Program Participants and Activities	5
1.K-12 Individual School Version	6
2.K-12 Multiple Schools Version	15
3.Higher Education Version	24
4.Community-Based Version	33
B.Institutional Supports for Service-Learning	41
1.Individual School	42
2.School District	47
3.Higher Education Institution	52
4.Community-Based Organization	57
C.Training and Technical Assistance	61

I. Grant Profile

Organization

Grant ID number: PREASSIGNED

Organization/School Name:

Organization/School Nickname:

Grant Amount: PROVIDED BY GRANTING INSTITUTION

Organization Location

School District (if applicable):

Website (if any):

Street Address 1:

Street Address 2:

City:

State:

Zip plus four:

Contacts (You may enter additional contacts as needed)

Primary Contact Person:

Prefix:

First Name:

Last Name:

Title:

Email:

Telephone:

Fax:

1. Select the organizational type that best describes your organization.

K-12 District	Higher Education		Community-Based Organization
 School District	 2 Year Public College		 National Nonprofit Organization
 Regional Education Agency	 2 Year Private College		 State or Regional Nonprofit
 State Education Agency	 4 Year Public College or University		 Local Nonprofit
K-12 School	 4 Year Private College or University		 State Service Commission
 Public School	 Graduate/Professional Program
 Private School	 Higher Education Association
 Public Charter School
 Indian/Tribal School

1a. If you are a higher education institution, please indicate if your college or university is a: (Definitions of the following institution types can be found in the US Department of Education’s Higher Education Act)

 Historically Black College/ University	 Native-American Serving (Non-Tribal) Institution	 Alaska Native Serving Institution
 Predominately Black Institution	 Tribally Controlled College/University	 Asian American and Pacific Islander Serving Institution
 Hispanic Serving Institution	 Native Hawaiian Serving Institution	 Predominately Minority Population Community College

2. Is your organization religious or faith-based?

 Yes  No  Don’t Know

3. Please indicate which of the following activities you performed during the 2010-2011 program year using Learn and Serve America grant funds:

My institution or organization ran Learn and Serve America supported service-learning activities. (Note: Answering yes to this question indicates that you will report on participants and service-learning activities for this program year.) [Positive respondents are directed to complete questions under Program Participants and Activities and Institutional Supports for Service-Learning sections of the Program Reporting Form.]	 Yes	 No
My institution or organization used Learn and Serve America funds to provide (directly or through a third party) training and technical assistance for service-learning activities. [Positive respondents are directed to complete questions under Training and Technical Activities Section of the Program Reporting Form.]	 Yes	 No
My institution or organization subgranted Learn and Serve America funds to other institutions or organizations. [Positive respondents are directed to complete question 5 of the Grant Profile.]	 Yes	 No

4. Would you like to enable E-Worksheets? The E-Worksheets function is an optional tool for administrators and facilitators to maintain electronic records for certain collected data elements of the survey (e.g. participant counts and demographics). E-Worksheets can be sent to service-learning providers to record details on the service-learning activities. Data collected from E-Worksheets can be reviewed and automatically imported into your survey. For more information on the E-Worksheets, visit the LASSIE on-line help page.

 Yes  No

5. If you provided subgrants, please list all of the institutions or organizations to which you make grants of Learn and Serve America funds. For each, please provide the name of the organization, the size of the grant, and contact information for the lead contact person for the programs. Please note, do not include mini-grants or grants to individuals within your institution, or small grants to individuals (for example, training stipends) in other institutions.

Institution/ Organization	Grant Size (Dollars)	Address	Contact Person	Telephone/ Fax	Email

End of Grant Profile Questions

II. Program Reporting Form

A. Program Participants and Activities

There are four versions of this section of the survey. Respondents are directed to respond to the appropriate version based on the type of Learn and Serve America grant funds they received. Those who received K-12 School-Based grant funds and operate service-learning in a single school are directed to complete the K-12 Individual School form; those who received K-12 School-Based funds and operate service-learning in multiple schools are directed to complete the K-12 Multiple Schools form; those who received Higher Education grant funds are directed to complete the Higher Education form; and those who received Innovative and Community-Based grant funds (with the exception of special initiatives, such as Summer of Service and Youth Engagement Zones) are directed to complete the Community-Based form. NOTE: Recipients of special initiatives under Innovative and Community-Based grant funds are directed to complete distinct surveys. The on-line reporting system automatically identifies the appropriate form type based on the respondents’ grant numbers.

II-A: K-12 Individual School Version

1. Are you reporting on Learn and Serve America supported service-learning activities in an individual school or multiple schools? [This is a screening question to determine which version of the K-12 Formula survey the respondent completes.]

 Individual School  Multiple Schools

I. Organizational Questions

2. What grade levels are included in the school? Lowest grade _____ Highest grade _____

3. What percentage of students in the school qualifies for free or reduced price lunch? _______%

4. Institution size: provide the total number of students in the school.

Total Number of Students

5. Approximately what percentage of students in the school were engaged in service-learning activities during the 2010-2011 academic year. Include all service-learning activities whether or not they were supported by Learn and Serve America grant funds.

 Less than 10%

 10-49%

 50-89%

 90-99%

 100%

 Don’t Know

6. Approximately what percentage of service-learning activities occurs during the following periods? Note: Percentages should add to 100%.

	Percent	Don’t Know
In-school time		
Extracurricular programs
After-school programs

II. Service-Learning Participants

In this section we are interested in the individuals who have participated in Learn and Serve America supported service-learning programs and activities.

7. P

   Note: For the purpose of this survey, a service-learner is a student, between the ages of 5 and 17, who participates in service-learning programs or activities that engage him or her in learning activities, assessment and reflection, and direct or indirect service to beneficiaries. Service-learning programs and activities include preparation and reflection, as well as direct service. Youth or adults engaged in one-time volunteer activities, as well as beneficiaries of the service-learning activities, should not be counted as service-learners.

   lease provide demographic information on the service-learners who were engaged in Learn and Serve America supported activities from July 1, 2010 to June 30, 2011. If you have no students in a given category, enter “0” in the relevant box.

Learn and Serve America Supported Service-Learners	Estimated Number of Service-Learners
Total number of individual service-learners in Learn and Serve America supported activities/programs

Grade Level of Learn and Serve America Service-Learners	Estimated Number of Service-Learners
K - 5th grade
6th grade – 8th grade
9th grade – 12th grade
School Dropouts
Grade Unknown

Ethnic Background of Learn and Serve America Service-Learners	Estimated Number of Service-Learners
Hispanic
Non-Hispanic
Ethnicity Unknown

Racial Background of Learn and Serve America Service-Learners	Estimated Number of Service-Learners
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or More Races
Race Unknown

Gender of Learn and Serve America Service-Learners	Estimated Number of Service-Learners
Male
Female
Gender Unknown

Learn and Serve America Service-Learners with Disabilities	Estimated Number of Service-Learners
Service-learners with disabilities

Learn and Serve America Service-Learners Serving in Summer Service-Learning Programs	Estimated Number of Service-Learners	Do Not Have Summer Programs
Service-learners serving in summer programs		

Teacher and Staff Participation in Service-Learning

III.How many teachers and staff were involved in teaching, leading, and operating Learn and Serve America supported service-learning programs in the school this year? Count each teacher and staff, regardless of part-time or full-time status.

_______ Total number of teachers and staff

Additional volunteers

8. Approximately how many K-12 youth volunteers (defined as youth 5-17 years old) were involved in Learn and Serve America supported service activities (i.e. one-time volunteers or volunteers recruited for service-learning activities). Do not include regular service-learners reported above.

_______ Estimated number of youth volunteers  Don’t Know

9. Approximately how many adult volunteers (defined as 18 or older) were involved in Learn and Serve America supported service-related activities (i.e. one-time volunteers or volunteers recruited for service-learning activities). Do not include staff and teachers reported above.

_______ Estimated number of adult volunteers  Don’t Know

10a. Approximately how many of these adult volunteers are 55 years or older?

_______ Estimated number of adult volunteers 55 and older  Don’t Know

III. Beneficiaries

IV.How many youth from disadvantaged circumstances received services through the Learn and Serve America supported service-learning activities during the 2010-2011 program year? Youth from disadvantaged circumstances are defined as those youth who are economically disadvantaged and one or more of the following: (a)are out-of-school, including out-of-school youth who are unemployed; (b) are in or aging out of foster care; (c) have limited English proficiency; (d) are homeless or have run away from home; (e) are at-risk to leave secondary school without a diploma; (f) are former juvenile offenders or at risk of delinquency; (g) are individuals with disabilities.

______ Estimated Number  Don’t Know

10. Approximately how many youth (ages 5-17) were mentored through the Learn and Serve America supported service-learning activities?

_____ Estimated Number  Don’t Know  Do not have mentoring activities (skip to question 13)

12a. Approximately how many of those mentored are from disadvantaged circumstances (see definition above)?

______ Estimated Number  Don’t Know

11. Approximately how many youth (ages 5-17) were tutored through the Learn and Serve America supported service-learning activities?

_____ Estimated Number  Don’t Know  Do not have tutoring activities (skip to question 14)

13a. Approximately how many of those tutored are from disadvantaged circumstances (see definition above)?

______ Estimated Number  Don’t Know

IV. Program Duration and Service-Learning Characteristics

12. This question is designed to gather information on the duration of Learn and Serve America service-learning activities in the school and the amount of time students are engaged in preparation, reflection, and service. Please fill in the table below with the numbers of service-learners and average hours of preparation and service. If you do not run projects for any of the three durations, check “Do Not Run.” If you don’t know the number of service-learners and average hours for any of the three durations, check “Don’t Know.”

Instructions for completing table on service hours

1. First, estimate the number of service-learners who were in service-learning programs of the durations listed in the table below from July 1, 2010 to June 30, 2011. If you have more than one activity or program in a given duration, please combine them in reporting participant numbers and hours. The total number of service-learners reported for this question may not equal the total number of service-learners reported in question 7 if individuals participated in more than one service-learning activity.

2. Next, for each of the project durations, calculate the average hours of preparation for the service and formal reflection per service-learner during or after the service and enter that figure in column 3.

