SAMPLE EVALUATION FORM

The following is an example of the evaluation form that can be created using this system. This form includes five indicator statements taken from the indicator list found at View Life Skills.

SAMPLE
4-H Science Camp Evaluation

We want to know how well 4-H Science Camp works. We are asking you to answer the following questions about what you may have learned from being in 4-H Science Camp. It should take about 10 minutes of your time to complete the survey. Your answers will be anonymous and will not be identified in any way. This means that no one will know how you have answered any of the questions. Answering the questions means you have agreed to participate in this evaluation. You do not have to fill out this survey. If you decide not to fill out the survey, it will not affect your participation in future MSU Extension programs.If you have any questions about this survey or the evaluation, please contact Sandy Bailey at (406) 994-6745.

Because of my participation in 4-H Science Camp I am able to:	Back . . . before I participated in 4-H Science Camp				Now . . . after I have participated in 4-H Science Camp
	Circle one number for each statement				Circle one number for each statement
	No	Sometimes	Usually	Yes	No	Sometimes	Usually	Yes
1. Wisely use the natural resources in my environment.	1	2	3	4	1	2	3	4
2. Listen carefully to what others say.	1	2	3	4	1	2	3	4
3. Treat people who are different from me with respect.	1	2	3	4	1	2	3	4
4. Work out problems that are presented to me.	1	2	3	4	1	2	3	4
5. Follow instructions as they are given to me.	1	2	3	4	1	2	3	4

Tell us about yourself. (Check one response to each question).

1. My age falls in the following group:

    ___11-13
    ___14-17
    ___18-25
    ___26-35
    ___36-45
    ___46-55
    ___55+

2. I am:

    ___female
    ___male

3. My current home is:

     ___farm
     ___rural non-farm
     ___town under 50,000
     ___city over 50,000

4. I would describe myself as:

    ___African American
    ___American Indian
    ___Asian American
    ___Hispanic
    ___White/Caucasian
    ___Racially mixed

1. The most important thing I have gained from attending 4-H Science Camp is...

2. The one thing, if anything, I would change about 4-H Science Camp is...

3. Other comments I would like to make...

Lifeskills programs and database designed and developed by Kathleen Duncan, WSU in Cooperation with Montana State University Extension Service
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