Our Kids Network Evaluate and celebrate

Asset Building Toolkit

After-school program survey

1. How old are you? ______

2. For each of the following activities, please circle whether or not you did the activity during the past 7 days. Think about activities you did before and after school, in the evenings, and on the weekends, by yourself or with others. Do not include Phys Ed or gym class. Include activities you did just for fun or in competition.

Activity / Past 7 days
1)  Active video games (Wii, Dance Dance Revolution [DDR]) / Yes No
2)  Aerobics / Yes No
3)  Baseball/softball / Yes No
4)  Basketball / Yes No
5)  Bike riding / Yes No
6)  Cheerleading / Yes No
7)  Dance / Yes No
8)  Field hockey/street hockey/roller hockey / Yes No
9)  Football / Yes No
10) Frisbee / Yes No
11) Golf / Yes No
12) Gymnastics/tumbling / Yes No
13) Hiking / Yes No
14) Horseback riding / Yes No
15) Ice hockey / Yes No
16) Ice skating / Yes No
17) Jumping rope / Yes No
18) Lacrosse / Yes No
19) Marching band / Yes No
20) Martial arts (karate, tae kwon do, judo, etc.) / Yes No
21) Racquetball / Yes No
22) Roller blading/roller skating / Yes No
23) Running/jogging / Yes No
24) Skateboarding / Yes No
25) Soccer / Yes No
26) Surfing / Yes No
27) Swimming / Yes No
28) Tennis / Yes No
29) Track and field / Yes No
30) Volleyball / Yes No
31) Waterskiing / Yes No
32) Walking / Yes No
33) Weightlifting / Yes No
34) Wrestling / Yes No
35) Yoga / Yes No

Our Kids Network Evaluate and celebrate

Asset Building Toolkit

3. How much do you agree or disagree with each statement? (Mark one answer for each statement.)

When I am physically active… / Agree
J / Not sure / Disagree
L /
a)  I have fun
b)  It gives me energy
c)  I feel good

The next 6 questions ask about food and what you eat or drink. Think about all your meals and snacks. Be sure to include food you ate at home, at school, at restaurants, or anywhere else.

4. How often do you eat or drink the following: (Mark one answer for each statement.)

/ Less than once a day / Once a day / Twice a day / 3 times a day / 4 times a day / 5 or more times a day /
a)  Fruit juice or vegetable juice
b)  Vegetables including salad (not juice)
c)  Fruits (not juice)

Our Kids Network Evaluate and celebrate

Asset Building Toolkit

5. What do you eat for snacks? (Put an ‘X’ beside all that apply)

______cereal, bread, popcorn, rice

______apple, orange juice, grapes, banana, raisins

______carrots, lettuce salad, broccoli, celery, vegetable juice

______milk, cheese, yogurt

______peanut butter, eggs, peanuts, chickpeas, lentils, beans

______cookies, candy, pop, donuts

______potato chips, french fries

6. Mark an ‘X’ in the box that best describes you:

/ Very often
J / Sometimes / Never
L /
a)  I wash my hands before I eat
b)  I wash fruits and vegetables before eating them
c)  I ask for help when I use knives, blenders, mixers
d)  I clean up the kitchen after I make food
e)  I help make meals at home
f)  I help with grocery shopping
g)  I make my own snacks between meals
h)  I pack my own lunch for school


7. Write down all the new foods that you have tried in this program (food that you never ate before):

8. Put an ‘X’ beside the food on each line that you think is healthier:

Plain popcorn / Potato chips
French fries / Baked potato
Cracker / Cookie

Our Kids Network Evaluate and celebrate

Asset Building Toolkit

9. Tell us about this program. Please rate the following:

/ Agree
J / Not Sure / Disagree
L /
a)  My instructor was helpful and friendly
b)  I had fun
c)  I made new friends
d)  I feel good about myself
e)  I learned new things

10. Use words or a picture to tell us anything else about this program:

Our Kids Network Section 6 Evaluate and celebrate

Asset Building Toolkit Big surveys and toolkits

Adapted from Benson (1997), Chapter 6, with permission of Jossey-Bass, Inc., a subsidiary of John Wiley & Sons, Inc. This tool may be reproduced for educational, non-commercial uses only. From First Steps in Evaluation: Basic Tools for Asset-Building Initiatives, by Thomas H. Berkas and Kathryn L. Hong. Copyright © 2000 by Search Institute; 800-888-7828; www.search-institute.org