3. Finally, enter the average number of hours of service for a service-learner. Enter that figure in column 4.

• Preparation activities might include conducting background research, collecting data, attending trainings, assembling materials, rehearsing parts, and meeting to plan project activities during and after class.

• Formal reflection activities might include classroom discussions, keeping a journal, writing an essay or a poem, and making a class presentation.

• Service might include a variety of activities, including the following: providing direct service to individuals (tutoring, assisting at a human services agency, working in a classroom, etc.); service projects addressing a community need (for example, cleaning a park, raising money for a local program, monitoring local water quality), or educational efforts such as presenting a play on a community issue, organizing or testifying at a public hearing, or preparing educational materials (brochures, posters, etc.) on a local issue.

Example 1. The “Plant a Tree Project” lasted 2 months and involved 60 students (see ‘a’ in the table below). The average student in this project spent 8 hours engaged in preparation for the service and in formal reflection activities during and after the service (see ‘b’). The service activity itself took approximately 2 hours per student (see ‘c’).

Example 2: The senior Civics Class is organized around a core service-learning program. It meets one hour, two days a week for one semester, and has 25 students (see ‘d’). Each student in this class spent 63 hours engaged in service-learning preparation for the service and formal reflection during and after the service (see ‘e’). The service activity itself was 10 hours (see ‘f’). (Calculation: 2 hours of class + 1 hour of preparation + .5 hours of formal reflection x 18 weeks = 63 hours per student; 10 hours of service per student).

EXAMPLES

Duration	Do Not Run This Type of Program	Number of Service-Learners	Average Hours of Preparation and/or Formal Reflection per Service-Learner	Average Hours of Service per Service-Learner	Do Not Know
Programs and activities that last 2 months or less		a. 60 students	b. 8 hours each	c. 2 hours each
Programs and activities that last for most or all of one semester or term		d. 25 students	e. 63 hours each	f. 10 hours each
Programs and activities that last for most or all of the whole school year

[End of pop-up instruction page]

PLEASE FILL IN

Duration	Do Not Run This Type of Program	Number of Service-Learners	Average Hours of Preparation and/or Formal Reflection per Service-Learner	Average Hours of Service per Service-Learner	Do Not Know*
Programs and activities that last approximately 2 months or less
Programs and activities that last for most or all of one semester or term
Programs and activities that last for most or all of the whole school year

* If DO NOT KNOW – instruction will pop up: “If you do not know, please estimate the number of hours you expect someone to spend.”

V. Project Characteristics

13. How frequently do the Learn and Serve America supported service-learning activities in the school include the following characteristics?

	Never (0%)	Less than 50% of the time	More than 50% of the time	Always (100%)	N/A
Service-learners participate in a community needs assessment to plan the service-learning project				
The service-learning activities are of a sustained and significant duration (i.e. concentrated blocks of time over a period of several months)				
The learning objectives for the service-learning activities are aligned with the academic curriculum					
The service-learning activities are included in student records					
Community partners collaborate in setting goals and establishing an action plan				
Service-learners generate ideas and make decisions on the design and implementation of the service-learning project				
Service-learners present their findings from the service-learning project to community members				
Service-learners engage with diverse perspectives through the service-learning project				
Service-learners examine the broader social and civic context for the identified community need				
The project includes a variety of reflection activities that examine changes in service-learners’ knowledge and attitudes				
Service-learners measure their progress toward meeting specific service goals and learning outcomes during the project				
The service activities present opportunities for the participants to apply newly acquired skills and knowledge to a community need				

VI. Community Needs and Service Activities

Issue Areas and Community Needs

14. This question is designed to gather information on the types of community needs that the Learn and Serve America supported service-learning activities have been designed to address. The community needs have been categorized into ten general issue areas. For each issue area, provide the percentage of the service-learning activities that address the relevant issue area. If there are no service activities that address a given area, leave the % field blank (do not enter “0”). For each area with activities, check up to three of the most common types of community needs being addressed by the activities.

Community Development ____ % of service activities

 Civic/Public Infrastructure	 Homeless Assistance	 Transportation
 Community Clean-up	 Social Services Planning/Delivery	 Volunteer Capacity/Management
 Historic Preservation	 Animal Care Services	 Independent Living Assistance
		 Other Community Development (specify)

Economic Development ____ % of service activities

 Financial Literacy	 Workforce Development	 Financial Asset Development
 Economic Revitalization	 Technology Access	 Other Economic Development (specify)

Disaster Recovery and Relief ____ % of service activities

 Disaster Mitigation	 Disaster Recovery	 Other Disaster (specify)
 Disaster Preparedness	 Disaster Relief

Education ____ % of service activities

 Adult Literacy	 Computer Literacy	 Special Education Programs
 After School Programs	 English Language Learning	 Classroom Education
 Child Literacy	 Job Preparedness	 Cultural Heritage
	 School Preparedness	 Other Education (specify)

Environment and Energy ____ % of service activities

 Clean Air	 Environmental Protection	 Waste Reduction/Recycling
 Clean Water	 Environmental Restoration	 Weatherization
 Energy Conservation	 Indoor Environment	 Environmental Awareness
		 Other Environment (specify)

Health & Wellness/Nutrition _____ % of service activities

 Disabilities Services	 HIV/AIDS Prevention	 Nutrition Education
 Food Distribution/Collection	 Health & Wellness Education	 Substance Abuse Prevention/Rehabilitation
 Food Production	 Maternal/Child Health Services	 Aid to Seniors/Elders
 Health Service Delivery	 Mental Health Services	 Other Health/Nutrition (specify)

Public Safety ____ % of service activities

 Accident Prevention	 Crisis Intervention	 Victim/Witness Services
 Community Policing	 Fire Prevention	 Public Safety Education
 Conflict Resolution/Mediation	 Legal Assistance	 Crime Awareness/Prevention
 Offender/Ex-Offender Services/Rehabilitation	 Children and Youth Safety	 Other Public Safety (specify)

Youth Development ____ % of service activities

 Children and Youth Safety	 Juvenile Justice Services	 Bullying Prevention
 Delinquency Prevention	 Teen Pregnancy/Parenting Services	 Other Youth Development (specify)
 Gang Prevention/Rehabilitation	 Youth Leadership Development

Veterans Assistance ____ % of service activities

 Housing Assistance	 Military Family Assistance	 Veteran Employment Services
 Outreach and Counseling	 Veteran Disabilities/ Rehabilitation Assistance	 Other Veterans (specify)

Service Activities

15. (For the most common issue area, or the issue area with the highest percentage of activities in question 16) Please provide a brief description (200 word limit) the specific service-learning activities that were used in addressing the community need. In the description, include the goals of the project, the participants and beneficiaries involved, the location of the service-learning activities, and any measured outcomes.

(Note: You only need to provide activities for the most common community need. If desired, you may select a different community need or provide a description of service activities for more than one community need.)

II-A: K-12 Multiple Schools Version

1. Are you reporting on Learn and Serve America supported service-learning activities in an individual school or multiple schools? [This is a screening question to determine which version of the K-12 Formula survey the respondent completes.]

 Individual School  Multiple Schools

I. Organizational Questions

When answering the following questions, include all of the schools that had Learn and Serve America supported service-learning activities.

2. In how many schools are the Learn and Serve America supported service-learning activities taking place during the 2010-2011 program year?

_____ Elementary schools _____ Middle schools _____ Secondary schools

3. What grade levels are included in the schools with Learn and Serve America supported service-learning activities?

Lowest grade _____ Highest grade _____

4. On average, what percentage of students in the schools is qualified for free or reduced price lunch?

_______%

5. Institution size: provide the total number of students in all of the schools with Learn and Serve America supported service-learning activities.

Total Number of Students

6. Approximately what percentage of students in the schools were engaged in service-learning activities during the 2010-2011 academic year. Include all service-learning activities whether or not they were supported by Learn and Serve America grant funds.

 Less than 10%

 10-49%

 50-89%

 90-99%

 100%

 Don’t Know

7. Approximately what percentage of service-learning activities in the schools occurs during the following periods? Note: Percentages should add to 100%.

	Percent	Don’t Know
In-school time		
Extracurricular programs
After-school programs

II. Service-Learning Participants

In this section we are interested in the individuals who participate in Learn and Serve America service-learning programs and activities.

8. P

   Note: For the purpose of this survey, a service-learner is a student, between the ages of 5 and 17, who participates in service-learning programs or activities that engage him or her in learning activities, assessment and reflection, and direct or indirect service to beneficiaries. Service-learning programs and activities include preparation and reflection, as well as direct service. Youth or adults engaged in one-time volunteer activities, as well as beneficiaries of the service-learning activities, should not be counted as service-learners.

   lease provide demographic information on the service-learners who were engaged in Learn and Serve America supported activities from July 1, 2010 to June 30, 2011. If you have no students in a given category, enter “0” in the relevant box.

Learn and Serve America supported Service-Learners	Estimated Number of Service-Learners
Total number of individual service-learners in Learn and Serve America supported activities/programs

Grade Level of Learn and Serve America Service-Learners	Estimated Number of Service-Learners
K - 5th grade
6th grade – 8th grade
9th grade – 12th grade
School dropouts
Grade unknown

Ethnic Background of Learn and Serve America Service-Learners	Estimated Number of Service-Learners
Hispanic
Non-Hispanic
Ethnicity Unknown

Racial Background of Learn and Serve America Service-Learners	Estimated Number of Service-Learners
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or more races
Race Unknown

Gender of Learn and Serve America Service-Learners	Estimated Number of Service-Learners
Male
Female
Gender Unknown

Learn and Serve America Service-Learners with Disabilities	Estimated Number of Service-Learners
Service-learners with disabilities

Learn and Serve America Service-Learners Serving in Summer Service-Learning Programs	Estimated Number of Service-Learners	Do Not Have Summer Programs
Service-learners serving in summer programs		

Teacher/Staff Participation in Service-Learning

V.How many teachers and staff were involved in teaching, leading, and operating Learn and Serve America supported service-learning programs in the schools this year? Count each teacher and staff, regardless of part-time or full-time status.

