Educational Activity Cover Sheet

Educational Activity Cover Sheet

To be completed by the instructor and submitted with the forms by someone other than the instructor.

Instructor:

Unit, County, or Department:

Last 4 digits of SS# (For internal tracking.):

Date of presentation

Title of presentation:

Number of forms completed (Please do not send blank forms.):

Name of person collecting and sending forms:

Association with instructor (Circle all that apply.):

a. Colleague

b. Participant

c. Other:

Date received:

Date returned to instructor:

Adapted from Ohio State University materials.

Programs and activities offered by the West Virginia University Extension Service are available to all persons without regard to race, color, sex, disability, religion, age, veteran status, political beliefs, sexual orientation, national origin, and marital or family status. Issued in furtherance of Cooperative Extension work. Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture. Director, Cooperative Extension Service, West Virginia University.

West Virginia University is governed by the West Virginia Higher Education Policy Commission and the WVU Board of Governors.

A publication of West Virginia University Extension Service

– continued –

Circle the appropriate response for each of the following:

Group Characteristics

1. Group Size (Circle one)

a. LESS than 20

b. 20 to 50

c. MORE than 50

2. Group History (Circle one)

a. ONGOING Group

b. NEW Group that is likely to continue

c. ONE-TIME Group

d. UNKNOWN

3. Predominant Group Membership (Circle one for each group of responses)

3.1 Age

a. Youths

b. Adults

c. Both

3.2) EXPERIENCE with WVU Extension Programs

a. Group has experience with WVU ES

b. Group is NEW to WVU ES

c. Group is WVU ES personnel

d. Group is a combination of more than one group

e. Other ______

4. History of Instructor’s Contact with the Group (Circle one)

a. FIRST TIME with group

b. Has met with group INFREQUENTLY

c. Has met with group REGULARLY

Teaching Environment

5. Teaching Location (Circle all that apply)

a. Traditional Classroom Setting

b. Field Setting (home, business,

camp, fair, etc.)

c. Laboratory Setting

d. Other: ______

6. Teaching Methodology (Circle all that apply)

a. Lecture

b. Group Discussion

c. Hands-on

d. Mass Media (radio, TV, newspaper,

newsletters)

e. Demonstrations

f. Other: ______

7. Type of Session (Circle one)

a. ONE-TIME only

b. PART of a Program Series

c. REGULARLY Scheduled Meetings

d. Other: ______

Instructor Characteristics

8. Appointment (Circle one)

a. Program Assistant

b. Extension Agent

c. State Specialist

d. Administrator

e. Other: ______

9. Main Program Area (Circle one)

a. Agriculture and Natural Resources

b. Family and Health

c. 4-H Youth Development

d. Community Development

e. Other: ______

10. Location (Circle the one that best describes your office location)

a. County

b. State

c. Other: ______

11. Length of employment (Circle one)

a. LESS than 2 years

b. 2 to 6 years

c. MORE than 6 years