Commitment to Community Service

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					                                                             BLT Long Term Outcome Instrument

                  Commitment to Community Service
                                         Youth Survey
Today’s Date:________________                                              Class of______________
                                             Team Number _____             Participant Number_____
Please indicate to what extent you agree with each of the following statements, using this scale:
As a young person working with Totally      Somewhat Uncertain Somewhat Totally
other youth in a non-formal        Disagree Disagree           Agree    Agree
setting, you…
1. Encourage youth to accept
   positions of responsibility and
   leadership.
2. Actively involve youth in
   evaluating programs/activities.
3. Changed your commitment to
   serving the community.
4. Encourage youth to participate
   in implementing a
   program/activity.
5. Provide youth with
   opportunities to participate in
   their community through youth-
   led service.
6. Reach out to youth community
   members to assist you with
   your program.
7. Reach out to other adult
   community members to assist
   you with your program.
8. Advocate for youth at
   community meetings/events.

As a young person working with        Not At            Rarely        Some         More             All
other youth in a non-formal           All                                          Often            The
setting, you…                                                                      Than Not         Time
9. The youth in my program feel they
    learn new skills.
10. This program has helped me learn
    to interact more effectively with
    other adults also working with
    youth.
11. This program has helped me learn
    to be a better planner and
    organizer of programs/activities.
12. This program has helped me learn
    to be a better coordinator and
    motivator of people.
                                                                                                           1
                                                         BLT Long Term Outcome Instrument

Over the past 2-3 year period briefly describe your experience for each of the questions
below.
13. Briefly share 1-2 projects you have been involved with in your community, school, job or
    organizations for which you are pleased/proud.




14. Briefly share experiences where you provided leadership which allowed youth an
    opportunity to advocate for themselves.




15. Briefly identify specific experiences that have helped you enhance/utilize your skills and
    knowledge for youth governance, civic activism and youth-adult partnerships.
    Youth Governance



   Civic Activism



   Youth-Adult Partnerships



17. How did BLT help you learn to better work with youth in today's ever-changing
    environments?



For each of the following items, please mark the one response that best describes you.

18. I am a: (check one) ___ male ___ female

19. How old are you? ______ years old.

20. Grade in School: _________

21. How do you describe yourself? (check one)
    ___ African-American, not of Hispanic origin
    ___ American Indian or Alaskan Native
    ___ Asian/Pacific Islander
    ___ Hispanic
    ___ White, not of Hispanic origin
    ___ Other- please specify _____________________________________________

                                                                                                 2
                                                         BLT Long Term Outcome Instrument

21. My major role in working with youth is best described as (please remember: mark one
    response only, the most appropriate response):
    ___ Working directly with youth on a daily basis
    ___ Supervising/planning individual educational activities for youth
    ___ Supervising/planning entire educational programs for youth
    ___ Supervising/supporting paid staff working directly with youth
    ___ Supervising/supporting un-paid volunteers working directly with youth
    ___ Advocating for youth with public/governmental entities
    ___ Some other role not described above please specify briefly
         ____________________________________________________________

22. How many years have you been in 4-H? ____ years

23. If you have been involved in other youth activities and organizations in the past, please
    indicate below how many years you have been involved:
    ___ Sports
    ___ Student Government
    ___ Drama or Dance
    ___ Academic Club
    ___ Pep Club
    ___ Band or Symphony
    ___ Community organization (i.e., Boy Scouts, Girl Scouts, YMCA, Girls Inc., Junior
          Achievement) please specify: _______________________________________
    ___ Youth group at church, synagogue or mosque
    ___ Other youth activities or organizations, please specify:
          _______________________________________________________________

                        Thank you for providing this information!




                                                                                                3
                                                             BLT Long Term Outcome Instrument

                  Commitment to Community Service
                                         Adult Survey
Today’s Date:________________                                              Class of______________
                                             Team Number _____             Participant Number_____
Please indicate to what extent you agree with each of the following statements, using this scale:
As an adult working with other          Totally  Somewhat Uncertain Somewhat Totally
youth in a non-formal setting,          Disagree Disagree           Agree    Agree
you…
1. Encourage youth to accept
   positions of responsibility and
   leadership.
2. Actively involve youth in
   evaluating programs/activities.
3. Changed your commitment to
   serving the community.
4. Encourage youth to participate
   in implementing a
   program/activity.
5. Provide youth with
   opportunities to participate in
   their community through youth-
   led service.
6. Reach out to youth community
   members to assist you with
   your program.
7. Reach out to other adult
   community members to assist
   you with your program.
8. Advocate for youth at
   community meetings/events.

