ACT Facilitators - Quantitative Data Survey

First Name:*

M. I.

Last Name:*

Email address:*

Your organization's name:*

Indicate the city and state of your program site:*

Indicate the month and year of reporting period:*

Program group start date:* (mm/dd/yyyy)

Program group completion date:* (mm/dd/yyyy)

Program group location:*
Your own organization's facility
Childcare center/preschool/elementary school
Shelter
Community-based agency or social service provider
Other

Total number of parents that started the program:*

Race/ethnicity of parents/caregivers who began the program (indicate number for each group):

African-American:*

Asian-American:*

American Indian:*

Latino/a:*

White:*

Mixed race/ethnicity:*

Challenges you faced while teaching the program to this group (check all that apply):*
None
Group dynamics management
Familiarity/knowledge of program curriculum
Experience conducting groups for adults
Techniques to conduct curriculum activities
Other

If childcare was provided, who provided the service? Was the ACT Children's Activity Guide used?

Characters remaining: 1000

If you provided incentives, do you think they helped retain parents in the program? Please explain.

Characters remaining: 2000