Instrument 5: Facilitator exit ticket

THE PAPERWORK REDUCTION ACT OF 1995

This collection of information is voluntary and will be used to provide the Administration for Children and Families with information to help refine and guide SRAE program development. Public reporting burden for the collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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. The OMB number and expiration date for this collection are OMB #: XXXX-XXXX, Exp: XX/XX/20XX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Melissa Thomas at [email protected].

INSTRUMENT 5: FACILITATOR Exit Ticket

OMB Control No: XXXX-XXXX

Expiration Date: XX/XX/20XX

INSTRUMENT 5: FACILITATOR EXIT TICKET

This study is sponsored by the Administration for Children and Families (ACF) within the U.S. Department of Health and Human Services and is being conducted by Mathematica. The purpose of this log is to learn about your experience delivering [PROGRAM] / using [STRATEGY]. The information we collect will not be used to evaluate your performance as a facilitator so please just do your best to answer honestly.

If you have any questions or comments about this information collection, contact Melissa Thomas, the survey director, at [email protected] or (609) 275-2231. If you have any questions or concerns about your rights as a study participant, please contact the Health Media Lab Institutional Review Board at (202) 246-8504.

Please complete this log after each class where you deliver [PROGRAM]. This should take 2 minutes to complete.

Facilitator: ____________________ School: ____________________ Class period: ________ [PROGRAM] lesson #: ________

	During this class, did you [use/implement] …		For [strategies/approaches] I used, I thought it went …
[STRATEGY/APPROACH 1]	Yes	No	Poorly	Pretty good	Excellent
[STRATEGY/APPROACH 2]	Yes	No	Poorly	Pretty good	Excellent
[STRATEGY/APPROACH 3]	Yes	No	Poorly	Pretty good	Excellent

Overall, how comfortable did you feel delivering [PROGRAM/STRATEGY] during this class period?

Not at all comfortable Somewhat comfortable Very comfortable

Overall, how engaged do you think the students were during this class period?

Not at all engaged Somewhat engaged Very engaged

Did anything happen during class that prevented you from delivering the [PROGRAM] lesson as intended? (for example, a fire drill, school assembly, etc.)

Yes No