_______ Total number of teachers and staff

Additional volunteers

9. Approximately how many K-12 youth volunteers (defined as youth 5-17 years old) were involved in Learn and Serve America supported service activities (i.e. one-time volunteers or volunteers recruited for service-learning activities). Do not include regular service-learners reported above.

_______ Estimated number of youth volunteers  Don’t Know

10. Approximately how many adult volunteers (defined as 18 or older) were involved in Learn and Serve America supported service-related activities (i.e. one-time volunteers or volunteers recruited for service-learning activities). Do not include staff and teachers reported above.

_______ Estimated number of adult volunteers  Don’t Know

11a. Approximately how many of these adult volunteers are 55 years or older?

_______ Estimated number of adult volunteers 55 and older  Don’t Know

III. Beneficiaries

VI.How many youth from disadvantaged circumstances received services through the Learn and Serve America supported service-learning activities during the 2010-2011 program year? Youth from disadvantaged circumstances are defined as those youth who are economically disadvantaged and one or more of the following: (a)are out-of-school, including out-of-school youth who are unemployed; (b) are in or aging out of foster care; (c) have limited English proficiency; (d) are homeless or have run away from home; (e) are at-risk to leave secondary school without a diploma; (f) are former juvenile offenders or at risk of delinquency; (g) are individuals with disabilities.

______ Estimated Number  Don’t Know

11. Approximately how many youth (ages 5-17) were mentored through your Learn and Serve America supported service-learning activities?

_____ Estimated Number  Don’t Know  Do not have mentoring activities (skip to question 14)

13a. Approximately how many of those mentored are from disadvantaged circumstances (see definition above)?

______ Estimated Number  Don’t Know

12. Approximately how many youth (ages 5-17) were tutored through your Learn and Serve America supported service-learning activities?

_____ Estimated Number  Don’t Know  Do not have tutoring activities (skip to question 15)

14a. Approximately how many of those tutored are from disadvantaged circumstances (see definition above)?

______ Estimated Number  Don’t Know

IV. Program Duration and Service-Learning Characteristics

13. This question is designed to gather information on the duration of Learn and Serve America service-learning activities in the schools and the amount of time students are engaged in preparation, reflection, and service. Please fill in the table below with the numbers of service-learners and average hours of preparation and service. If you do not run projects for any of the three durations, check “Do Not Run.” If you don’t know the number of service-learners and average hours for any of the three durations, check “Don’t Know.”

Instructions for completing table on service hours

1. First, estimate the number of service-learners who were in service-learning programs of the durations listed in the table below from July 1, 2010 to June 30, 2011. If you have more than one activity or program in a given duration, please combine them in reporting participant numbers and hours. The total number of participants reported for this question may not equal the total number of participants reported in question 8 if individuals participated in more than one service-learning activity.

2. Next, for each of the project durations, calculate the average hours of preparation for the service and formal reflection per service-learner during or after the service and enter that figure in column 3.

3. Finally, enter the average number of hours of service for a service-learner. Enter that figure in column 4.

• Preparation activities might include conducting background research, collecting data, attending trainings, assembling materials, rehearsing parts, and meeting to plan project activities during and after class.

• Formal reflection activities might include classroom discussions, keeping a journal, writing an essay or a poem, and making a class presentation.

• Service might include a variety of activities, including the following: providing direct service to individuals (tutoring, assisting at a human services agency, working in a classroom, etc.); service projects addressing a community need (for example, cleaning a park, raising money for a local program, monitoring local water quality), or educational efforts such as presenting a play on a community issue, organizing or testifying at a public hearing, or preparing educational materials (brochures, posters, etc.) on a local issue.

Example 1. The “Plant a Tree Project” lasted 2 months and involved 60 students (see ‘a’ in the table below). The average student in this project spent 8 hours engaged in preparation for the service and in formal reflection activities during and after the service (see ‘b’). The service activity itself took approximately 2 hours per student (see ‘c’).

Example 2: The senior Civics Class is organized around a core service-learning program. It meets one hour, two days a week for one semester, and has 25 students (see ‘d’). Each student in this class spent 63 hours engaged in service-learning preparation for the service and formal reflection during and after the service (see ‘e’). The service activity itself was 10 hours (see ‘f’). (Calculation: 2 hours of class + 1 hour of preparation + .5 hours of formal reflection x 18 weeks = 63 hours per student; 10 hours of service per student).

EXAMPLES

Duration	Do Not Run This Type of Program	Number of Service-Learners	Average Hours of Preparation and/or Formal Reflection per Participant	Average Hours of Service per Participant	Do Not Know
Programs and activities that last 2 months or less		a. 60 participants	b. 8 hours each	c. 2 hours each
Programs and activities that last for most or all of one semester or term		d. 25 students	e. 63 hours each	f. 10 hours each
Programs and activities that last for most or all of the whole school year

PLEASE FILL IN

Duration	Do Not Run This Type of Program	Number of Participants	Average Hours of Preparation and/or Formal Reflection per Participant	Average Hours of Service per Participant	Do Not Know
Programs and activities that last approximately 2 months or less
Programs and activities that last for most or all of one semester or term
Programs and activities that last for most or all of the whole school year

* If DO NOT KNOW – instruction will pop up: “If you do not know, please estimate the number of hours you expect someone to spend.”

V. Project Characteristics

14. How frequently do the Learn and Serve America supported service-learning activities in the schools include the following characteristics?

	Never (0%)	Less than 50% of the time	More than 50% of the time	Always (100%)	N/A
Service-learners participate in a community needs assessment to plan the service-learning project					
The service-learning activities are of a sustained and significant duration (i.e. concentrated blocks of time over a period of several months)					
The learning objectives for the service-learning activities are aligned with the academic curriculum					
The service-learning activities are included in student records					
Community partners collaborate in setting goals and establishing an action plan					
Service-learners generate ideas and make decisions on the design and implementation of the service-learning project					
Service-learners present their findings from the service-learning project to community members					
Service-learners engage with diverse perspectives through the service-learning project					
Service-learners examine the broader social and civic context for the identified community need					
The project includes a variety of reflection activities that examine changes in service-learners’ knowledge and attitudes					
Service-learners measure their progress toward meeting specific service goals and learning outcomes during the project					
The service activities present opportunities for the participants to apply newly acquired skills and knowledge to a community need					

VI. Community Needs and Service Activities

Issue Areas and Community Needs

15. This question is designed to gather information on the types of community needs that the Learn and Serve America supported service-learning activities have been designed to address. The community needs have been categorized into ten general issue areas. For each issue area, provide the percentage of the service-learning activities that address the relevant issue area. If there are no service activities that address a given area, leave the % field blank (do not enter “0”). For each area with activities, check up to three of the most common types of community needs being addressed by the activities.

Community Development ____ % of service activities

 Civic/Public Infrastructure	 Homeless Assistance	 Transportation
 Community Clean-up	 Social Services Planning/Delivery	 Volunteer Capacity/Management
 Historic Preservation	 Animal Care Services	 Independent Living Assistance
		 Other Community Development (specify)

Economic Development ____ % of service activities

 Financial Literacy	 Workforce Development	 Financial Asset Development
 Economic Revitalization	 Technology Access	 Other Economic Development (specify)

Disaster Recovery and Relief ____ % of service activities

 Disaster Mitigation	 Disaster Recovery	 Other Disaster (specify)
 Disaster Preparedness	 Disaster Relief

Education ____ % of service activities

 Adult Literacy	 Computer Literacy	 Special Education Programs
 After School Programs	 English Language Learning	 Classroom Education
 Child Literacy	 Job Preparedness	 Cultural Heritage
	 School Preparedness	 Other Education (specify)

Environment and Energy ____ % of service activities

 Clean Air	 Environmental Protection	 Waste Reduction/Recycling
 Clean Water	 Environmental Restoration	 Weatherization
 Energy Conservation	 Indoor Environment	 Environmental Awareness
		 Other Environment (specify)

Health & Wellness/Nutrition _____ % of service activities

 Disabilities Services	 HIV/AIDS Prevention	 Nutrition Education
 Food Distribution/Collection	 Health & Wellness Education	 Substance Abuse Prevention/Rehabilitation
 Food Production	 Maternal/Child Health Services	 Aid to Seniors/Elders
 Health Service Delivery	 Mental Health Services	 Other Health/Nutrition (specify)

Public Safety ____ % of service activities

 Accident Prevention	 Crisis Intervention	 Victim/Witness Services
 Community Policing	 Fire Prevention	 Public Safety Education
 Conflict Resolution/Mediation	 Legal Assistance	 Crime Awareness/Prevention
 Offender/Ex-Offender Services/Rehabilitation	 Children and Youth Safety	 Other Public Safety (specify)

Youth Development ____ % of service activities

 Children and Youth Safety	 Juvenile Justice Services	 Bullying Prevention
 Delinquency Prevention	 Teen Pregnancy/Parenting Services	 Other Youth Development (specify)
 Gang Prevention/Rehabilitation	 Youth Leadership Development

Veterans Assistance ____ % of service activities

 Housing Assistance	 Military Family Assistance	 Veteran Employment Services
 Outreach and Counseling	 Veteran Disabilities/ Rehabilitation Assistance	 Other Veterans (specify)

Service Activities

16. (For the most common issue area, or the issue area with the highest percentage of activities in question 17) Please provide a brief description (200 word limit) the specific service-learning activities that were used in addressing the community need. In the description, include the goals of the project, the participants and beneficiaries involved, the location of the service-learning activities, and any measured outcomes.

(Note: You only need to provide activities for the most common community need. If desired, you may select a different community need or provide a description of service activities for more than one community need.)

II-A: Higher Education Version

I. Organizational Questions

1. Institution size: provide the total number of students in the higher education institution.

Total Number of Students

2. Approximately what percentage of students in the higher education institution was engaged in service-learning activities during the 2010-2011 academic year. Include all service-learning activities whether or not they were supported by Learn and Serve America grant funds.

 Less than 10%

 10-49%

 50-89%

 90-99%

 100%

 Don’t Know

3. Approximately what percentage of service-learning activities occurs during the following periods? Note: Percentages should add to 100%.

	Percent	Don’t Know
Curricular courses		
Co-curricular/Extracurricular programs
Noncurricular academic activities

II. Service-Learning Participants

In this section we are interested in the individuals who participate in your Learn and Serve America supported service-learning programs and activities.

4. Please provide demographic information on the service-learners who were engaged in Learn and Serve America supported activities from July 1, 2010 to June 30, 2011. If you have no students in a given category, enter “0” in the relevant box.

Learn and Serve America Supported Service-Learners		Estimated Number of Service-Learners
Total number of higher education student service-learners in Learn and Serve America supported activities/programs
	Undergraduate student service-learners
	Graduate student service-learners
	Unknown
Total number of non-higher education student service-learners in Learn and Serve America supported activities/programs
	K – 5th grade
	6th grade – 8th grade
	9th grade – 12th grade
	School dropouts
	Grade unknown

Ethnic Background of Learn and Serve America Service-Learners	Estimated Number of Service-Learners
Hispanic
Non-Hispanic
Ethnicity Unknown

Racial Background of Learn and Serve America Service-Learners	Estimated Number of Service-Learners
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or more races
Race Unknown

Gender of Learn and Serve America Service-Learners	Estimated Number of Service-Learners
Male
Female
Gender Unknown

Learn and Serve America Service-Learners with Disabilities	Estimated Number of Service-Learners
Service-learners with disabilities

Learn and Serve America Service-Learners Serving in Summer Service-Learning Programs	Estimated Number of Service-Learners	Do Not Have Summer Programs
Service-learners serving in summer programs		

Faculty and Staff Participation in Service-Learning

VII.How many faculty and staff were involved in Learn and Serve America-funded service-learning activities in the higher education institution this year? Include faculty and staff who taught service-learning courses, participated in service-learning curriculum development, or otherwise assisted in the development and/or implementation of service-learning activities. Count each faculty and staff member, regardless of part-time or full-time status.

_______ Total number of faculty and staff

Adult Community Members

5. How many adult community members participated in Learn and Serve America supported service-learning activities? Community members include those involved in the planning and implementation of service-learning activities, such as staff from partner organizations. Do not include one-time volunteers or volunteers recruited for service-learning activities.

_______ Total number of faculty and staff

Additional Volunteers

6. Approximately how many youth volunteers (defined as youth 5-17 years old) were involved in Learn and Serve America supported service activities (one-time volunteers). Do not include service-learners reported above.

________ Estimated number of youth volunteers  Don’t Know

7. Approximately how many adult volunteers (defined as 18 or older) were involved in Learn and Serve America supported service-related activities (one-time volunteers). Do not include participants reported above.

________ Estimated number of adult volunteers  Don’t Know

8a. Approximately how many of these adult volunteers are 55 years or older?

_______ Estimated number of adult volunteers 55 and older  Don’t Know

III. Beneficiaries

VIII.How many youth from disadvantaged circumstances received services through the Learn and Serve America supported service-learning activities during the 2010-2011 program year? Youth from disadvantaged circumstances are defined as those youth who are economically disadvantaged and one or more of the following: (a)are out-of-school, including out-of-school youth who are unemployed; (b) are in or aging out of foster care; (c) have limited English proficiency; (d) are homeless or have run away from home; (e) are at-risk to leave secondary school without a diploma; (f) are former juvenile offenders or at risk of delinquency; (g) are individuals with disabilities.

______ Estimated Number  Don’t Know

8. Approximately how many youth (ages 5-17) were mentored through your Learn and Serve America supported service-learning activities?

_____ Estimated Number  Don’t Know  Do not have mentoring activities (skip to question 11)

10a. Approximately how many of those mentored are from disadvantaged circumstances (see definition above)?

______ Estimated Number  Don’t Know

9. Approximately how many youth (ages 5-17) were tutored through your Learn and Serve America supported service-learning activities?

_____ Estimated Number  Don’t Know  Do not have tutoring activities (skip to question 12)

11a. Approximately how many of those tutored are from disadvantaged circumstances (see definition above)?

______ Estimated Number  Don’t Know

IV. Program Duration and Service-Learning Characteristics

10. This question is designed to gather information on the duration of Learn and Serve America service-learning activities in the school and the amount of time students are engaged in preparation, reflection, and service. Please fill in the table below with the numbers of service-learners and average hours of preparation and service. If you do not run projects for any of the three durations, check “Do Not Run.” If you don’t know the number of service-learners and average hours for any of the three durations, check “Don’t Know.”

Instructions for completing table on service hours

1. First, estimate the number of service-learners who were in service-learning programs of the durations listed in the table below from July 1, 2010 to June 30, 2011. If you have more than one activity or program in a given duration, please combine them in reporting participant numbers and hours. The total number of service-learners reported for this question may not equal the total number of service-learners reported in question 4 if individuals participated in more than one service-learning activity.

2. Next, for each of the project durations, calculate the average hours of preparation for the service and formal reflection per service-learner during or after the service and enter that figure in column 3.

3. Finally, enter the average number of hours of service for a service-learner. Enter that figure in column 4.

• Preparation activities might include conducting background research, collecting data, attending trainings, assembling materials, rehearsing parts, and meeting to plan project activities during and after class.

• Formal reflection activities might include classroom discussions, keeping a journal, writing an essay or a poem, and making a class presentation.

• Service might include a variety of activities, including the following: providing direct service to individuals (tutoring, assisting at a human services agency, working in a classroom, etc.); service projects addressing a community need (for example, cleaning a park, raising money for a local program, monitoring local water quality), or educational efforts such as presenting a play on a community issue, organizing or testifying at a public hearing, or preparing educational materials (brochures, posters, etc.) on a local issue.

Example 1. The “Plant a Tree Project” lasted 2 months and involved 60 students (see ‘a’ in the table below). The average student in this project spent 8 hours engaged in preparation for the service and in formal reflection activities during and after the service (see ‘b’). The service activity itself took approximately 2 hours per student (see ‘c’).

Example 2: The senior Civics Class is organized around a core service-learning program. It meets one hour, two days a week for one semester, and has 25 students (see ‘d’). Each student in this class spent 63 hours engaged in service-learning preparation for the service and formal reflection during and after the service (see ‘e’). The service activity itself was 10 hours (see ‘f’). (Calculation: 2 hours of class + 1 hour of preparation + .5 hours of formal reflection x 18 weeks = 63 hours per student; 10 hours of service per student).

EXAMPLES

Duration	Do Not Run this Type of Program	Number of Service-Learners	Average Hours of Preparation and/or Formal Reflection per Service-Learner	Average Hours of Service per Service-Learner	Don’t Know
Programs and activities that last 2 months or less		a. 60 students	b. 8 hours each	c. 2 hours each
Programs and activities that last for most or all of one semester or term		d. 25 students	e. 63 hours each	f. 10 hours each
Programs and activities that last for most or all of the whole academic year

[End of pop-up instruction page]

PLEASE FILL IN

Duration	Do Not Run this Type of Program	Number of Service-Learners	Average Hours of Preparation and/or Formal Reflection per Service-Learner	Average Hours of Service per Service-Learner	Don’t Know
Programs and activities that last 2 months or less
Programs and activities that last for most or all of one semester or term
Programs and activities that last for most or all of the whole academic year

*If DO NOT KNOW – instruction will pop up: “If you do not know, please estimate the number of hours you expect someone to spend.”

V. Project Characteristics

11. How frequently do the Learn and Serve America supported service-learning activities in the higher education institution include the following characteristics?

	Never (0%)	Less than 50% of the time	More than 50% of the time	Always (100%)	N/A
Service-learners participate in a community needs assessment to plan the service-learning project					
The service-learning activities are of a sustained and significant duration (i.e. concentrated blocks of time over a period of several months)					
The learning objectives for the service-learning activities are aligned with the academic curriculum					
The service-learning activities are included in student records					
Community partners collaborate in setting goals and establishing an action plan					
Service-learners generate ideas and make decisions on the design and implementation of the service-learning project					
Service-learners present their findings from the service-learning project to community members					
Service-learners engage with diverse perspectives through the service-learning project					
Service-learners examine the broader social and civic context for the identified community need					
The project includes a variety of reflection activities that examine changes in service-learners’ knowledge and attitudes					
Service-learners measure their progress toward meeting specific service goals and learning outcomes during the project					
The service activities present opportunities for the participants to apply newly acquired skills and knowledge to a community need					

VI. Community Needs and Service Activities

Issue Areas and Community Needs

12. This question is designed to gather information on the community needs that the Learn and Serve America supported service-learning activities have been designed to address. The community needs have been categorized into ten general issue areas. For each issue area, provide the percentage of the service-learning activities that address the relevant issue area. If there are no service activities that address a given area, leave the % field blank (do not enter “0”). For each area with activities, check up to three of the most common types of community needs being addressed by the activities.

