Form 0990 survey

Form Approved OMB No. 0990-

Exp. Date

Today’s Date: Program Location: Trainer Name(s):

This is Session # Session START Time: Session END Time:

Who attended this session?  Parents/Caregivers How many (#) attended this session? ____ Parents/Caregivers

 Children ____ Children

 Both

1. Please check off any activity you implemented during this session.

			 Check in/Discussion
			 Energizer and healthy snack
			 Closing Exercise/Discussion/Homework assignments
Below is a list of other BodyWorks activities you may have implemented today. Please check all other BodyWorks activities that you implemented during today’s session.
	Introduction to BodyWorks and Tools for Changing Habits				Setting Goals. Meal Planning, and Shopping
		Introduction of trainer and participants				Cooking healthy meals discussion
		Why BodyWorks and Toolkit Distribution				Cooking demonstration
		Behavior change & Goal-setting exercise				Using the weekly planner and goal-setting activity
		Smoothie demonstration
		Healthy lifestyle discussion

	Healthy Eating Part 1			Cooking and Eating Together
		Basics of healthy eating for children, teens, adults			Understanding the Nutrition Facts Label discussion
		BodyWorks Journals – Why and How to Use them			Involving the family in planning, shopping, cooking discussion
					Eating together discussion

	Physical Activity, Part 1			Physical Activity Part 2 and Media Influences
		Physical activity discussion (Types, barriers, benefits)			Media influences discussion
		Limiting screen time case study			Physical activity

	Healthy Eating Part 2			Maintaining Changes
		Serving size icebreaker and review serving sizes			Maintaining changes discussion
		Making healthy lunch choices			Physical activity
		Turkey sandwich demonstration			Potluck Party
		Making healthy fast food and beverage choices

2. Please answer the following questions about the activities you implemented in your session today. For each question, check only one box.

	Not at all	A Little	Mostly	Completely
To what extent did you implement the activities as written in the curriculum?				
How much did the activities help achieve the session learning objectives?				
How engaged were the participants in the activities?				
How satisfied were you with the time allotted for these activities?				
How satisfied were you with the activities overall?				

2. Did you modify any of the activities that were planned in the curriculum for today’s session?

 YES, I modified today’s activities. [Continue with Question 5]

 NO, I did not modify today’s activities. [Skip to Question 6]

2. If you modified any of today’s planned activities:

1. WHY did you modify them? (Choose one or more.)

 I did NOT LIKE the activity	 Group members seemed to DISLIKE the activity
 I felt UNCOMFORTABLE leading the activity	 Group members seemed UNCOMFORTABLE with the activity
 I had ANOTHER IDEA I thought would work better	 Topic/activity seemed too EASY for this group
 I needed more TIME	 Topic/activity seemed too HARD for this group
 I needed more RESOURCES (e.g. materials, supplies, equipment, space)	 Other:

2. HOW did you modify them? (Choose one or more.)

 I DELETED some content	 I COMBINED the content of two or more activities
 I SIMPLIFIED some content	 I brought in extra MATERIALS, supplies, or equipment
 I ADDED some content	 I brought in GUEST SPEAKER(S)
 Other:

3. Tell us more about your answers to A and B. (For example, which activity did you leave out, which topic was too hard, describe the activity you created, etc.): _____________________

6a. Please tell us what worked well in this session? (Use the back if you need more space.) ____________________________

6b. What should be improved in this session? (Use the back if you need more space.) ____________________________________

7. On a scale of 1-10, how would you rate your overall satisfaction with the current 8-week BodyWorks program so far?

Not at all satisfied									Extremely satisfied
	1	2	3	4	5	6	7	8	9	10

Page 3 of 3 Trainer Feedback Form – April, 2011