Program Data Collection Worksheet

WiSTEM2D Evaluation

If you are submitting data for more than one event in a series you can complete this survey at the end of the event series. Contact crandazz@its.jnj.com if you have any questions.

Question Title

* 1. Region

Question Title

* 2. Name of Country/Area Champion

Question Title

* 3. Event Name

Question Title

* 4. Event Dates

Event start date

Date

Event end date

Date

Question Title

* 5. City/Town:

Question Title

* 6. State/Province

Question Title

* 7. Country

Question Title

* 8. Did you work with a partner?

FHI360

Girl Scouts/Girl Guides

Smithsonian Science Education Center

Junior Achievement

First Robotics

N/A

Other (please specify)

Question Title

* 9. Activity used

Question Title

* 10. Student ages:

Ages 0-5 (early childhood)

Ages 6-12 (elementary, middle school)

Ages 13-19 (middle school, high school)

Program Data Collection Worksheet

WiSTEM2D Evaluation

Question Title

* 1. Region

Question Title

* 2. Name of Country/Area Champion

Question Title

* 3. Event Name

Question Title

* 4. Event Dates

Question Title

* 5. City/Town:

Question Title

* 6. State/Province

Question Title

* 7. Country

Question Title

* 8. Did you work with a partner?

Question Title

* 9. Activity used

Question Title

* 10. Student ages:

Question Title

* 11. Total number of attendees (students):

Question Title

* 12. Number of female students:

Question Title

* 13. Number of J&J volunteers