Form 1190-0NEW CRS Program Evaluation Forms Facilitated Dialogues

OMB No. XXXX-XXXX

Expiration Date: XX/XX/XXXX

CRS Program Evaluation Forms
Facilitated Dialogues

August 2024

Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control Number. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is voluntary. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CRS/DOJ, Contracts & Forms, 145 N. ST NE, Washington, DC 20002 and reference the OMB Control Number XXXX-XXXX.

Facilitated Dialogues

In what language do you want to complete the survey?

¿En qué idioma desea completar la encuesta?

 English/Inglés 1

 Spanish/Español 2

This survey will help the Community Relations Service (CRS) improve facilitated dialogue programs. CRS will not publish or make public any comments or other information collected that could identify any specific person without written consent from that person.

1. Program name (select from list):

 School-SPIRIT 1

 Campus-SPIRIT 2

 City-SPIRIT 3

 General Facilitated Dialogue 4

 Dialogue on Race 5

 Strengthening Police and Community Partnerships 6

2. Name of CRS staff administering program

CRS STAFF

 N/A (online program)

3. Date of Program

DATE

4. Location (City, State)

LOCATION

5. Please select one category that best describes your role:

 Community member 1

 Faith leader 2 GO TO 5b

 Law enforcement 3 GO TO 5b

 City or government official 4 GO TO 5b

 School administrator, teacher, or other staff 5 GO TO 5b

 Nonprofit organization leaders 6 GO TO 5b

 Advocacy group member 7 GO TO 5b

 Student 8 GO TO 6

 [IF SCHOOL SPIRIT: Parent 9 GO TO 6]

 Other (please specify) 99 GO TO 5b

5a. [IF ROLE = 1] How many years have you lived in your community?

YEARS

(STRING (NUM))

5b. [IF ROLE NE 1] How many years have you been in your current role?

YEARS

(STRING (NUM))

6. Were you involved in planning this program?

 Yes 1

 No 0

 Unsure 2

We greatly appreciate receiving your feedback, and we will use your responses to help improve the program.

7. Please rate how strongly you agree or disagree with each of the following statements.

PROGRAMMER: CODE ONE PER ROW

Select one per row

	Strongly Disagree	Disagree	Neither agree nor disagree	Agree	Strongly Agree
a. The program had clear, understandable goals.	1 	2 	3 	4 	5 
b. The program was interactive.	1 	2 	3 	4 	5 
c. The program was engaging.	1 	2 	3 	4 	5 
d. The program created a safe environment and made it comfortable for me to share my perspectives.	1 	2 	3 	4 	5 
e. The facilitator(s) effectively managed the process, promoted productive dialogue, and handled any tensions that arose.	1 	2 	3 	4 	5 
f. Participation helped identify the issues that are important for the [school] [community] to address.	1 	2 	3 	4 	5 
g. Participation helped to develop and prioritize solutions to address important issues in the [school] [community]. (If applicable)	1 	2 	3 	4 	5 
h. I feel motivated to stay engaged in addressing important [school] [community] issues.	1 	2 	3 	4 	5 
i. I feel prepared to apply what I learned from the program to my professional, [school] or personal life.	1 	2 	3 	4 	5 
j. The program was culturally responsive, applicable, and appropriately tailored to meet my [community’s] [school’s] needs.	1 	2 	3 	4 	5 
k. The program met my expectations.	1 	2 	3 	4 	5 
l. The program was a worthwhile use of my time.	1 	2 	3 	4 	5 

In the next sections, we will first ask you questions about your current level of knowledge on different topics now that you have completed the program. Then, we will ask you about how much you learned as a result of the program.

8. On a scale of 1 to 5, where 1 is you have no understanding at all and 5 is you had a very comprehensive understanding of the topic, please rate your current level of understanding on the following topics.

PROGRAMMER: CODE ONE PER ROW

Select one per row

	No understanding at all	A little	Moderate	Comprehensive	Very comprehensive understanding
a. The perspectives of people with different personal experiences, views, or opinions (even if you don’t agree with them)	1 	2 	3 	4 	5 
b. Underlying causes of tension or conflict in the [school] [community].	1 	2 	3 	4 	5 
c. My role in addressing tension or conflict in the [school] [community]	1 	2 	3 	4 	5 
d. Strategies I can use to address tension or conflict in the [school] [community].	1 	2 	3 	4 	5 

9. On a scale of 1 to 5, where 1 is not at all and 5 is a great amount, please indicate how much your understanding or knowledge about the following topics increased as a result of the program.

PROGRAMMER: CODE ONE PER ROW

Select one per row

	Not at all	A little	Some	A good amount	A great amount
a. The perspectives of people with different personal experiences, views, or opinions (even if you don’t agree with them)	1 	2 	3 	4 	5 
b. Underlying causes of tension or conflict in the [school] [community].	1 	2 	3 	4 	5 
c. My role in addressing tension or conflict in the [school] [community].	1 	2 	3 	4 	5 
d. Strategies I can use to address tension or conflict in the [school] [community].	1 	2 	3 	4 	5 

10. What did you like best (or find most valuable) about the program?

(FIELD DESCRIPTION)

11. What could improve the program? For example, could the material have been more engaging in some way? Were there topics you have liked to see included? Please be specific.

(FIELD DESCRIPTION)

12. Do you have additional comments you would like to share?

(FIELD DESCRIPTION)

Thank you for your feedback!