Sample Assessment 2009
Page 1: Demographic Information
Your Recration Center Name
NOTE: The recreation center's Director DOES NOT need to complete the nrgBalance Zone Assessment. The Director information is requested to ensure that he/she is aware of the center's participation in nrgBalance Zones.
It is recommended that a team of staff/community members complete this assessment.
3. Population size served by recreation center:
6. List the contact information for the individual completing this online assessment. This person's name, email, and phone number will be listed as the contact on the nrgBalance website.
Some of these fields will be pre-populated with your recreation center's mailing address. You may change these if necessary.
Page 2: Organization Strategies
7. How does your recreation center promote its after school program? Please check all communication methods that apply:
8. What setting is the after school program offered?
9. Does your recreation center seek staff input regarding the after school program's activities and policies that promote healthy eating and physical activity?
9a. If yes, check all that apply
10. Does your recreation center communicate to parents about the after school program's policies and activities related to healthy eating and physical activity?
10a. If yes, check all that apply
11. Does your recreation center seek youth input about the after school program's policies and activities related to healthy eating and physical activity?
11a. If yes, check all that apply
12. During the past year, did your after school program staff attend any professional development sessions related to healthy eating and physical activity?
12a. If yes, were these sessions on any of the following topics (select all that apply)
Page 3: #1
13. Does your recreation center include time for physical activity in daily after school program sessions?
13a. If yes, how many minutes of physical activity per day are available during the after school program?
14. Is there adequate equipment for every child to participate fully in physical activity segments of your after school program (e.g. balls, jump ropes, etc)?
15. Does the after-school program have access to any of the following physical activity resources during program time? (select all that apply)
Page 4: #2
16. Does the after school program have access to computers, TV, video games, or DVDs during programs time?
16a. If yes to question 16, for what purpose are these media equipment used?
16b. If yes to question 16, how much time per day is allowed?
Page 5: #3
17. Does your after school program provide a daily meal or snack for participants?
17a. If yes, please specify:
18. Does your recreation center have a written policy about nutrition standards for FOOD provided during the after school program?
18a. If yes, please select policies that apply:
Snacks must contain at least two different components of the following four food groups: milk, meat or meat alternate, vegetable(s) or fruit(s), whole grain or enriched bread or cereal
Page 5: #4
19. Does your recreation center have a written policy about standards for BEVERAGES provided during the after school program?
19a. If yes, please check all that apply:
Page 6: #5
20. Does your after school program include at least one fruit or vegetable each day in meal or snack options?
21. Does your recreation center purchase Pennsylvania produce for after school program meals or snacks?
Page 7: More Strategies for Creating an Energy Balanced Recreation Center
22. What events has or will your after school program participate in this school year (2008-2009)?
23. Has your recreation center and after school program used any of the following nrgBalance free online materials?
-SAMPLE ONLY-
