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* 1. Site Name

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* 2. What is your role in the after-school program?

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* 3. Fill in this box with your title/position if you also work at the school during the regular school day

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* 4. Please check the highest level of education that you have completed:

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* 5. In which area do you feel the after school program excels? (Select one).

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* 6. In which area do you feel the after school program needs improvement? (Select one).

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* 7. What opportunities for staff development have you had this year? (Check all that apply)

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* 8. Please check the top 3 areas in which you'd like training

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* 9. Briefly describe the types of activities you regularly do with kids in the after-school program

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* 10. To what extent do you agree or disagree with the following statements?

  Strongly Disagree Disagree Agree Strongly Agree Don't know
I am aware of what happens during the school day, for example, the work students are doing in their classes
The school supports the after-school program in general
The school shares its resources (rooms, equipment, etc) with the after-school program
Teachers inform AS program staff when individual students are having a bad day
The program relates to what is being taught during the school day
School day teachers are well informed of what happens in the after-school program
After school staff communicate regularly with school day teachers about students' homework
Students are able to complete and hand in their homework on time
The after-school staff keeps parents informed about the program
The after-school staff keeps parents informed about individual students
The AS program staff welcomes parents to observe
The AS program staff welcomes parents to participate
There is a balance between academic and enrichment activities
The AS program staff have sufficient resources to conduct our activities
The AS program staff have adequate support from the site coordinator
The AS program staff have adequate support from the Project Director
The program helps students academically and/or in homework completion
The program helps students learn how to get along with others
The program facilitates positive behavior among the participants
The after school program provides enough time for physical activity
The after school program environment promotes healthy eating and food choices

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