Instrument 4: Youth exit ticket

THE PAPERWORK REDUCTION ACT OF 1995

This collection of information is voluntary and will be used to provide the Administration for Children and Families with information to help refine and guide SRAE program development. Public reporting burden for the collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number and expiration date for this collection are OMB #: XXXX-XXXX, Exp: XX/XX/20XX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Melissa Thomas at mthomas@mathematica-mpr.com.

Instrument 4: Youth Exit Ticket

OMB Control No: XXXX-XXXX

Expiration Date: XX/XX/20XX

INSTRUMENT 4: Youth Exit Ticket

Date:

School or Community-based Organization: [pre-filled]

Name of class teacher: [pre-filled]

Name of facilitator: [pre-filled]

[PROGRAM] lesson #: [pre-filled]

Class period: [pre-filled]

Note: Once you remove the cover sheet, your name will not be connected with your response. Your teacher or facilitator will not be able to see your answers to these questions.

For each of the following, please answer based on your experience with today’s lesson.

	Not at all	Slightly	Somewhat	Mostly	A great deal
1. I enjoyed the lesson	1 m	2 m	3 m	4 m	5 m
2. The lesson really made me think	1 m	2 m	3 m	4 m	5 m
3. I tried hard during the lesson	1 m	2 m	3 m	4 m	5 m
4. I paid attention during the lesson	1 m	2 m	3 m	4 m	5 m
5. Today’s lesson is going to help me deal with important issues in my life in the next few years.	1 m	2 m	3 m	4 m	5 m
6. The facilitator and I connected during today’s lesson	1 m	2 m	3 m	4 m	5 m
7. The facilitator was enthusiastic about teaching the lesson.	1 m	2 m	3 m	4 m	5 m
8. The facilitator knows a lot about what they were teaching during the lesson.	1 m	2 m	3 m	4 m	5 m