Participant feedback survey
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Tell us what you think: [PROGRAM NAME]

Thank you for taking part in [PROGRAM NAME]. We'd like to know what's working and what we could do better. This survey takes about [NUMBER] minutes.

- [FOR PARTICIPANTS UNDER 18: "A parent or guardian has given permission for you to take this survey, but it's still your choice."]
- It's optional. You can skip any question. Your answers won't affect any help or service you get from us.
- It's private. [CHOOSE ONE: "Please don't write your name." OR "We ask for your name only so we can [REASON]. We keep it separate from your answers."]
- Only [WHO, FOR EXAMPLE "OUR PROGRAM COORDINATOR"] will see your answers. We'll share results only as totals or without names.

About the program

How much do you agree? Tick one box for each line.

| | Strongly agree | Agree | Not sure | Disagree | Strongly disagree |
|---|---|---|---|---|---|
| I was treated with respect. | [ ] | [ ] | [ ] | [ ] | [ ] |
| The times and place were easy for me. | [ ] | [ ] | [ ] | [ ] | [ ] |
| I understood the information I was given. | [ ] | [ ] | [ ] | [ ] | [ ] |
| I would recommend this program to someone I know. | [ ] | [ ] | [ ] | [ ] | [ ] |

What changed for you

Compared with before you started the program:

| | Much better | A little better | About the same | A little worse | Much worse |
|---|---|---|---|---|---|
| [OUTCOME 1, FOR EXAMPLE "HOW CONFIDENT I FEEL READING WITH MY CHILD"] | [ ] | [ ] | [ ] | [ ] | [ ] |
| [OUTCOME 2] | [ ] | [ ] | [ ] | [ ] | [ ] |
| [OUTCOME 3] | [ ] | [ ] | [ ] | [ ] | [ ] |

In your own words

1. What was the most useful part of the program for you?

   [SPACE TO WRITE]

2. What is one thing we could do better?

   [SPACE TO WRITE]

3. Is there anything else you'd like to tell us?

   [SPACE TO WRITE]

Optional: about you

[ONLY INCLUDE QUESTIONS YOU WILL USE, FOR EXAMPLE:]

- How long have you been coming to [PROGRAM NAME]? [ ] Less than 3 months [ ] 3 to 12 months [ ] More than a year
- How did you hear about us? [SPACE TO WRITE]

Thank you. If you'd like to talk to someone about the program, contact [NAME] at [PHONE OR EMAIL].

For staff: after the survey

- Date collected: [DATE]
- Number handed out: [NUMBER]. Number returned: [NUMBER]
- Where completed surveys are stored: [LOCATION]
- Destroy by: [DATE]
- What we'll change as a result: [NOTES]