Grant Organization:
Grant Number:
Date:

Organization-Specific Questions
The following questions are about your institution/organization. Be sure to save the report periodically (after every few questions) as you fill it out so you don't lose data.
1. Institution Size: Please provide the total number of youth and staff in your organization as a whole. In reporting the number of youth, please include only those youth who are considered members or are regularly involved with your organization.
Youth Staff
2. Is your organization religious or faith-based ?
3. Do you currently collect data on the number of hours youth are engaged in service-learning activities and programs ?

Funding Sources
4. 2004- 2005 Learn and Serve Grant Amount:   $10,000
5. Is the current grant the first Learn and Serve America grant that your organization has received?
6. What are the other (non-Learn and Serve) sources of funding for your service-learning programs this year? Please include any funds designated as match as well as other sources of funds used for service-learning. (check all that apply)
7. What is your total 2004-2005 estimated budget for service learning from all sources (including cash, your LSA grant, and all non Learn and Serve grants)? Do not include in-kind contributions.  $
8. Describe the area in which your organization is located (check all that apply)
IMPORTANT: The questions in this section refer only to programs and activities that are funded in whole or part by Learn and Serve America funds during the 2004-2005 program year. DO NOT INCLUDE NON-LSA FUNDED ACTIVITIES.
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9. What best describes the scope of LSA funded service-learning activities at your organization during the 2004-2005 program year? Check the one response that best describes activities at your organization.
 
10. When do your organization's LSA funded service learning activities occur?
11. Do most of the activities occur during school time or outside of school time? (Check only one)
Service Learning Participants
IMPORTANT: The questions in this section refer only to programs and activities that are funded in whole or part by Learn and Serve America funds during the 2004-2005 program year. DO NOT INCLUDE NON-LSA FUNDED ACTIVITIES.
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12. In this section we are interested in the people who are in your LSA service learning programs and activities.

Please provide demographic information on those youth who participated as service-learners in Learn and Serve-supported activities from July 1, 2004 to June 30, 2005. NOTE: For the purpose of this survey, service-learning participants are youth, between the ages of 5 and 17, who are involved in service-learning programs or activities on a regular basis. A service-learning program or activity should engage these participants in learning activities, assessment and reflection, and direct or indirect service to beneficiaries. Youth engaged in one-time volunteer activities should not be counted as service-learning participants; please record these volunteers under Question 15.


Please provide the following information on LSA program participants:
LSA Funded Service-Learning Participants Estimated Number
Total number of individual service-learners in LSA supported activities/programs at your organization

Grade Level of all LSA service-learning participants Estimated Number
Kindergarten - 5th grade
6th grade - 8th grade
9th grade - 12th grade
School Dropout
Grade Unknown

Ethnic background of all LSA service-learning participants Estimated Number
Hispanic
Non-Hispanic
Ethnicity Unknown

Racial background of all LSA service-learning participants Estimated Number
American Indian/Alaska Native
Asian
Black or African-American
Native Hawaiian or Other Pacific Islander
White
Two or more races
Race Unknown

Gender Estimated Number
Male
Female

Disabled Estimated Number
Service learners with disabilities

13. Do your organization's LSA funded service-learning programs or activities target any of the following types of students as program participants?
  Yes No Don't Know
Foster children
Children of incarcerated parents
Service learners who are disabled/ in special education

Staff Participation in Service-Learning
14. How many staff were involved in teaching, leading, and operating LSA funded service-learning programs in your organization this year? Number (part- and full-time combined) 

Additional Volunteers
15. Approximately how many other youth volunteers (defined as youth 5-17 years old) were involved in LSA supported service activities (e.g. one-time volunteers). Do not include regular program participants reported above.
Total number of other youth volunteers:
16. Approximately how many adult volunteers (defined as 18 or older) were involved in LSA supported service-related activities (e.g. one-time volunteers). Do not include program staff.
Total number of adult volunteers:
Service-Learning/Participant Experience
IMPORTANT: The questions in this section refer only to programs and activities that are funded in whole or part by Learn and Serve America funds during the 2004-2005 program year. DO NOT INCLUDE NON-LSA FUNDED ACTIVITIES.
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17. In this question we are trying to get information about the duration of the LSA programs and activities in your organization and the amount of time service-learners are engaged in preparation, reflection, and service. Please fill in the table below with the numbers of program participants and average hours of preparation and service.