Community Development ____ % of service activities

 Civic/Public Infrastructure	 Homeless Assistance	 Transportation
 Community Clean-up	 Social Services Planning/Delivery	 Volunteer Capacity/Management
 Historic Preservation	 Animal Care Services	 Independent Living Assistance
		 Other Community Development (specify)

Economic Development ____ % of service activities

 Financial Literacy	 Workforce Development	 Financial Asset Development
 Economic Revitalization	 Technology Access	 Other Economic Development (specify)

Disaster Recovery and Relief ____ % of service activities

 Disaster Mitigation	 Disaster Recovery	 Other Disaster (specify)
 Disaster Preparedness	 Disaster Relief

Education ____ % of service activities

 Adult Literacy	 Computer Literacy	 Special Education Programs
 After School Programs	 English Language Learning	 Classroom Education
 Child Literacy	 Job Preparedness	 Cultural Heritage
	 School Preparedness	 Other Education (specify)

Environment and Energy ____ % of service activities

 Clean Air	 Environmental Protection	 Waste Reduction/Recycling
 Clean Water	 Environmental Restoration	 Weatherization
 Energy Conservation	 Indoor Environment	 Environmental Awareness
		 Other Environment (specify)

Health & Wellness/Nutrition _____ % of service activities

 Disabilities Services	 HIV/AIDS Prevention	 Nutrition Education
 Food Distribution/Collection	 Health & Wellness Education	 Substance Abuse Prevention/Rehabilitation
 Food Production	 Maternal/Child Health Services	 Aid to Seniors/Elders
 Health Service Delivery	 Mental Health Services	 Other Health/Nutrition (specify)

Public Safety ____ % of service activities

 Accident Prevention	 Crisis Intervention	 Victim/Witness Services
 Community Policing	 Fire Prevention	 Public Safety Education
 Conflict Resolution/Mediation	 Legal Assistance	 Crime Awareness/Prevention
 Offender/Ex-Offender Services/Rehabilitation	 Children and Youth Safety	 Other Public Safety (specify)

Youth Development ____ % of service activities

 Children and Youth Safety	 Juvenile Justice Services	 Bullying Prevention
 Delinquency Prevention	 Teen Pregnancy/Parenting Services	 Other Youth Development (specify)
 Gang Prevention/Rehabilitation	 Youth Leadership Development

Veterans Assistance ____ % of service activities

 Housing Assistance	 Military Family Assistance	 Veteran Employment Services
 Outreach and Counseling	 Veteran Disabilities/ Rehabilitation Assistance	 Other Veterans (specify)

Service Activities

13. (For the most common issue area, or the issue area with the highest percentage of activities in question 14) Please provide a brief description (200 word limit) the specific service-learning activities that were used in addressing the community need. In the description, include the goals of the project, the participants and beneficiaries involved, the location of the service-learning activities, and any measured outcomes.

(Note: You only need to provide activities for the most common community need. If desired, you may select a different community need or provide a description of service activities for more than one community need.)

II-A: Community-Based Version

I. Service-Learning Participants

In this section we are interested in the individuals who have participated in the Learn and Serve America supported service learning programs and activities.

1. Please provide demographic information on the service-learners who were engaged in Learn and Serve America supported activities from July 1, 2010 to June 30, 2011. If you have no service-learners in a given category, enter “0” in the relevant box.

Learn and Serve America Supported Service-Learners	Estimated Number of Service-Learners
Total number of individual service-learners in Learn and Serve America supported activities/programs

Grade Level of Learn and Serve America Service-Learners	Estimated Number of Service-Learners
K – 5th grade
6th grade – 8th grade
9th grade – 12th grade
School dropouts
Grade unknown

Ethnic Background of Learn and Serve America Service-Learners	Estimated Number of Service-Learners
Hispanic
Non-Hispanic
Ethnicity Unknown

Racial Background of Learn and Serve America Service-Learners	Estimated Number of Service-Learners
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or more races
Race Unknown

Gender of Learn and Serve America Service-Learners	Estimated Number of Service-Learners
Male
Female
Gender Unknown

Learn and Serve America Service-Learners with Disabilities	Estimated Number of Service-Learners
Service-learners with disabilities

Learn and Serve America Service-Learners in Summer Service-Learning Programs	Estimated Number of Service-Learners	Do Not Have Summer Programs
Service-learners serving in summer programs		

Teacher and Staff Participation in Service-Learning

IX.How many teachers and staff were involved in teaching, leading, and operating Learn and Serve America supported service-learning programs this year? Count each teacher and staff, regardless of part-time or full-time status.

_______ Total number of teachers and staff

Additional Volunteers

2. Approximately how many youth volunteers (defined as youth 5-17 years old) were involved in Learn and Serve America supported service activities (i.e. one-time volunteers or volunteers recruited for service-learning activities). Do not include regular service-learners reported above.

________ Estimated number of youth volunteers  Don’t Know

3. Approximately how many adult volunteers (defined as 18 or older) were involved in Learn and Serve America supported service-related activities (i.e. one-time volunteers or volunteers recruited for service-learning activities). Do not include staff and teachers reported above.

________ Estimated number of adult volunteers  Don’t Know

4a. Approximately how many of these adult volunteers are 55 years or older?

_______ Estimated number of adult volunteers 55 and older  Don’t Know

II. Beneficiaries

X.How many youth from disadvantaged circumstances received services through the Learn and Serve America supported service-learning activities during the 2010-2011 program year? Youth from disadvantaged circumstances are defined as those youth who are economically disadvantaged and one or more of the following: (a)are out-of-school, including out-of-school youth who are unemployed; (b) are in or aging out of foster care; (c) have limited English proficiency; (d) are homeless or have run away from home; (e) are at-risk to leave secondary school without a diploma; (f) are former juvenile offenders or at risk of delinquency; (g) are individuals with disabilities.

______ Estimated Number  Don’t Know

4. Approximately how many youth (ages 5-17) were mentored through your Learn and Serve America supported service-learning activities?

_______ Estimated Number  Don’t Know  Do not have mentoring activities (skip to question 7)

6a. Approximately how many of those mentored are from disadvantaged circumstances (see definition above)?

_______ Estimated Number  Don’t Know

5. Approximately how many youth (ages 5-17) were tutored through your Learn and Serve America supported service-learning activities?

_______ Estimated Number  Don’t Know  Do not have tutoring activities (skip to question 8)

7a. Approximately how many of those tutored are from disadvantaged circumstances (see definition above)?

_______ Estimated Number  Don’t Know

III. Program Duration and Service-Learning Characteristics

6. This question is designed to gather information on the duration of Learn and Serve America service-learning activities and the amount of time youth are engaged in preparation, reflection, and service. Please fill in the table below with the numbers of service-learners and average hours of preparation and service. If you do not run projects for any of the three durations, check “Do Not Run.” If you don’t know the number of service-learners and average hours for any of the three durations, check “Don’t Know.”

Instructions for completing table on service hours

1. First, estimate the number of service-learners who were in service-learning programs of the durations listed in the table below from July 1, 2010 to June 30, 2011. If you have more than one activity or program in a given duration, please combine them in reporting participant numbers and hours. The total number of service-learners reported for this question may not equal the total number of service-learners reported in question 1 if individuals participated in more than one service-learning activity.

2. Next, for each of the project durations, calculate the average hours of preparation for the service and formal reflection per service-learner during or after the service and enter that figure in column 3.

3. Finally, enter the average number of hours of service for a service-learner. Enter that figure in column 4.

• Preparation activities might include conducting background research, collecting data, attending trainings, assembling materials, rehearsing parts, and meeting to plan project activities during and after class.

• Formal reflection activities might include classroom discussions, keeping a journal, writing an essay or a poem, and making a class presentation.

• Service might include a variety of activities, including the following: providing direct service to individuals (tutoring, assisting at a human services agency, working in a classroom, etc.); service projects addressing a community need (for example, cleaning a park, raising money for a local program, monitoring local water quality), or educational efforts such as presenting a play on a community issue, organizing or testifying at a public hearing, or preparing educational materials (brochures, posters, etc.) on a local issue.

Example 1. The “Plant a Tree Project” lasted 2 months and involved 60 students (see ‘a’ in the table below). The average student in this project spent 8 hours engaged in preparation for the service and in formal reflection activities during and after the service (see ‘b’). The service activity itself took approximately 2 hours per student (see ‘c’).

Example 2: The senior Civics Class is organized around a core service-learning program. It meets one hour, two days a week for one semester, and has 25 students (see ‘d’). Each student in this class spent 63 hours engaged in service-learning preparation for the service and formal reflection during and after the service (see ‘e’). The service activity itself was 10 hours (see ‘f’). (Calculation: 2 hours of class + 1 hour of preparation + .5 hours of formal reflection x 18 weeks = 63 hours per student; 10 hours of service per student).

EXAMPLES

Duration	Do Not Run This Type of Program	Number of Service-Learners	Average Hours of Preparation and/or Formal Reflection per Service-Learner	Average Hours of Service per Service-Learner	Do Not Know
Programs and activities that last 2 months or less		a. 60 youth	b. 8 hours each	c. 2 hours each
Programs and activities that last for 3 to 6 months		d. 25 youth	e. 63 hours each	f. 10 hours each
Programs and activities that last for 7 months to one year

[End of pop-up instruction page]

PLEASE FILL IN

Duration	Do Not Run this Type of Program	Number of Service-Learners	Average Hours of Preparation and/or Formal Reflection per Service-Learner	Average Hours of Service per Service-Learner	Do Not Know*
Programs and activities that last 2 months or less
Programs and activities that last for 3 to 6 months
Programs and activities that last for 7 months to one year

* IF DO NOT KNOW – instruction will pop up: “If you do not know, please estimate the number of hours you expect someone to spend.”

IV. Project Characteristics

7. How frequently do the Learn and Serve America supported service-learning activities in the community-based organization include the following characteristics?

	Never (0%)	Less than 50% of the time	More than 50% of the time	Always (100%)	N/A
Service-learners participate in a community needs assessment to plan the service-learning project					
The service-learning activities are of a sustained and significant duration (i.e. concentrated blocks of time over a period of several months)					
The learning objectives for the service-learning activities are aligned with the academic curriculum					
The service-learning activities are included in student records					
Community partners collaborate in setting goals and establishing an action plan					
Service-learners generate ideas and make decisions on the design and implementation of the service-learning project					
Service-learners present their findings from the service-learning project to community members					
Service-learners engage with diverse perspectives through the service-learning project					
Service-learners examine the broader social and civic context for the identified community need					
The project includes a variety of reflection activities that examine changes in service-learners’ knowledge and attitudes					
Service-learners measure their progress toward meeting specific service goals and learning outcomes during the project					
The service activities present opportunities for the participants to apply newly acquired skills and knowledge to a community need					

V. Community Needs and Service Activities

Issue Areas and Community Needs

8. This question is designed to gather information on the types of community needs that the Learn and Serve America supported service-learning activities have been designed to address. The community needs have been categorized into ten general issue areas. For each issue area, provide the percentage of the service-learning activities that address the relevant issue area. If there are no service activities that address a given area, leave the % field blank (do not enter “0”). For each area with activities, check up to three of the most common types of community needs being addressed by the activities.

