Johnson County Out-of-School Time Provider Survey

* Organization Name

Contact Person

* First Name :

* Last Name :

* Address 1 :

Address 2 :

* City :

* State :

* Zip :

* Phone :

* Email Address :

Contact Person's Title:

Mission Statement

Website

Organizational Information

Is your organization a registered 501(c)3?

Yes

No

In what year did you begin operations?

Number of employees/FTE?

Number of volunteers?

* Do you conduct background checks for staff?

Yes

No

* Do you conduct background checks for volunteers?

Yes

No

* Do you ensure annual safety checks of equipment and facility?

Yes

No

* Do you have a written emergency plan?

Yes

No

* Do you practice emergency drills?

Yes

No

PROGRAM INFORMATION

Please provide information for each program that you offer for ages 3-18 years. In order to provide information for each of your programs, please select all program numbers that apply. For example, if you offer three programs, you would select 1, 2 and 3 in order to enter information for three programs, if you offer 5 programs, you would select 1, 2, 3, 4 and 5.

* How many distinct programs do you offer? (Select all numbers that apply)

* ${piping_text}: Program Name

* ${piping_text}: Your organization is:

Lead Organization that enrolls participants

Partner with Lead Organization that provides programming services

${piping_text}: If you are Partner that provides programming, please identify the Lead Organization:

* ${piping_text}: This program is offered (Select all that apply)

During School Year

Summer

* ${piping_text}: What is the age range that you serve? (select as many as apply)

${piping_text}: Days and Hours of Operation of Program (You must put an answer in every box, you may put NA for days you are not open):

	Hours of Operation (hour - hour)
* Monday

* Tuesday

* Wednesday

* Thursday

* Friday

* Weekend

* ${piping_text}: Do you provide programs during school holidays/breaks?

Yes

No

${piping_text}: How many children does your program serve and what is the capacity of the program:

	Total Number of Children Served	Number of Children from Johnson County	Capacity of Program
* Program

* ${piping_text}: How do children get to your program (Select all that apply)?

* ${piping_text}: How do children get home from your program(Select all that apply)?

* ${piping_text}: Program provides food for: (select all that apply)

${piping_text}: What is the cost per child per week to attend your program?

	Cost Per Child Per Week
* Program

* ${piping_text}: Does your program charge tuition?

Yes

No

* ${piping_text}: What types of funding supports tuition (Select all that apply)?

* ${piping_text}: What types of funding supports programming (Select all that apply)?

* ${piping_text}: What activities are included in your program (Select all that apply)?

* ${piping_text}: Where are your services provided (Select all that apply)?

* ${piping_text}: What kind of information do you collect related to your program (Select all that apply)?

Participation (attendance, duration, frequency)

Program Quality (standards, service delivery)

Program Outcomes (changes in knowledge, skills, behaviors)

Do Not Collect Information

Other

* ${piping_text}: What methods do you currently use to collect information (Select all that apply)?

* ${piping_text}: What Quality Standards are utilized by your Organization (Select all that apply)?

Child Care Licensing

National Early Child Care Accreditation

Iowa Quality Preschool Standards

Iowa Quality Rating Systems (IQRS)

Search Institute's 40 Developmental Assets

IAA/Quality Standards

Youth Program Quality Assessment (YPQA)

N/A

Other, Please specify

* ${piping_text}: What evaluation data is collected (Select all that apply)?

Grades/Test Scores

Improvement in Behavior

Improvement in Social Skills

Program Attendance

Improved Attitude towards School

Improvement in Skills

Positive Choices (leadership, conflict resolution, plans for the future)

No Evaluation Data Collected

Other

${piping_text}: Services are provided to English Language Learning (ELL) children in the following languages (Select all that apply):

* ${piping_text}: What populations are currently the focus of your program (Select all that apply)?

* What resources do you access for Best Practices in Out of School time (Select all that apply)?

* Are you interested in future partnerships?

Yes

No

In what types of partnerships are you interested (Select all that apply)?

* What are the top 3 things that would most improve your programs (Select three)?

* Do you have interest in expanding your programs?

Yes

No

If Yes, please describe:

If yes, what are specific barriers that you see as a factor?

Do you have ability to expand at this time?

Yes

No

* How do you market/advertise for participants (Select all that apply)?

* Do you have any cooperative agreements or contracts that bring participants to your programs?

Yes

No

If Yes, please describe:

What are the biggest challenges you face at this time with running your programs?

Is there anything else you would like us to know?

* I would like to be contacted by a member of the coalition.

Yes

No

* I would like to receive results of this survey when they are available:

Yes

No