Colorado Campus Compact - UCAN Serve Evaluation - Public Health and Safety Survey

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Colorado Campus Compact UCAN Serve AmeriCorps Program

Public Health and Safety Survey ~ Agency Questionnaire

Demographics

About your organization

1.	Date: (mm/dd/yy)
2.	Please identify your State: Arizona Colorado Utah New Mexico
3.	Please identify your University Site:
		Arizona State University Brigham Young University College of Eastern Utah Colorado Christian University Colorado College Colorado Mountain College Colorado State University Colorado State University at Pueblo Dixie State College Fort Lewis College Front Range Community College Johnson & Wales University Lamar Community College LDS Business College Mesa Community College Morgan Community College Naropa University Red Rocks Community College Regis University	Salt Lake Community College San Juan College Snow College Southern Utah University Trinidad State Junior College University of Colorado at Boulder University of Colorado at Colorado Springs University of Colorado at Denver & Health Sciences Center University of Denver University of New Mexico-Gallup University of Northern Colorado Utah College of Applied Technology University of Utah Utah State University Utah Valley State College Weber State University Western State College Westminster College Other
4.	Your Agency's Name:
5.	Please describe your agency’s location: Urban Rural
6.	Please indicate the categories which your agency serves (check all that apply)
		Community Emergency Response Team Public School Health Centers/Hospitals Fire Department Community Health Center Criminal Justice Agencies Correctional Facility Disabilities Center	Alcoholism/Drug Abuse Center Nursing Home Social Services Mental Illness Center Police Department Rehabilitation Hospital Occupational/Physical Therapy Other (List)

1.	How many people work at your agency per week? (Please DO NOT count AmeriCorps members): people
2.	How many hours do these people at your agency work per week? (i.e. total person hours per week) total person hours per week
3.	How many members of the community are currently served by these people per week? community members served per week
4.	Please check ALL direct services provided to your agency by the AmeriCorps member(s):
	Participated in community health fairs Participated in home visits Assisted in support and training at local fire departments Provided communities with health education and safety preparedness literature	Performed health screenings at public schools Served at local non-profit agencies responding to critical public health and safety situations Attended to victims of natural disasters in temporary emergency shelters Other examples: (Please list below)

5.	Please list the various training sessions and orientation sessions your agency has provided to the UCAN Serve AmeriCorps members.

6.	How many UCAN Serve AmeriCorps member(s) work at your agency per week? AmeriCorps Members
7.	How many hours do AmeriCorps member(s) work per week? (i.e. total person hours per week)
8.	How many members of the community are served per week AFTER AmeriCorps members started their program? community members served

Agency Satisfaction with AmeriCorps Members

Please place a check mark in the box that most closely reflects your answers to the questions below according to the following rating scale:

1 = Strongly Disagree,

2 = Disagree,

3 = Neutral,

4 = Agree,

5 = Strongly Agree,

n/a= Not Applicable

Please answer all of the following questions rating each of the following statements based on your personal experiences/observations at your agency over the past year:

Agency Satisfaction Rating
1.	The UCAN Serve AmeriCorps member(s) were available when support was needed.	1 2 3 4 5 n/a
2.	The UCAN Serve AmeriCorps member(s) were quick to respond when the agency needed help.	1 2 3 4 5 n/a
3.	The UCAN Serve AmeriCorps member(s) completed tasks on time.	1 2 3 4 5 n/a
4.	The UCAN Serve AmeriCorps member(s) completed everything they said they would do.	1 2 3 4 5 n/a
5.	The UCAN Serve AmeriCorps member(s) were courteous.	1 2 3 4 5 n/a
6.	The support provided by the UCAN Serve AmeriCorps member(s) met my expectations.	1 2 3 4 5 n/a
7.	The UCAN Serve AmeriCorps member(s) helped foster positive partnerships between our agency and the community.	1 2 3 4 5 n/a
8.	Overall, I am satisfied with the UCAN Serve AmeriCorps member(s) at my agency.	1 2 3 4 5 n/a
9.	This agency is interested in working with UCAN Serve AmeriCorps member(s) in the future.	1 2 3 4 5 n/a
Capacity Building Rating
10.	The UCAN Serve AmeriCorps member(s) helped increase the number of services the agency was able to provide this past year compared to the year before.	1 2 3 4 5 n/a
11.	The UCAN Serve AmeriCorps member(s) helped increase the quality of services offered by the agency in the past year compared to the year before.	1 2 3 4 5 n/a

	Please include any additional comments or clarifications (below):
	Please describe any challenges you encountered with the UCAN Serve AmeriCorps member(s) or with their affiliated group(s) (e.g. College/University Site Coordinator, CCC, CNCS, etc.)?
	Please estimate the monetary value of the services provided by the UCAN Serve AmeriCorps member(s) to your agency: $

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