Form 1190-0021 Participant Surveyt

LEVEL 3 SURVEY

OMB # 1190-0021

Expiration Date: XX/XX/XXXX

Evaluation of Community Relation Service (CRS) Outcome Evaluation
L3 Program Evaluation Forms

Program Evaluation Form: SPIRIT Programs

Purpose: This survey will help the Community Relations Service (CRS) improve facilitated dialogue programs. CRS will not publish or make public any comments or other information collected that could identify any specific person without written consent from that person.

Timing: This survey is intended to be delivered before programming, within 3 months after programming, and 12 months after programming.

Program name (select from list): School-SPIRIT Campus-SPIRIT City-SPIRIT	CRS staff:
Date:	Location:
1. Please select one category that best describes your role: 1. Community member  GO TO 2a 2. Faith leader 3. Law enforcement 4. City or government official 5. School administrator, teacher, or other staff  GO TO 2b 6. Nonprofit organization leaders 7. Advocacy group member 8 Student 9. Other (please specify)	2a. [IF ROLE = 1] How many years have you [lived in your community? | | | YEARS 2b. [IF ROLE NE 1] How many years have you been in your current role? | | | YEARS
3. Were you involved in planning this program? Yes No Unsure

We greatly appreciate receiving your feedback, and we will use your responses to help improve the program.

The questions below are intended to be completed by participants of the School and Campus SPIRIT programs only.

4. For these next questions, please think about the specific tension or issue being addressed by the SPIRIT program. In your opinion…

	Very low	Low	Neither high nor low	High	Very high	Not Applicable
What is the current level of tension and conflict within the participants of the program?
How well did the different student groups that are/were participating in the program get along?
How well do the students and administrators who are participating in the program get along?
How well do students and teachers participating in the program currently get along?

5. For the following questions, consider how the tension or issue addressed by the SPIRIT program affects the wider school or community. In your opinion….

	Very low	Low	Neither high nor low	High	Very high
What is the current level of tension and conflict within the school or community?
How well do different student groups get along?
How well do students and administrators currently get along at your school?
How well do students and teachers currently get along at your school?

The questions below are intended to be completed for participants of the City-SPIRIT program only.

6. For these next questions, please think about the specific tension or issue being addressed by the City-SPIRIT program. In your opinion…

	Very low	Low	Neither high nor low	High	Very high	Not Applicable
What is the current level of tension and conflict within the participants of the program?
What is the current level of trust between community leaders and local institutions (e.g., schools, non-profits, religious institutions, etc.) participating in the program?

7. For the following questions, consider how the tension or issue addressed by the city-SPIRIT program affects the wider community. In your opinion…

	Very low	Low	Neither high nor low	High	Very high	Not Applicable
What is the current level of tension and conflict within the community?
What is the current level of trust between community leaders and local institutions (e.g., schools, non-profits, religious institutions, etc.) ?

NEW SURVEY OPENS

Are you willing to be contacted to discuss your experience with the program? Your previous responses will not be linked in anyway to your contact information.

If yes, please enter your email address or phone number.

Email address:

Phone number:

Thank you

Program Evaluation Form: Strengthening Police and Community Partnerships (SPCP)

Purpose: This survey will help the Community Relations Service (CRS) improve facilitated dialogue programs. CRS will not publish or make public any comments or other information collected that could identify any specific person without written consent from that person.

Timing: This survey is intended to be delivered before programming, within 3 months after programming, and 12 months after programming.

Program name (select from list): Strengthening Police and Community Partnerships	CRS staff:
Date:	Location:
1. Please select one category that best describes your role: 1. Community member  GO TO 2a 2. Faith leader 3. Law enforcement 4. City or government official 5. School administrator, teacher, or other staff  GO TO 2b 6. Nonprofit organization leaders 7. Advocacy group member 8. Student 9. Other (please specify)	2a. [IF ROLE = 1] How many years have you [lived in your community? | | | YEARS 2b. [IF ROLE NE 1] How many years have you been in your current role? | | | YEARS
3. Were you involved in planning this program? Yes No Unsure

We greatly appreciate receiving your feedback, and we will use your responses to help improve the program.

1. In your opinion, how is the current state of the relationships between police and the community?

   Very Poor	Poor	Neither good nor poor	Good	Very Good
   				

2. In your opinion, what is the current level community trust in the police?

Very Poor	Poor	Neither good nor poor	Good	Very Good
				

For the next questions, please respond using a scale of 1 to 5 where 1 is “very weak” and 5 is “very strong”. When we ask about “your” relationships, we are asking about your perception of your personal relationships as an individual.

3. How strong are your current relationships with other community groups?

   Very weak				Very Strong
   1	2	3	4	5

4. How strong are your current relationships with local officials?

   Very weak				Very Strong
   1	2	3	4	5

5. How strong are your relationships with the police department?

Very weak				Very Strong
1	2	3	4	5

NEW SURVEY OPENS

Are you willing to be contacted to discuss your experience with the program? Your previous responses will not be linked in anyway to your contact information.

If yes, please enter your email address or phone number.

Email address:

Phone number:

Thank you

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control Number. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is voluntary. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to ATF, Contracts & Forms please contact Melody Diegor Caprio, CRS/DOJ, at 202-353-1806 or melody.caprio@usdoj.gov located at 145 N. ST NE, Washington, DC 20002, and reference OMB No. 1190-0021.

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File Title	1-column report template
Author	Brandon Hollie
File Modified	0000-00-00
File Created	2025-05-19