Instructions
Answer questions as they relate to you. For most answers, check the boxes most applicable to you or fill in the blanks.
Service Learning Opportunity Provider - Site/Student Supervisor
1.
Name:
2.
Title:
3.
How Long in Position:
4.
Phone:
5.
Email:
6.
Agency/Program/School:
7.
Address:
8.
9.
10.
How does this Service Learning Opportunity support and connect with student learning?
11.
Student Goals and Responsibilities at Service Learning Opportunity to accomplish Goals:
12.
Hours of Service (includes orientation, training, and ongoing service, reflection, and celebration):
13.
Number of outputs (trees planted, meals served, books collected, pounds of food collected, clients served, students tutored, conflicts mediated, etc.):
14.
Number of student(s)/service learner(s):
15.
Describe the demographics of the community or service recipients (age groups, poverty, ethnicity/race, gender, ESL, etc.):
16.
Number of other volunteers recruited:
17.
Number and name of other collaborative agencies/organizations:
18.
Other:
Least - 1
2
3
4
Greatest - 5
19.
Please evaluate the Service Learner's Motivation at the Beginning of the Service
20.
Please evaluate the Service Learner's Connection to Community at the Beginning of the Service
21.
Please evaluate the Service Learner's Connection to Learning Goals at the Beginning of the Service
22.
Please evaluate the Service Learner's Commitment to the Service Learning Activity (on-time, ready to go, completes tasks) at the Beginning of the Service
23.
Please evaluate the Service Learning Activity's Benefit to your Agency/Organization at the Beginning of the Service
24.
Please evaluate the Service Learning Activity's Benefit to Recipients at the Beginning of the Service
25.
Please evaluate the Service Learning Activity's Fun & of Mutual Benefit at the Beginning of the Service
26.
Please evaluate the ease of organizing the Service Learning Activity and keeping it on track at the Beginning of the Service
27.
Please evaluate the communication kept everyone informed at the Beginning of the Service
28.
Please evaluate the Service Learner's Motivation at the End of the Service
29.
Please evaluate the Service Learner's Connection to Community at the End of the Service
30.
Please evaluate the Service Learner's Connection to Learning Goals at the End of the Service
31.
32.
Please evaluate the Service Learning Activity's Benefit to your Agency/Organization at the End of the Service
33.
Please evaluate the Service Learning Activity's Benefit to Recipients at the End of the Service
34.
Please evaluate the Service Learning Activity's Fun & of Mutual Benefit at the End of the Service
35.
Please evaluate the ease of organizing the Service Learning Activity and keeping it on track at the End of the Service
36.
Please evaluate the communication kept everyone informed at the End of the Service
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