Implementation Survey: Fall 2010

							                                                                                                   SCHOOL:


                                                         STATUS SURVEY
                                             Implementation of Components: Fall 2010



The purpose of this survey is to get a “snapshot” of the grant components af ter the f irst
9-w eek period. Please complete the survey and put it in your netw ork f older by Monday,
November 1, 2010. Thank you.


 SC HO O L - R EL AT ED B EH AV I O R S I nd ica t e y o u r st ud ent s’ lev el o f i mp r o v e me nt in th e a re a s
li ste d to t he lef t . Us e a n “ X” f o r y o ur cho ice .



           AREA                    D i d N ot
                                    Need to          S i g ni f i c a n t      M od e r at e             Slight                  No
                                   I mp r o v e    I mp r o v e me n t      I mp r o v e me n t      I mp r o v e me n t      C ha ng e       Decline

 1     R e a di ng

 2     M at h

 3     Science

 4     C o mp l e t i ng
       H o me w o r k

 5     B e h a vi or i n 2 1 s t
       C C L C p r og r a m




F AM ILY / P AR E NT I N V O LV EM ENT Pl ea s e i n dic a te if y o u ha v e o ffe r ed a ny o f t he se w o r ks h o ps .
If no t, in di ca t e w he n y o u pla n t o o f f er it i n t h e fut ur e.

                                                                        YES (Write date
      W o r ks h o p s                                                  of f e r e d )            NO        FUTURE PLANS
 1    F a mi l y l i t e r ac y p r og r a m ( e . g .
      h o me w or k a s s i s t a n c e w or ks h o p )
 2    T r ai ni ng p r og r a m i n c o mp ut e r l i t e r a c y
      f o r p ar e nt s
 3    W o r ks h o p o r or i e n t a t i o n s e s s i o n o n
      c o mmu n i t y s e r vi c e s ( e . g . , H e al t h
      S e r vi c e s , U s e of L i br a r y R e s o u r c e s ,
      W o r kf o r c e S ki l l s )
 4    Other (specify)




P AR T N E R S       H ow ma ny p a r t ne r s h av e y o u w or ke d w i t h s o f ar ?          _ _ _ _ _ _ _ __ ( w r i t e i n t h e n u mb e r o f
p a r t ne r s )




C:\Docs toc\Wor ki ng \pdf\b8212401 -8589-4671-ac59-4c81096a7062.doc
ACT I VIT I E S In d ica t e t he e xt e nt t o w h ic h y o u ha v e i mp l e me nte d ea ch a ctiv ity i n y o u r pro g r a m.
Us e a n “ X” fo r y o ur c h o ice.

                                                                             A t l e as t
      ACTIVITY                                                                 2x a          O n-      B i -w e e kl y          As            Not
                                                                W e e kl y    week          g oi ng   or mo n t h l y    s c h e d ul e d   of f e r e d
1     H o me w o r k as s i s t a nc e

2     I n di vi d u al i z e d t ut o r i ng

3     S ma l l - g r o u p i n s t r uc t i o n

4     H a n ds - o n s c i e n c e ac t i vi t i e s
      ( C h al l e ng e r L e ar n i ng C e nt e r ,
      M ag L a b, e t c . )
5     M e nt o r i ng

6     C ha r ac t e r E d u c at i o n ( e . g .
      P r i n c i pl e W o o ds )

7     R e c r e at i o n ( da n c e , mu s i c , s p or t s )

8     D r o p o ut P r e ve n t i o n

9     S e r vi c e L e a r ni ng

10    P a r e n t w or ks h o p s – h ow t o h e l p
      c hi l d b e s u c c e s s f ul i n s c h o ol
11    C o mp u t e r t r ai ni ng f o r p a r e n t s

12    Other (specify)




Add additional comments here.




C:\Docs toc\Wor ki ng \pdf\b8212401 -8589-4671-ac59-4c81096a7062.doc