Title: Success Factors in Youth 4-H Outreach Program
Contact who has experience using this assessment instrument:
Created for the 4-H Urban Outreach Program by Joan Demko
Cornell Cooperative Extension of Tompkins County 12/97
(First) (Last) (Date)
This set of questions is borrowed from a list of different things
that have been linked with success. Some are inside of you and
others are the factors around you, such as school and neighbors.
We hope you can use this to find out things about you that have
aided in your success thus far. There are many different things
that have helped you inside and outside, within the community
and school.
Circle One.
1. I feel like my family life is loving and understanding.
2. I talk with my parents (guardians) and feel comfortable talking
to them about what is on my mind, or troubling me.
3. I have at least three other adults, not including my parents
that I can talk to or go to for help.
4. I have caring neighbors.
5. I enjoy reading.
6. I like the people and activities at school.
7. My parents will help me with my homework.
8. My parents care about my grades.
9. I feel important where I live, and around adults.
10. I do things where I live that make me feel good.
11. I help out by doing community projects one time a week for
one hour.
12. I feel safe at home, school, and in my neighborhood.
13. My family has rules. I follow my family rules.
14. My family knows where I am at all times.
15. I understand my school rules and consequences.
16. If my neighbors knew I was in trouble, they would tell my
parents.
17. My best friends are responsible and have good behavior.
18. My teachers and parents teach me to be the best that I can.
19. I practice music, art, theater, or something else at least
three or more hours a week.
20. I am involved in sports, clubs, or organizations at school
at least three hours or more per week.
21. I am involved with my church one or more hours per week.
22. I am out with my friends one or two nights per week, "with
nothing special to do".
23. I am trying to do the best that I can in school.
24. I am really busy in school.
25. I do one or more hours of homework everyday.
26. I care about my school.
27. I read just for fun three or more hours a week.
28. I really enjoy helping other people.
29. I believe that everybody is equal.
30. When I believe in something, I will defend it and stand up
for what I believe in.
31. I tell the truth, even when it is not easy.
32. I take responsibility for my personal actions.
33. I believe it is important not to be sexually active, or not
to use alcohol or other drugs.
34. I can plan ahead and make choices.
35. I can understand how others are feeling.
36. I have good friendship skills.
37. I know about people from other racial backgrounds, and feel
comfortable with them.
38. I can say "NO" if my friends pressure me.
39. I like to solve problems in a positive manner.
40. I feel in control over "things that happen to me."
41. I have high self-esteem (I feel good about myself).
42. I feel like my life has a special meaning.
43. I am hopeful about my future, and know that I can control
what happens to me.
Evaluation Tools Page
ENTRY DATE:: April 1998