Community Development ____ % of service activities

 Civic/Public Infrastructure	 Homeless Assistance	 Transportation
 Community Clean-up	 Social Services Planning/Delivery	 Volunteer Capacity/Management
 Historic Preservation	 Animal Care Services	 Independent Living Assistance
		 Other Community Development (specify)

Economic Development ____ % of service activities

 Financial Literacy	 Workforce Development	 Financial Asset Development
 Economic Revitalization	 Technology Access	 Other Economic Development (specify)

Disaster Recovery and Relief ____ % of service activities

 Disaster Mitigation	 Disaster Recovery	 Other Disaster (specify)
 Disaster Preparedness	 Disaster Relief

Education ____ % of service activities

 Adult Literacy	 Computer Literacy	 Special Education Programs
 After School Programs	 English Language Learning	 Classroom Education
 Child Literacy	 Job Preparedness	 Cultural Heritage
	 School Preparedness	 Other Education (specify)

Environment and Energy ____ % of service activities

 Clean Air	 Environmental Protection	 Waste Reduction/Recycling
 Clean Water	 Environmental Restoration	 Weatherization
 Energy Conservation	 Indoor Environment	 Environmental Awareness
		 Other Environment (specify)

Health & Wellness/Nutrition _____ % of service activities

 Disabilities Services	 HIV/AIDS Prevention	 Nutrition Education
 Food Distribution/Collection	 Health & Wellness Education	 Substance Abuse Prevention/Rehabilitation
 Food Production	 Maternal/Child Health Services	 Aid to Seniors/Elders
 Health Service Delivery	 Mental Health Services	 Other Health/Nutrition (specify)

Public Safety ____ % of service activities

 Accident Prevention	 Crisis Intervention	 Victim/Witness Services
 Community Policing	 Fire Prevention	 Public Safety Education
 Conflict Resolution/Mediation	 Legal Assistance	 Crime Awareness/Prevention
 Offender/Ex-Offender Services/Rehabilitation	 Children and Youth Safety	 Other Public Safety (specify)

Youth Development ____ % of service activities

 Children and Youth Safety	 Juvenile Justice Services	 Bullying Prevention
 Delinquency Prevention	 Teen Pregnancy/Parenting Services	 Other Youth Development (specify)
 Gang Prevention/Rehabilitation	 Youth Leadership Development

Veterans Assistance ____ % of service activities

 Housing Assistance	 Military Family Assistance	 Veteran Employment Services
 Outreach and Counseling	 Veteran Disabilities/ Rehabilitation Assistance	 Other Veterans (specify)

Service Activities

9. (For the most common issue area, or the issue area with the highest percentage of activities in question 10) Please provide a brief description (200 word limit) the specific service-learning activities that were used in addressing the community need. In the description, include the goals of the project, the participants and beneficiaries involved, the location of the service-learning activities, and any measured outcomes.

(Note: You only need to provide activities for the most common community need. If desired, you may select a different community need or provide a description of service activities for more than one community need.)

II. Program Reporting Form

B. Institutional Supports for Service-Learning

There are four versions of this section of the survey. Respondents are directed to respond to the appropriate version based on their organizational type. The on-line reporting system automatically identifies the appropriate form type based on the respondents’ answer to question 1 of the Grant Profile. Those who indicated that they are a K-12 school are directed to complete the K-12 School form; those who indicated that they are a K-12 school district are directed to complete the K-12 School District form; those who indicated that they are a higher education institution are directed to complete the Higher Education Institution form; and those who indicated that they are a community-based organization are directed to complete the Community-Based Organization form. NOTE: Recipients of special initiatives under Innovative and Community-Based grant funds, such as Summer of Service and Youth Engagement Zones, are directed to complete distinct surveys.

II-B: K-12 School Version

I. Community Partners

The following questions are designed to gather information on the community partners (community agencies, local government, businesses, etc.) that were formally involved in managing, planning, and/or implementing Learn and Serve America supported service-learning activities with the school during the 2010-2011 program year.

1. How many community partners were involved in Learn and Serve America supporting service-learning activities?

_______  Don’t Know

1a. Of the total number of partners, how many served as a service-learning placement site?

_______  Don’t Know

1b. Of the total number of partners, how many are faith based organizations?

______  Don’t Know

1c. Of the total number of partners, how many provide in-kind or cash support for service-learning?

______  Don’t Know

2. Does the service-learning program have an advisory board?

 Yes  No  Don’t Know

2a. If YES, do one or more of the community partners serve as members of the advisory board?

 Yes  No  Don’t Know

Collaboration with Other Federal Programs

3. Which of the following Corporation for National and Community Service programs collaborated with the school in implementing Learn and Serve America service-learning activities? (Check all that apply)

 AmeriCorps	 Senior Corps
 AmeriCorps*VISTA	 None
 AmeriCorps*NCCC	 Don’t Know

4. Which of the following other federal programs collaborated with the school in implementing the Learn and Serve America service-learning activities? (Check all that apply)

 Career and Technical Education	 GEAR-UP	 Other (specify)
 Character Education	 21st Century Learning Centers	 None
 Federal Work Study	 Upward Bound	 Don’t Know

II. Institutional Supports for Service-Learning

These questions refer to all service-learning activities at the school, whether or not they are supported by Learn and Serve America.

5. How long have there been organized service-learning activities at the school (e.g. regular, ongoing service-learning)?

 One year or less

 Two to four years

 Five to nine years

 Ten years or more

 Don’t Know

6. Please indicate which policies listed below are in place at the school.

	Yes	No	Don’t Know
Service-learning is recognized by the school as an improvement strategy in its strategic plan or improvement plan			
Service-learning is part of the board approved course curriculum in at least one subject in at least one grade in the school. *(If yes, answer question 7)			
Service-learning is part of the board approved course curriculum in at least one course that is a required for graduation.			
Service-learning participants are formally recognized through the President’s Volunteer Service Award			

7. * If service-learning is part of the board approved course curriculum in one or more subjects for one or more grades, please indicate the subjects. Check all that apply.

 Art/Music/Theater	 Math	 Vocational/ Career Education
 Computer Science	 Physical Education	 Advisory Period
 English/ Language Arts	 Science	 Elective
 Foreign Languages	 Social Studies	 Gifted/ Talented
 Health	 Special Education	 Other

8. Indicate the extent to which the following policies and practices were present at the school over the past year:

	Never	Rarely	Occasionally	Frequently	Always
Service-learning is included in the school’s current professional development plans					
Service-learning is included in new staff and teacher orientation					
Service-learning is considered as one of the criteria for teacher and staff evaluations and/or in performance standards for teachers and staff					
Students are involved in decision-making about the service-learning activities, for example, through an advisory council or other formal decision-making body					
Parent and/or family volunteers participate in service learning activities					

9. During the past year, to what extent were the following available at the school? Please indicate how regularly or widely each type of support was available.

	Never	Rarely	Occasionally	Frequently	Always
Financial support for planning, training, and implementation of service-learning projects or programs					
Reduction in teaching load to allow time for service-learning program development or supervision					
Technical assistance on planning or implementation of service-learning activities					
Recognition or rewards for teachers and staff for quality service-learning practice					

III. Service-Learning Coordinator

10. Does the school have a full or part-time service-learning coordinator or staff person with responsibility for service-learning?

 Yes  No (skip to question 16)

11. If there is a service-learning coordinator for the school, how many years of professional experience has the coordinator had with service-learning (for example, as a coordinator, teacher, etc.)? If there is more than one coordinator, please provide information on the primary coordinator.

 Less than 1 year  1-4 years  5 years or more

12. Is the service-learning coordinator a full time or part-time employee of the school?

 Full-time  Part-time

13. Approximately what percentage of the coordinator’s total job responsibilities is devoted to service-learning?

 100 %  75%  50%  25%  Less than 25%

14. Please select the answer that best describes the extent of training and professional development the service-learning coordinator has received.

 No formal education, training, or professional development related to service-learning

 One workshop, conference, or training session

 Multiple workshops, conferences, or training sessions, OR one or more semesters of formal education (pre-service or in-service) focused on service-learning

 A combination of a semester or more of formal education and multiple workshops or training sessions

15. What percentages of the service-learning coordinator’s salary came from grants and institutional funds in 2010-2011 (including Learn and Serve America funds):

Grants _____% Institutional funds _____%

IV. Technical Assistance Strengths and Needs (Optional)

This information may be used to plan peer to peer training.

16. In which of the following areas do you think your service-learning program is particularly strong and capable of providing technical assistance to other Learn and Serve America programs? Please check all that apply.

Program Management

Program Content

 Program Design  Strategic Planning  Developing Community Partnerships  Assessing community impact  Building Community/Institutional Support  Service Site Recruitment  Volunteer/service site training  Staff development/teacher education  Managing/Overseeing Service Sites  Program evaluation strategies/Performance measurement  Financial/grant management  Marketing  Other (specify) ________________________  None

 Curriculum/program design (specify subject area)  Development/Leadership  Orientation  Reflection techniques  Youth voice/youth governance  Individual assessment strategies (portfolios, etc.)  Promotion and tenure  Other (specify) _____________________  None

17. In which of the following areas do you think your service-learning program is most in need of technical assistance or training? Please check the three highest priority areas for assistance.

Program Management

Program Content

 Program Design  Strategic Planning  Developing Community Partnerships  Assessing community impact  Building Community/Institutional Support  Service Site Recruitment  Volunteer/service site training  Staff development/teacher education  Managing/Overseeing Service Sites  Program evaluation strategies/Performance measurement  Financial/grant management  Marketing  Other (specify) ________________________

 Curriculum/program design (specify subject area)  Development/Leadership  Orientation  Reflection techniques  Youth voice/youth governance  Individual assessment strategies (portfolios, etc.)  Promotion and tenure  Other (specify) _____________________________

II-B: K-12 School District Version

I. Community Partners

The following questions are designed to gather information on the community partners (community agencies, local government, businesses, etc.) that were formally involved in managing, planning, and/or implementing Learn and Serve America supported service-learning activities with the schools during the 2010-2011 program year.

1. How many community partners were involved in Learn and Serve America supporting service-learning activities?

_______  Don’t Know

1a. Of the total number of partners, how many served as a service-learning placement site?

