Fast-Track Template Submission Form

MSY Teen Leaders Program: Final Program Satisfaction Survey for Teen Leader
Thank you for your participation in the Media­Smart Youth Teen Leaders Program. We look forward to receiving your 
feedback! 
___________________________ 

OMB Number: 0925­0643 
Expiration Date: 10/31/2017 

Public reporting burden for this collection of information is estimated to average 30 minutes, including the time for 
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and 
reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond 
to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this 
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: 
NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892­7974, ATTN: PRA (0925­0643). 
Do not return the completed form to this address. 

Site Information

*1. Name of Nonprofit Partner Organization:

*2. City and State

*3. How did your site use your mini­grant funds? Please provide estimates of what you

spent for the categories below, plus costs for any additional categories if applicable.
Food and snack supplies
Program supplies (art 
supplies, copies, etc.)
Printing
Gas/Transportation
Stipend for teen leader(s)
Other (please specify)
Other (please specify)
Other (please specify)

*4. How did your nonprofit partner support your program? (Check all that apply)
c Transferred award funds
d
e
f
g

c Helped promote the program
d
e
f
g
c Helped recruit participants
d
e
f
g
c Provided space for lessons
d
e
f
g

c Provided free program materials (snacks, art and craft supplies, copies, etc.)
d
e
f
g
Other (Please describe) 

5
6

*5. If you enlisted community partners, beyond your nonprofit partner and a media

partner, what support did they provide?
Grocery store
Farm
Office supply store
School
Another youth­serving 
organization
Faith organization
Local parks & recreation 
department
Other

*6. Did your National Institutes of Health (NIH) funding award and community partner

contributions (if you received any) cover all of your costs?

j Yes
k
l
m
n
j No
k
l
m
n

If not, please explain. 

5
6

Program Activities

*7. What did the participants at your site do for their Big Production?
5
6  

*8. Did your site have a media partner help with the program?

j Yes
k
l
m
n
j No
k
l
m
n

If yes, who was your partner and how did they help? 

5
6

*9. Did your site take any field trips?
j No, our site did not take any field trips.
k
l
m
n
j Yes, to a grocery store
k
l
m
n

j Yes, to visit the media partner on site
k
l
m
n
j Yes, other
k
l
m
n

Please describe. 

5
6

10. If your site took a field trip, please tell us about your experience.
5
6  

Satisfaction with Media­Smart Youth Lessons

*11. Please tell us how you feel about the Media­Smart Youth curriculum by letting us

know how much you agree or disagree with the following sentences.
The lessons helped 

Strongly Agree

Agree

Disagree

Strongly Disagree

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

participants think more 
critically about media 
messages.
Since being in the 
program, the participants 
have shown a stronger 
interest in making healthy 
choices, like eating 
nutritious foods or being 
physically active.

*12. What activity or activities did the participants like best?
5
6  

*13. What activity or activities did the participants like least?
5
6  

Satisfaction with the Level of Program Support

*14. Please rate your level of agreement with the following statements.
Strongly Agree

Agree

Disagree

Strongly Disagree

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

I received the support I 
needed from my adult 
advisor.
I received the support I 
needed from my nonprofit 
partner.

*15. What additional support, if any, would you have liked from your:
Advisor
Nonprofit partner

*16. Please rate your level of agreement with the following statements.
I received the support I 

Strongly Agree

Agree

Disagree

Strongly Disagree

Not applicable

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

needed from the NIH and 
its contractor, IQ Solutions.
The webinar training I 
received at the start of the 
program was helpful.
I felt well prepared to lead 
Media­Smart Youth lessons.
The check­in calls during 
the program were helpful.

17. What additional support, if any, would you have liked from NIH and/or its contractor, IQ
Solutions?
5
6  

*18. Could NIH/IQ Solutions have done anything more to better prepare you to be a

Media­ Smart Youth Teen Leader? If yes, what?

j Yes
k
l
m
n
j No
k
l
m
n

If yes, what? 

5
6

Satisfaction as a Media­Smart Youth Teen Leader

*19. Overall, how satisfied were you with your experience as a Media­Smart Youth Teen

Leader?

j Very Satisfied
k
l
m
n

j Satisfied
k
l
m
n

j Dissatisfied
k
l
m
n

j Very Dissatisfied
k
l
m
n

*20. What did you like best about being a Media­Smart Youth Teen Leader?
5
6  

*21. What did you like least about being a Media­Smart Youth Teen Leader?
5
6  

Successes and Challenges

*22. We know from previous Media­Smart Youth leaders that keeping all participants

involved through the full program can be a challenge. Was that a challenge you faced?

j Yes
k
l
m
n
j No
k
l
m
n

Please explain.  

5
6

*23. What strategies did you use to try to keep participants engaged?
5
6  

*24. What do you consider to be your site’s biggest success with the Media­Smart Youth

program?

5
6  

*25. What do you think were the reasons for the success?
5
6  

*26. Please describe an instance where you felt you were not successful in your

coordination of the program. What happened and what would you do differently if you did
the program again?
5
6  

*27. Would you recommend that other teens lead Media­Smart Youth in their community?

Why or why not?

5
6  

*28. What advice do you have for future Media­Smart Youth Teen Leaders?
5
6