Curriculum Feedback Form

Name*

Tribe and/or Organization*

State*

Phone

Cell Phone*

Email*

What is your role in your organization (i.e. job title)?*

The first set of questions are about your experience implementing the curriculum. Please complete this form for each curriculum you’ve implemented in the last 6 months.

Which curricula have you implemented in the last 6 months? (select one at a time)

Where did you deliver the program? (check all that apply)

During school
After school
Community event
Cultural event
Other

Please enter the program:

How many participants were male?

How many participants were female?

How many participants were non-binary or two spirit?

What grade level did you teach? (check all that apply)

K-2
3-5
Middle school
High School
Young adult

Do you plan on using the curriculum again in the future?

Yes
No

Why not?

How well was the program received by your students?

Please share your experience implementing the curriculum, or any feedback that describes the experience of your students, parents, or community.

May we share your feedback on the www.HealthyNativeYouth.org website?*

Do you have funding from a specific grant to do this work?*

Yes
No

Who is your funder?*

Did you make any changes, enhancements, or adaptations to the curriculum?*

Yes
No

Please describe:*

Do you have any feedback or changes that you’d recommend to improve the facilitator training materials?

Do you have any feedback or changes that you’d recommend to improve the lesson plans, handouts, quizzes, or other materials provided to support its implementation?

Is there anything else you’d like to share with us?

Optional: In appreciation for your time, if you would like to receive a small gift, please provide a mailing address.

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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