_______  Don’t Know

1b. Of the total number of partners, how many are faith based organizations?

______  Don’t Know

1c. Of the total number of partners, how many provide in-kind or cash support for service-learning?

______  Don’t Know

2. Does the service-learning program have an advisory board?

 Yes  No  Don’t Know

2a. If YES, do one or more of the community partners serve as members of the advisory board?

 Yes  No  Don’t Know

Collaboration with Other Federal Programs

3. Which of the following Corporation for National and Community Service programs collaborated in implementing Learn and Serve America service-learning activities in the schools? (Check all that apply)

 AmeriCorps	 Senior Corps
 AmeriCorps*VISTA	 None
 AmeriCorps*NCCC	 Don’t Know

4. Which of the following other federal programs collaborated in implementing the Learn and Serve America service-learning activities in the schools? (Check all that apply)

 Career and Technical Education	 GEAR-UP	 Other (specify)
 Character Education	 21st Century Learning Centers	 None
 Federal Work Study	 Upward Bound	 Don’t Know

II. Institutional Supports for Service-Learning

These questions refer to all service-learning activities at the district level, whether or not they are funded by Learn and Serve America.

5. How long have there been organized service-learning activities in the school district (e.g. regular, ongoing service-learning)?

 One year or less

 Two to four years

 Five to nine years

 Ten years or more

 Don’t Know

6. Please indicate which policies listed below are in place in the school district.

	Yes	No	Don’t Know
Service-learning is recognized by the district as an improvement strategy in its strategic plan or improvement plan			
Service-learning is part of the board approved course curriculum in at least one subject in at least one grade in the district. *(If yes, answer question 7)			
Service-learning is part of the board approved course curriculum in at least one course that is a required for graduation in the district.			
Service-learning participants are formally recognized through the President’s Volunteer Service Award			

7. * If service-learning is part of the board approved course curriculum in one or more subjects for one or more grades, please indicate the subjects. Check all that apply.

 Art/Music/Theater	 Math	 Vocational/ Career Education
 Computer Science	 Physical Education	 Advisory Period
 English/ Language Arts	 Science	 Elective
 Foreign Languages	 Social Studies	 Gifted/ Talented
 Health	 Special Education	 Other

8. Indicate the extent to which the following policies and practices were present in the school district over the past year:

	Never	Rarely	Occasionally	Frequently	Always
Service-learning is included in the district’s current professional development plans					
Service-learning is included in new staff and teacher orientation					
Service-learning is considered as one of the criteria for teacher and staff evaluations and/or in performance standards for teachers and staff					
Students are involved in decision-making about the service-learning activities, for example, through an advisory council or other formal decision-making body					
Parent and/or family volunteers participate in service learning activities					

9. During the past year, to what extent were the following available in the school district? Please indicate how regularly or widely each type of support was available.

	Never	Rarely	Occasionally	Frequently	Always
Financial support for planning, training, and implementation of service-learning projects or programs					
Reduction in teaching load to allow time for service-learning program development or supervision					
Technical assistance on planning or implementation of service-learning activities					
Recognition or rewards for teachers and staff for quality service-learning practice					

III. Service-Learning Coordinator

10. Is there full or part-time service-learning coordinator(s) or staff person(s) with responsibility for service-learning in the school district?

 Yes  No (skip to question 16)

11. If there is a service-learning coordinator in the school district, how many years of professional experience has the coordinator had with service-learning (for example, as a coordinator, teacher, etc.)? If there is more than one coordinator, please provide information on the primary coordinator.

 Less than 1 year  1-4 years  5 years or more

12. Is the service-learning coordinator a full time or part-time employee?

 Full-time  Part-time

13. Approximately what percentage of the coordinator’s total job responsibilities is devoted to service-learning?

 100 %  75%  50%  25%  Less than 25%

14. Please select the answer that best describes the extent of training and professional development the service-learning coordinator has received.

 No formal education, training, or professional development related to service-learning

 One workshop, conference, or training session

 Multiple workshops, conferences, or training sessions, OR one or more semesters of formal education (pre-service or in-service) focused on service-learning

 A combination of a semester or more of formal education and multiple workshops or training sessions

15. What percentages of the service-learning coordinator’s salary came from grants and institutional funds in 2010-2011 (including Learn and Serve America funds):

Grants _____% Institutional funds _____%

IV. Technical Assistance Strengths and Needs (Optional)

This information may be used to plan peer to peer training.

16. In which of the following areas do you think your service-learning program is particularly strong and capable of providing technical assistance to other Learn and Serve America programs? Please check all that apply.

Program Management

Program Content

 Program Design  Strategic Planning  Developing Community Partnerships  Assessing community impact  Building Community/Institutional Support  Service Site Recruitment  Volunteer/service site training  Staff development/teacher education  Managing/Overseeing Service Sites  Program evaluation strategies/Performance measurement  Financial/grant management  Marketing  Other (specify) ________________________  None

 Curriculum/program design (specify subject area)  Development/Leadership  Orientation  Reflection techniques  Youth voice/youth governance  Individual assessment strategies (portfolios, etc.)  Promotion and tenure  Other (specify) _____________________  None

17. In which of the following areas do you think your service-learning program is most in need of technical assistance or training? Please check the three highest priority areas for assistance.

Program Management

Program Content

 Program Design  Strategic Planning  Developing Community Partnerships  Assessing community impact  Building Community/Institutional Support  Service Site Recruitment  Volunteer/service site training  Staff development/teacher education  Managing/Overseeing Service Sites  Program evaluation strategies/Performance measurement  Financial/grant management  Marketing  Other (specify) ________________________

 Curriculum/program design (specify subject area)  Development/Leadership  Orientation  Reflection techniques  Youth voice/youth governance  Individual assessment strategies (portfolios, etc.)  Promotion and tenure  Other (specify) _____________________________

II-B: Higher Education Institution Version

I. Community Partners

The following questions are designed to gather information on the community partners (community agencies, local government, businesses, etc.) that were formally involved in managing, planning, and/or implementing Learn and Serve America supported service-learning activities with the higher education institution during the 2010-2011 program year.

1. How many community partners were involved in Learn and Serve America supporting service-learning activities?

_______  Don’t Know

1a. Of the total number of partners, how many served as a service-learning placement site?

_______  Don’t Know

1b. Of the total number of partners, how many are faith based organizations?

______  Don’t Know

1c. Of the total number of partners, how many provide in-kind or cash support for service-learning?

______  Don’t Know

2. Does the service-learning program have an advisory board?

 Yes  No  Don’t Know

2a. If YES, do one or more of the community partners serve as members of the advisory board?

 Yes  No  Don’t Know

Collaboration with Other Federal Programs

3. Which of the following Corporation for National and Community Service programs collaborated with the higher education institution in implementing Learn and Serve America service-learning activities? (Check all that apply)

 AmeriCorps	 Senior Corps
 AmeriCorps*VISTA	 None
 AmeriCorps*NCCC	 Don’t Know

4. Which of the following other federal programs collaborated with the higher education institution in implementing the Learn and Serve America service-learning activities? (Check all that apply)

 Career and Technical Education	 GEAR-UP	 Other (specify)
 Character Education	 21st Century Learning Centers	 None
 Federal Work Study	 Upward Bound	 Don’t Know

II. Institutional Supports for Service-Learning

These questions refer to all service-learning activities at the higher education institution, whether or not they are supported by Learn and Serve America.

5. How long have there been organized service-learning activities at the higher education institution (e.g. regular, ongoing service-learning)?

 One year or less

 Two to four years

 Five to nine years

 Ten years or more

 Don’t Know

6. Please indicate which policies listed below are in place at the higher education institution.

	Yes	No	Don’t Know
Service-learning is included in the campus strategic plan.			
Service-learning is part of the official core curriculum in at least one discipline or major at the institution *(If yes, answer question 7)			
Service-learning is part of the official core curriculum in at least one course that is required for graduation.			
Public or institution-wide recognition is given to students receiving the President’s Volunteer Service Award			

7. *If service-learning is part of the official core curriculum in at least one discipline or major, please indicate the subject(s). Check all that apply.

 Arts	 Law/Criminal Justice	 Social Work
 Education	 Public Policy/Public Administration	 Vocational/Technical
 Health Sciences/Professions	 Sciences/Mathematics/Engineering	 Other
 Humanities	 Social Sciences

8. During the past year, how many courses with service-learning activities were created at the higher education institution as result of Learn and Serve America funds?

__________ Estimated number of courses  Don’t Know

9. Indicate the extent to which the following policies and practices were present at the higher education institution over the past year:

	Never	Rarely	Occasionally	Frequently	Always
Service-learning is included in the institution’s current professional development plans					
Service-learning is included in the orientation for new faculty					
Service-learning is considered as one of the criteria in faculty promotion and/or tenure.					
Students are involved in decision-making about the service-learning activities, for example, through an advisory council or other formal planning or decision-making body					

10. During the past year, to what extent were the following available at the higher education institution? Please indicate how regularly or widely each type of support was available.

	Never	Rarely	Occasionally	Frequently	Always
Financial support for planning, training, and implementation of service-learning projects or programs					
Reduction in course load to allow time for service-learning program development or supervision					
Technical assistance on planning or implementation of service-learning activities					
Recognition or rewards for faculty and staff for quality service-learning practice					

III. Service-Learning Coordinator

11. Does the higher education institution have a full or part-time service-learning coordinator(s) or staff person(s) with responsibility for service-learning?

 Yes  No (skip to question 17)

12. If there is a service-learning coordinator for the higher education institution, how many years of professional experience has the coordinator had with service-learning (for example, as a coordinator, faculty member, etc.)? If there is more than one coordinator, please provide information on the primary coordinator.

 Less than 1 year  1-4 years  5 years or more

13. Is the service learning coordinator a full time or part-time employee of the higher education institution?

 Full-time  Part-time

14. Approximately what percentage of the coordinator’s total job responsibilities is service-learning?

 100 %  75%  50 %  25%  Less than 25%

15. Please select the answer that best describes the extent of training/professional development the service-learning coordinator has received:

 No formal education/training/professional development related to service-learning

 One workshop, conference, or training session

 Multiple workshops/conferences/training sessions, OR one or more semesters of formal education
(pre-service or in-service) focused on service-learning

 A combination of a semester or more of formal education and multiple workshops/training sessions.