As an adult working with other        Not At            Rarely        Some         More             All
youth in a non-formal setting,        All                                          Often            The
you…                                                                               Than Not         Time
9. The youth in my program feel they
    learn new skills.
10. This program has helped me learn
    to interact more effectively with
    other adults also working with
    youth.
11. This program has helped me learn
    to be a better planner and
    organizer of programs/activities.
12. This program has helped me learn
    to be a better coordinator and
    motivator of people.
                                                                                                           4
                                                        BLT Long Term Outcome Instrument
Over the past 2-3 year period briefly describe your experience for each of the questions
below.
13. Briefly share 1-2 projects you have been involved with in your community, school, job or
    organizations for which you are pleased/proud.




14. Briefly share experiences where you provided leadership which allowed youth an
    opportunity to advocate for themselves.




15. Briefly identify specific experiences that have helped you enhance/utilize your skills and
    knowledge for youth governance, civic activism and youth-adult partnerships.
    Youth Governance



   Civic Activism



   Youth-Adult Partnerships



16. How did BLT help you learn to better work with youth in today's ever-changing
    environments?



For each of the following items, please mark the one response that best describes you.

17. I am a: (check one) ___ male ___ female

18. How old are you? ___ 20-29 ___ 30-39 ___ 40-49 ___ 50-59 ___ 60 plus

19. How do you describe yourself? (check one)
    ___ African-American, not of Hispanic origin
    ___ American Indian or Alaskan Native
    ___ Asian/Pacific Islander
    ___ Hispanic
    ___ White, not of Hispanic origin
    ___ Other- please specify _____________________________________________




                                                                                                 5
                                                        BLT Long Term Outcome Instrument
20. The highest level of formal education I have completed is: (check one)
    ___ Some high school                          ___ Four year college/university bachelors
    ___ High school diploma                           degree (BA or BS)
    ___ GED                                       ___ Some college/university graduate work
    ___ Some college/university                   ___ College/university graduate degree (MA,
    ___ Two year college/university                   MS, EdD, or PhD)
        associate degree                          ___ College/university professional degree
                                                      (MD, JD, etc.)

21. I am a: (check one) ___ paid staff member ___ volunteer staff member

22. My major role in working with youth is best described as (please remember: mark one
    response only, the most appropriate response):
    ___ Working directly with youth on a daily basis
    ___ Supervising/planning individual educational activities for youth
    ___ Supervising/planning entire educational programs for youth
    ___ Supervising/supporting paid staff working directly with youth
    ___ Supervising/supporting un-paid volunteers working directly with youth
    ___ Advocating for youth with public/governmental entities
    ___ Some other role not described above please specify briefly
         ____________________________________________________________

23. My major role in working with youth is best described as (please remember: mark one
    response only, the most appropriate response):
    ___ Working directly with youth on a daily basis
    ___ Supervising/planning individual educational activities for youth
    ___ Supervising/planning entire educational programs for youth
    ___ Supervising/supporting paid staff working directly with youth
    ___ Supervising/supporting un-paid volunteers working directly with youth
    ___ Advocating for youth with public/governmental entities
    ___ Some other role not described above please specify briefly
         ____________________________________________________________

24. How many years have you been involved in 4-H? ____ years

25. If you have been involved in other youth activities and organizations in the past, please
    indicate below how many years you have been involved:
    ___ Sports                                 ___ Community organization (i.e., Boy Scouts,
    ___ Student Government                            Girl Scouts, YMCA, Girls Inc., Junior
    ___ Drama or Dance                                Achievement) please specify:
    ___ Academic Club                                 ________________________________
    ___ Pep Club                               ___ Youth group at church, synagogue or
    ___ Band or Symphony                              mosque
                                               ___ Other youth activities or organizations,
                                                      please specify:
                                                      ________________________________

                        Thank you for providing this information!

                                                                                                6

				
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