Form 1 MSY Teen Leaders_Midpoint Survey

MSY Teen Leaders Program: Midpoint Satisfaction Survey for Teen Leaders

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 many youth participants has your site recruited for the Media­Smart Youth Teen

Leaders Program?

*4. On average, how many participants attend each lesson?

*5. Which of your recruitment strategies were most effective in getting participants to

sign up?

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*6. Does your site conduct the program in English?

j Yes
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l
m
n
j No
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l
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n

If not, what language(s)? 

Satisfaction with the Media­Smart Youth Curriculum

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

know how much you agree or disagree with the following statements.
The Media­Smart Youth 

Strongly Agree

Agree

Disagree 

Strongly Disagree

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n

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lessons are easy to teach.
The participants enjoy the 
lessons.
The participants have 
learned something new 
about eating healthy and 
being physically active.

*8. Has your site made any changes to the curriculum to make it work better for your

participants?

j Yes
k
l
m
n
j No
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l
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n

If yes, please explain. 

Satisfaction as a Media­Smart Youth Teen Leader

*9. Overall, how satisfied are you in your role as a Media­Smart Youth Teen Leader?
j Very Satisfied
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l
m
n

j Satisfied
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l
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n

j Dissatisfied
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l
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n

j Very Dissatisfied
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n

*10. What do you like best about being a Media­Smart Youth Program Teen Leader?
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*11. What do you like least about being a Media­Smart Youth Program Teen Leader?
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Satisfaction with Program Support

*12. What support have you received from your advisor?
c Made me aware of the Media­Smart Youth Teen Leaders Program opportunity
d
e
f
g
c Helped me write the application
d
e
f
g
c Helped me develop a budget
d
e
f
g

c Helped me recruit participants
d
e
f
g

c Helped me gather parent permission forms
d
e
f
g
c Helped me plan for the lessons
d
e
f
g

c Supervised participants during the lessons
d
e
f
g

c Coordinated field trip(s)
d
e
f
g
c Other (Please describe)
d
e
f
g

c Helped me purchase/gather supplies
d
e
f
g

c Helped me facilitate lessons
d
e
f
g

*13. Has your nonprofit partner provided the funds in a timely manner?

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

If no, please explain.  

*14. Is there additional support you need from the Media­Smart Youth team to help you

succeed?

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

If yes, please tell us what we can do to support you as a Teen Leader. 

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Successes and Challenges

*15. To date, what has been your greatest accomplishment as a Media­Smart Youth Teen

Leader?

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*16. What factors contributed most to your success? (Please check all that apply)
c The quality of the program
d
e
f
g
c Support from adult advisor
d
e
f
g

c Support from nonprofit partner
d
e
f
g
c Support from program site
d
e
f
g

c Support from parents/caregivers
d
e
f
g

c Support from the National Institutes of Health and/or its contractor, IQ Solutions
d
e
f
g
c Webinar training
d
e
f
g
c Media partner(s)
d
e
f
g

c Other community partner(s)
d
e
f
g

c My own previous experience as a leader/working with youth
d
e
f
g
c Other (please specify)
d
e
f
g

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*17. What overall challenges, if any, have you faced as a Media­Smart Youth Teen

Leader? (Please check all that apply)
c Securing a location for lessons
d
e
f
g
c Recruiting participants
d
e
f
g

c Keeping participants’ attention during the lessons
d
e
f
g

c Keeping participants coming back for each lesson
d
e
f
g

c Getting all of the needed supplies/snacks with the allotted budget
d
e
f
g
c Having enough time to plan and lead the lessons
d
e
f
g
c Using the curriculum
d
e
f
g

c Other (please specify)
d
e
f
g

18. Please tell us anything else you think is important to know about your experience with
the Media­Smart Youth Teen Leaders Program.
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