Instrument 3_Youth Engagement Exit Ticket

INSTRUMENT 3

YOUTH ENGAGEMENT EXIT TICKET

OMB Control No: 0990-new

Expiration Date: XX/XX/XXXX

Youth Engagement Exit Ticket

Date:

School or CBO: [pre-filled]

Name of class teacher: [pre-filled]

Name of REA facilitator: [pre-filled]

Class session #: [pre-filled]

Youth ID #: [pre-filled]

Class period:

Note: Once you remove the cover sheet, your name will not be connected with your response. Your teacher or facilitator will not be able to see your answers to these questions

For each of the following, please answer based on your experience with today’s lesson.

	Not at all	Slightly	Somewhat	Mostly	A great deal
1. I enjoyed the lesson	1 	2 	3 	4 	5 
2. The lesson really made me think	1 	2 	3 	4 	5 
3. I tried hard during the lesson	1 	2 	3 	4 	5 
4. I paid attention during the lesson	1 	2 	3 	4 	5 
5. Today’s lesson is going to help me deal with important issues in my life in the next few years.	1 	2 	3 	4 	5 

THE PAPERWORK REDUCTION ACT OF 1995

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-new. The time required to complete this information collection is estimated to average 2 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer