This example form is for informational purposes only. The Tennessee Department of Education is in no way endorsing this product, simply providing general information. You should consult your administration for agency protocols.
Parent Survey
School Child(ren) Attend:______Date:______
Please circle the appropriate responses for each statement:
1. Strongly Disagree
2. Disagree
3. Neutral
4. Agree
5. Strongly Agree
1. I feel my child(ren) is/are safe in the afterschool program. 1 2 3 4 5
2. The afterschool program staff make my family feel welcome and comfortable. 1 2 3 4 5
3. The afterschool program staff relate to my child(ren) in positive ways. 1 2 3 4 5
4. The activities offered afterschool promote the needs of my child(ren). 1 2 3 4 5
5. The afterschool program staff keep me informed about what is going on in the 1 2 3 4 5
afterschool program.
6. The afterschool program staff interact with my child(ren) to help them learn. 1 2 3 4 5
7. The afterschool program staff support family involvement in the afterschool program. 1 2 3 4 5
8. I am aware of my child’s daily schedule and feel that it offers enough stimulation 1 2 3 4 5
to meet my child’s needs.
9. The afterschool program staff use positive techniques to guide the behavior of my 1 2 3 4 5
child(ren).
10. The afterschool program staff set appropriate limits for my child. 1 2 3 4 5
11. The afterschool program staff work with my child(ren) to get homework completed 1 2 3 4 5
on a daily basis.
12. The afterschool program staff employ quality, certified and non-certified staff to 1 2 3 4 5
plan and implement student activities at each site.
13. My child has expressed to me that they like to attend the afterschool program. 1 2 3 4 5
Comments/Concerns:______