You are invited to complete this short questionnaire about the afterschool program your child attends. By completing and submitting this survey, you agree to participate in this study. Your feedback is very important and will help us improve our afterschool program. Your responses will be kept confidential.

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* 1. School/Afterschool Site Name:

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 program is a safe place for my child to learn and have fun.
3. The rules are clear.
4. The rules are applied fairly to all students.
5. Staff treat my child with respect.
6. Staff listen to my child when he/she shares about interests and/or life outside of school.
7. It is easy for my child to make friends in the program.
8. The program helps my child get along better with their peers.
9. My child has input into what kind of activities are provided.
10. Staff listen to my child when he/she has suggestions or comments about the program.
11. The activities are fun and engaging for my child.
12. The program provides enough opportunity for my child to complete homework.
13. The activities are designed to help my child do better in school.
14. The program helps my child apply what they learn in school.
15. The afterschool program staff and school-day staff communicate with each other about my child.
16. Overall, I am happy with the program.
17. Afterschool staff involve parents in decision making and planning about activities.
18. Afterschool staff communicate well with parents.
19. I know how to reach afterschool program staff if I have an issue or concern. 
20. Afterschool staff share information about community resources to support family needs (e.g., food, transportation, housing, physical and mental health).
21. The program communicates regularly with parents about all afterschool activities (in-person, virtual, and online activities).
22. 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
23. Grades
24. School attendance
25. Ability to make friends
26. Preparation for school
27. Classroom behavior
28. 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
29. …talks with this child about the school day.
30. …supervises (or reviews) this child’s homework.
31. …helps (or encourages) this child to study for tests.
32. …helps (or encourages) this child to complete homework assignments.
33. …makes sure this child completes his/her homework.
34. …reviews this child’s grades on assignments and tests.
35. …helps (or encourages) this child to practice math skills.
36. …helps (or encourages) this child to practice reading or writing skills.
37. …encourages this child to check out library books.
38. …encourages this child to read for fun.
39. …suggests reading materials to this child.
40. …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. What do you like most about the afterschool program?

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

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