Evaluation Request Form
This form is not currently in use. The most current information on evaluation processes is in MyExtension at https://my.extension.iastate.edu/4-h-evaluation.
Name
*
First Name
Last Name
Position Title
*
County Youth 4-H Staff
Youth Field Specialist
State Program Specialist
Other
E-mail
*
Your County
*
Please Select
Campus
Adair
Adams
Allamakee
Appanoose
Audubon
Benton
Black Hawk
Boone
Bremer
Buchanan
Buena Vista
Butler
Calhoun
Carroll
Cass
Cedar
Cerro Gordo
Cherokee
Chickasaw
Clarke
Clay
Clayton
Clinton
Crawford
Dallas
Davis
Decatur
Delaware
Des Moines
Dickinson
Dubuque
Emmet
Fayette
Floyd
Franklin
Fremont
Greene
Grundy
Guthrie
Hamilton
Hancock
Hardin
Harrison
Henry
Howard
Humboldt
Ida
Iowa
Jackson
Jasper
Jefferson
Johnson
Jones
Keokuk
Kossuth
Lee
Linn
Louisa
Lucas
Lyon
Madison
Mahaska
Marion
Marshall
Mills
Mitchell
Monona
Monroe
Montgomery
Muscatine
O’Brien
Osceola
Page
Palo Alto
Plymouth
Pocahontas
Polk
Pottawattamie (East)
Pottawattamie (West)
Poweshiek
Ringgold
Sac
Scott
Shelby
Sioux
Story
Tama
Taylor
Union
Van Buren
Wapello
Warren
Washington
Wayne
Webster
Winnebago
Winneshiek
Woodbury
Worth
Wright
Program Name
Building Blocks of Leadership
Clover Cookie Factory
Crops Feed the World
Growing in the Garden Local Foods Healthy Living
Healthy Living Club Challenge
Mindful Teen
National 4-H STEM Challenge
On Their Own and OK
Ricochet
SWITCH
Other
Program Start Date
*
-
Month
-
Day
Year
Date
Program End Date
*
-
Month
-
Day
Year
Date
Please tell us the estimated attendance at this program.
*
This can be a rough estimate. If you aren't sure please just list your best estimate.
What format(s) would you like your survey in?
Paper copy
Digital Qualtrics with QR code
Digital Qualtrics with Link
Spanish
This program will be open to grades:
4
5
6
7
8
9
10
11
12
Please include the following content blocks for my survey:
*
4-H Experience (if all youth participating would consider themselves 4-H'ers)
Arts
College and Career Readiness (grades 8-12 only)
Communications
Healthy Living
STEM--Engineering (grades 8-12 only)
STEM--General
Civic Engagement
Leadership
I'm unsure, please use objectives to assist (below)
Main Objectives of the Program
This section is ONLY necessary if you selected "I'm unsure" in the section above. We will use this information to help select the appropriate blocks for your survey.
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How would you like "optional questions" handled?
*
Please include all optional questions and I will edit if necessary.
Please remove all optional questions.
Additional Questions or notes to our team
Do you have additional questions you'd like to have added to your survey? Do you have comments or questions for our team? Please enter that information here.
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