Duration Do Not Run this Type of Program Number of Participants Average Hours of Preparation and/or Formal Reflection per Participant Average Hours of Service per Participant Don't Know
Programs and activities that last 2 months or less including summer programs
Programs and activities that last for most or all of one semester or term (or about half the school year)
Programs and activities that last for most or all of the whole school year or are year-round
18. For each of the following service categories, fill in the percentage of your LSA-supported service-learning activities and/or programs that fall into the category. Then, for each category, please check up to three of the most common types of service being conducted.

Health/Nutrition   % of activities/programs
   

Education   % of activities/programs

Environmental   % of activities/programs
   

Homeland Security   % of activities/programs

Public Safety   % of activities/programs
 

Housing   % of activities/programs

Human Needs - General   % of activities/programs
   

Community and Economic Development   % of activities/programs
   
Community/Program Partners
IMPORTANT: The questions in this section refer only to programs and activities that are funded in whole or part by Learn and Serve America funds during the 2004-2005 program year. DO NOT INCLUDE NON-LSA FUNDED ACTIVITIES.
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19. How many community partners and placement sites were involved in your Learn and Serve-supported activities during this past year?

A partner is an external school, agency or other organization that cooperates (e.g., shares information), coordinates (e.g., helps plan a program) or collaborates (e.g. shares a leadership role) with an LSA grantee or sub-grantee in carrying out LSA funded service-learning activities and programs.

A service learning placement site is an external school, agency or other organization that provides service learning participants with opportunities to use their newly acquired academic skills and knowledge in real life situations.
a. Total number of community partners and placement sites:   
If you provided a value for Question 19a, please complete 19b through 22.  If you do not provide a value for 19a, no values will be saved for 19b through 22.
b. How many of the above partner agencies/organizations are faith based?   

20. Of the total number of partners referenced above: 
a. How many were regularly and actively involved in planning and managing LSA funded service-learning?  
b. How many were periodically involved in planning and/or managing LSA funded service-learning?  
c. How many advised on LSA funded service-learning but were not directly involved in planning or managing LSA funded service-learning?  
d. How many served as only a service site?  
21. Does your service-learning program have an advisory board?  


If YES, then: How many partner organizations are represented on the advisory board?
22. How many new community partnerships were formed as a result of your current LSA funding? 
Collaboration with Other Corporation Programs
23. With which, if any, of the following Corporation for National and Community Service-sponsored programs does your LSA program collaborate? (Check all that apply)
 
24. How many of the following types of national service participants were involved in coordinating service-learning programs and activities on a regular or on-going basis at your institution?
AmeriCorps  Senior Corps (SaYes Volunteer) 
AmeriCorps*VISTA 
 
25. To what extent are the following characteristics present in the Learn and Serve-funded service-learning initiatives and programs in your institution/organization?
  Never Rarely Occasionally Frequently Always Don't Know
a. Service activities are of sustained or significant duration (e.g. more than 40 hours per participant per year).
b. Service projects have clear and specific learning objectives.
c. Program staff (teachers, faculty, program coordinators, etc.) work with participants to draw the connections between the service that participants are providing and what they should be learning.
d. The service that participants perform is accompanied by opportunities to learn that are strongly related to the service.
e. The relationship between service and civic participation, responsibility, skills and concepts are made explicit.
f. Project participants are given organized time to reflect on their service.
g. Participants have a leadership role in all phases of a project, including making decisions about the development of the project as well as its execution.
h. Projects are based in strong partnerships with community groups that include mutually agreed upon goals, roles and responsibilities.
i. Both learning and service are emphasized in all projects.
III. Questions About Institutional Support for Service-Learning
These questions are about all service-learning in your organization (e.g. regular, on-going service learning).

