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Example Mid-Program Assessment Form
This form is built to be shared with general participants for feedback, not mentors or leadership counselors.
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Name and rank (optional):
Your answer
What best facilitates your learning in the program?
Your answer
What hinders your learning in the program?
Your answer
What would you like to see more of in the program's future?
Your answer
Please rank your regard for your Leadership Counselor using the scale below, with 1 highly unsatisfactory and 10 being highly satisfactory
Highy Unsatisfactory
1
2
3
4
5
6
7
8
9
10
Highly Satisfactory
Clear selection
If you ranked your Leadership in unsatisfactory range (at 5 or below), please explain:
Your answer
If you ranked your Leadership in satisfactory range (at 6 or above), please explain:
Your answer
Please rank your satisfaction with the program using the scale below, with 1 being highly unsatisfactory and 10 being highly satisfactory
Highy Unsatisfactory
1
2
3
4
5
6
7
8
9
10
Highly Satisfactory
Clear selection
If you ranked the program in unsatisfactory range (at 5 or below), please explain:
Your answer
If you ranked the program in satisfactory range (at 6 or above), please explain:
Your answer
If comfortable, please identify your leadership counselor(s):
Your answer
Is there anything this survey didn't ask that you want us to know?
Your answer
Thank you for your time!
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