16. What percentage of the service-learning coordinator’s salary is from grants and institutional funds in 2010-2011 (including Learn and Serve America funds):

Grants _____% Institutional funds _____%

IV. Technical Assistance Strengths and Needs (Optional)

This information may be used to plan peer to peer training.

17. In which of the following areas do you think your service-learning program is particularly strong and capable of providing technical assistance to other Learn and Serve America programs? Please check all that apply.

Program Management

Program Content

 Program Design  Strategic Planning  Developing Community Partnerships  Assessing community impact  Building Community/Institutional Support  Service Site Recruitment  Volunteer/service site training  Staff development/teacher education  Managing/Overseeing Service Sites  Program evaluation strategies/Performance measurement  Financial/grant management  Marketing  Other (specify) ________________________  None

 Curriculum/program design (specify subject area)  Development/Leadership  Orientation  Reflection techniques  Youth voice/youth governance  Individual assessment strategies (portfolios, etc.)  Promotion & tenure  Other (specify) _____________________  None

18. In which of the following areas do you think your service-learning program is most in need of technical assistance or training? Please check the three highest priority areas for assistance.

Program Management

Program Content

 Program Design  Strategic Planning  Developing Community Partnerships  Assessing community impact  Building Community/Institutional Support  Service Site Recruitment  Volunteer/service site training  Staff development/teacher education  Managing/Overseeing Service Sites  Program evaluation strategies/Performance measurement  Financial/grant management  Marketing  Other (specify) ________________________

 Curriculum/program design (specify subject area)  Development/Leadership  Orientation  Reflection techniques  Youth voice/youth governance  Individual assessment strategies (portfolios, etc.)  Promotion & tenure  Other (specify) _____________________  None

II-B: Community-Based Organization Version

I. Community Partners

The following questions are designed to gather information on the community partners (community agencies, schools, local government, businesses, etc.) that were formally involved in managing, planning, and/or implementing Learn and Serve America supported service-learning activities during the 2010-2011 program year.

1. How many community partners were involved in Learn and Serve America supporting service-learning activities?

_______  Don’t Know

1a. Of the total number of partners, how many served as a service-learning placement site?

_______  Don’t Know

1b. Of the total number of partners, how many are faith based organizations?

______  Don’t Know

1c. Of the total number of partners, how many provide in-kind or cash support for service-learning?

______  Don’t Know

2. Does the service-learning program have an advisory board?

 Yes  No  Don’t Know

2a. If YES, do one or more of the community partners serve as members of the advisory board?

 Yes  No  Don’t Know

Collaboration with Other Federal Programs

3. Which of the following Corporation for National and Community Service programs collaborated with the organization in implementing Learn and Serve America service-learning activities? (Check all that apply)

 AmeriCorps	 Senior Corps
 AmeriCorps*VISTA	 None
 AmeriCorps*NCCC	 Don’t Know

4. Which of the following other federal programs collaborated with the organization in implementing the Learn and Serve America service-learning activities? (Check all that apply)

 Career and Technical Education	 GEAR-UP	 Other (specify)
 Character Education	 21st Century Learning Centers	 None
 Federal Work Study	 Upward Bound	 Don’t Know

II. Institutional Supports for Service-Learning

These questions are about all service-learning in your organization.

5. How long have there been organized service-learning activities at the organization (e.g. regular, ongoing service-learning)?

 One year or less

 Two to four years

 Five to nine years

 Ten years or more

 Don’t Know

6. Please indicate which policies listed below are in place at the organization.

	Yes	No	Don’t Know
Service-learning is included in the organization’s strategic plan.			
Service-learning is part of the activities for youth in at least one program or department in the organization.			
Participation in service-learning is a requirement for the youth participants in the organization.			
Service-learning participants are formally recognized through the President’s Volunteer Service Award			

7. Indicate the extent to which the following policies/practices were present at the organization over the past year:

	Never	Rarely	Occasionally	Frequently	Always
Service-learning is included in the organization’s current professional development plans					
Service-learning is included in new staff orientation					
Service-learning is considered as one of the criteria for staff evaluations and/or performance standards					
Young people are involved in decision-making about the service-learning activities in the organization, for example, through an advisory council or other formal planning or decision-making body					

8. During the past year, to what extent were the following available at the organization? Please indicate how regularly or widely each type of support is available

	Never	Rarely	Occasionally	Frequently	Always
Financial support for planning, training, and implementation of service-learning projects or programs					
Reduction in work load to allow time for service-learning program development or supervision					
Recognition or rewards for staff for quality service-learning practice					
Technical assistance on planning or implementation of service-learning activities					

III. Service-Learning Coordinator

9. Does the organization have a full or part-time service-learning coordinator or staff person with responsibility for service-learning?

 Yes  No (skip to question 15)

10. If there is a service-learning coordinator for the organization, how many years of professional experience has the coordinator had with service-learning (for example, as a coordinator, former teacher, etc.)? If there is more than one coordinator, please provide information on the primary coordinator.

 Less than 1 year  1-4 years  5 years or more

11. Is the service learning coordinator a full time or part-time employee of the organization?

 Full-time  Part-time

12. Approximately what percentage of the coordinator’s total job responsibilities is devoted to service-learning?

 100 %  75%  50%  25%  Less than 25%

13. Please select the answer that best describes the extent of training/professional development the service-learning coordinator has received:

 No formal education/training/professional development related to service-learning

 One workshop, conference, or training session

 Multiple workshops/conferences/training sessions, OR one or more semesters of formal education
(pre-service or in-service) focused on service-learning

 A combination of a semester or more of formal education and multiple workshops/training sessions.

14. What percentage of the service-learning coordinator’s salary is from grants and organization operating funds in 2010-2011 (including Learn and Serve America funds):

Grants _____% Organizational operating funds _____%

IV. Technical Assistance Strengths and Needs (Optional)

This information may be used to plan peer to peer training.

15. In which of the following areas do you think your service-learning program is particularly strong and capable of providing technical assistance to other Learn and Serve America programs? Please check all that apply.

Program Management

Program Content

 Program Design  Strategic Planning  Developing Community Partnerships  Assessing community impact  Building Community/Institutional Support  Service Site Recruitment  Volunteer/service site training  Staff development/teacher education  Managing/Overseeing Service Sites  Program evaluation strategies/Performance measurement  Financial/grant management  Marketing  Other (specify) ________________________  None

 Curriculum/program design (specify subject area)  Development/Leadership  Orientation  Reflection techniques  Youth voice/youth governance  Individual assessment strategies (portfolios, etc.)  Other (specify) _____________________  None

16. In which of the following areas do you feel your service-learning program is most in need of technical assistance or training? Please check the three highest priority areas for assistance.

Program Management

Program Content

 Program Design  Strategic Planning  Developing Community Partnerships  Assessing community impact  Building Community/Institutional Support  Service Site Recruitment  Volunteer/service site training  Staff development/teacher education  Managing/Overseeing Service Sites  Program evaluation strategies/Performance measurement  Financial/grant management  Marketing  Other (specify) ________________________

 Curriculum/program design (specify subject area)  Development/Leadership  Orientation  Reflection techniques  Youth voice/youth governance  Individual assessment strategies (portfolios, etc.)  Other (specify) _____________________  None

II. Program Reporting Form

C. Training and Technical Assistance Activities

I. Training and Technical Assistance (Only for those who indicated that they provided training and technical assistance under question 3 of the Registration Form)

Please provide information on the training and technical assistance that your organization provided during the 2010-2011 program year that was supported by Learn and Serve America funds.

1. How many teachers, faculty and/or staff participated in training and technical assistance activities that were supported by Learn and Serve America grants funds during the 2010-2011 program year?

_______Number  None  Don’t Know

2. [If respondent reported teachers, faculty and/or staff in 33] How many teachers, faculty and/or staff participated in each of the following types of training and technical assistance activities?

	Number	Don’t Know
1-day in-person service-learning institute		
In-person service-learning institute that lasted more than one day		
Webinars		
Discussion lists, wikis, and other forums for electronic collaboration		
In-person meetings with representatives of community partner organizations		
Opportunities to participate in Professional Learning Communities		
Opportunities to work with a mentor who has experience using service-learning		
Opportunities to take part in service-learning projects as participants/service-learners		
Training and/or technical assistance for including service-learning within existing methods courses [HED ONLY]		
Training and/or technical assistance for including service-learning within existing foundations courses [HED ONLY]		
Training and/or technical assistance for providing stand-alone courses in service-learning pedagogy [HED ONLY]		

3. How many college students participated in training and technical assistance activities that were supported by Learn and Serve America grant funds during the 2010-2011 program year?

_______ Number  None  Don’t Know

35a. How many of the college students that participated in training and technical assistance activities were pre-service teachers?

_______ Number  None  Don’t Know

4. [If respondent reported college students in 35] How many college students participated in each of the following types of training and technical assistance activities?

	Number	Don’t Know
1-day in-person service-learning institute		
In-person service-learning institute that lasted more than one day		
Webinars		
Discussion lists, wikis, and other forums for electronic collaboration		
In-person meetings with representatives of community partner organizations		
Opportunities to participate in Professional Learning Communities		
Opportunities to work with a mentor who has experience using service-learning		
Opportunities to take part in service-learning projects as participants/service-learners		
Training and/or technical assistance for including service-learning within existing methods courses [HED ONLY]		
Training and/or technical assistance for including service-learning within existing foundations courses [HED ONLY]		
Training and/or technical assistance for providing stand-alone courses in service-learning pedagogy [HED ONLY]		

5. Please provide a brief description (100-150 words) of the training and technical assistance activities that were supported by Learn and Serve America funds. The description may include any special initiatives that you introduced, areas covered by training and technical assistance, and subject or service areas for curricula developed, as well as the number and type of school, teachers, staff, and students involved in these activities.

1

2011 Learn and Serve America Program and Performance Report

K12, HED, CBO Grants