You are invited to complete this short questionnaire about the afterschool program. Your responses will be kept confidential, so please do not write your name. Your feedback will help us improve our program. By completing and returning this survey, you agree to participate in this study. 
SECTION A: AFTERSCHOOL QUALITY

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* 2. How much do you agree with the following statements about the
21st Century Community Learning Center afterschool program?

  1
Strongly Disagree
2
Disagree
3
In the Middle
4
Agree
5
Strongly Agree
1. My child feels welcome in the program.
2. The rooms used for the afterschool program are safe and clean.
3. The rules are clear and fair.
4. Staff treat my child with respect.
5. Staff listen to what my child has to say.
6. It is easy for my child to make friends in the program.
7. The program helps my child get along better with their peers. 
8. My child has input into what kind of activities are provided.
9. The activities are fun and engaging for my child.
10. My child has good attendance in the program.
11. The program provides enough opportunity for my child to complete homework.
12. The activities are designed to help my child do better in school.
13. The program helps my child apply what they learn in school.
14. The afterschool program staff and school-day staff communicate with each other.
15. Overall, I am happy with the program.
16. Afterschool staff involve parents in decision making and planning about activities.
17. Afterschool staff communicate well with parents.
18. Parents feel welcome in the program.
19. I would recommend this program to other parents. 
SECTION B: PERCEPTIONS OF PROGRAM IMPACT

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* 3. Since attending the 21st CCLC afterschool program, has your
child declined, stayed the same, or improved in the following areas?
Note: If he/she did not need to improve, please select that option.

  Did not need to improve 1
Declined
2
Stayed the Same
3
Improved
18. Grades
19. School attendance
20. Ability to make friends
21. Preparation for school
22. Classroom behavior
23. Homework completion
SECTION C: INVOLVEMENT

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* 4. An adult (parent or other caregiver) in our family…

  1
Never
2
One or two times a semester
3
At least once every month
4
Two to three times a month
5
Once a week
6
A few times a week
7
Daily
24. …talks with this child about the school day.
25. …supervises (or reviews) this child’s homework.
26. …helps (or encourages) this child to study for tests.
27. …helps (or encourages) this child to complete homework assignments.
28. …makes sure this child completes his/her homework.
29. …reviews this child’s grades on assignments and tests.
30. …helps (or encourages) this child to practice math skills.
31. …helps (or encourages) this child to practice reading or writing skills.
32. …encourages this child to check out library books.
33. …encourages this child to read for fun.
34. …suggests reading materials to this child.
35. …participates in reading activities with this child (e.g., talks with the child about what the child is reading, reads with the child).

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* 5. Family Programs

  None One Two Three Four Five or More
36. During this semester, how many family programs (e.g., family nights, activities) have you attended at your child’s school?

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* 6. What do you like most about the afterschool program?

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* 7. How can we make the afterschool program better?

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