IMPORTANT: The questions in this section refer only to programs and activities that are funded in whole or part by Learn and Serve America funds during the 2004-2005 program year. DO NOT INCLUDE NON-LSA FUNDED ACTIVITIES.
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26. How long have there been organized service-learning activities at your organization (e.g. regular, on-going service learning)?
27. Please indicate which policies listed below are in place in your organization. For each type of policy, please indicate Yes, No, or Don't Know.
  Yes No Don't Know
a. Service-learning is included in the organization's strategic plan.
b. Service-learning is part of the activities for youth in at least one program or department in the organization.
c. Service-learning is part of the activities for youth in all programs and activities in the organization.
d. Other (specify) 
If you answered YES to question 27b then please answer this question. Otherwise skip to question 29.
28. If service-learning is part of the activities in at least one program or department, what kind of activity is it?
29. Indicate the extent to which the following policies/practices were present at your organization over the past year:
  Never Rarely Occasionally Frequently Always Don't Know
Service-learning is highlighted in agency brochures and materials
Service-learning is included in the organization's current professional development plans
The organization has adopted and/or disseminated quality standards for service-learning (for example, the Essential Elements of Service-Learning)
Organization policies encourage the integration of service-learning into programs
Service-learning is included in new staff orientation
Service-learning is considered as one of the criteria in hiring new staff
Service-learning is considered as one of the criteria for staff evaluations and/or performance standards
Young people are involved in decision-making about the service-learning activities in the organization, for example, through an advisory council or other formal planning or decision-making body
30. During the past year, to what extent were the following available at your organization? Please indicate how regularly or widely each type of support was available.
  Never Rarely Occasionally Frequently Always Don't Know
a. Financial support for planning, training, and implementation of service-learning projects or programs
b. Reduction in work load to allow time for service-learning program development or supervision
c. Technical assistance on planning or implementation of service-learning activities
d. Recognition or rewards for teachers/staff for quality service-learning practice
Service-Learning Coordinator:
31. Does the organization have a full or part-time service-learning coordinator or staff person with responsibility for service-learning?
If you answered "No" or "Don't know" for question 31, please skip to question 37 (on the next tab) and do not answer question 32 thru 36.
32. If there is a service-learning coordinator for the organization, how many years of professional experience has the coordinator had with service-learning (for example, as a coordinator, former teacher, etc.)? If more than one coordinator, please provide information on the primary coordinator.
33. Is the service learning coordinator a full time or part-time employee of the organization?
34. Approximately what percentage of the coordinator's total job responsibilities is service-learning?
35. Please select the answer that best describes the extent of training/professional development the service-learning coordinator has received.
36. What percentage of the service-learning coordinator's salary is from grants and organization operating funds in 2004-2005 (including LSA funds):
Grants: %
Organization operating funds (non-grant): %

Technical Assistance Strengths and Needs
IMPORTANT: The questions in this section refer only to programs and activities that are funded in whole or part by Learn and Serve America funds during the 2004-2005 program year. DO NOT INCLUDE NON-LSA FUNDED ACTIVITIES.
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37. In which of the following areas do you believe your organization/program is particularly strong and capable of providing technical assistance to other Learn and Serve programs? Please check all that apply.
Program Management Program Content
 
   
 
 
 
     
 

38. In which of the following areas do you think your organization/program is most in need of technical assistance or training? Please check the three highest priority areas for assistance.
Program Management Program Content

(specify subject area) 
   
 
 
 
     
 
39. Please indicate the primary service-learning outcome your organization is trying to achieve through the LSA funded program. If your program is designed to achieve several major outcomes, please select the ONE that best represents the primary goal of the program.
Participant Development Institutional Development Community Development
 
   
40. Specifically, how have you defined that outcome for the purposes of your program? Please briefly describe. (For example: "Youth will increase their understanding of the ways in which public policy decisions are made in their community.")

41. What tools/methods does your organization currently use to measure the primary program outcome listed above?
   
If using any standardized instruments to measure the outcome, please provide the name of the instrument(s):
42. Based on your experience with Learn and Serve funded activities over the past year, assess the impact of these activities and programs on:
  Substantial negative impact Moderate negative impact No impact Moderate positive impact Substantial positive impact Don't know
The general academic performance of service-learning participants
The habits of participants (habits refer to such things as attendance, extracurricular activities, participation in class)
The participants' civic engagement
Efforts to make service-learning a permanent part of your institution
The organizations that were served
Program Description

43. Please provide a brief (100-150 word) description of one service-learning project or activity funded by the current LSA sub-grant. In doing so, please make sure you answer the following questions: What is the purpose of the project? What are the academic or educational goals? Where and when does it take place? Who are the participants? Who are the beneficiaries of the service? What are the intended results? What did participants do in the project?
This is the end of the Program Report. Thank you for participating. If you would like to provide additional information that clarifies the answers you have given here or if you would like to provide feedback on the form, email LASSIEComments@cns.gov