Big Brothers Big Sisters of Washington County

Performance Outcome Evaluation (POE)
PARENT/GUARDIAN REPORT ON THE MATCH

Child's Name:              Parent/Guardian’s Name:

INSTRUCTIONS:
This form is used to report changes you have observed in your son/daughter who is being mentored.

The following definitions are offered to clarify the items on the survey. Note that these items are somewhat general. You are encouraged to report on your own specific observations with the general meaning of these definitions. Any questions should be referred to your match support specialist. If you feel you do not have enough information based on your interactions with the young person you are mentoring, mark Don’t Know as necessary.

Goal Area 1: Confidence

1. Self Confidence – a sense of being able to do or accomplish something.
2. Able to express feelings – Is able to reveal, talk about, or discuss feelings.
3. Can make decisions – thinks before acting and is aware of consequences of behavior.
4. Has interests or hobbies – pursues activities, reading, sports, music, computers, etc.
5. Personal hygiene/appearance – dresses appropriately and keeps self neat and clean.
6. Sense of the future – knows about educational and career opportunities.

Goal Area 2: Competence

7. Uses Community Resources – partakes in service activities, library, recreations, church or other community groups/activities.
8. Uses school resources – uses the library, guidance counselors, tutorial centers.
9. Academic performance – makes good grades or improves grades.
10. Attitude toward school – is positive about school or what can be learned.
11. School preparedness – completes homework and other assignments.
12. Classroom participation – actively takes part in learning; responds to questions.
13. Classroom behavior - pays attention in class; isn’t disruptive.
14. Able to avoid delinquency – refrains from behaviors that are illegal for a person his/her age.
15. Able to avoid substance abuse – doesn’t use illegal or harmful substances (e.g. drugs, alcohol, tobacco).
16. Able to avoid early parenting – doesn’t engage in sexual behavior to result in early parenting.

Goal Area 3: Caring

17. Shows trust toward you – isn’t reluctant to confide in you, to accept your suggestions.
18. Respects other cultures – doesn’t stereotype or put down other ethnic, racial, language, or national groups.
18. Relationship with family – Interacts well with other family members.
19. Relationship with peers – interacts well with persons of own age.
20. Relationship with other adults – Has good interactions with other adults who are not family members.

POE PARENT/GUARDIAN REPORT ON THE MATCH
Child’s Name:    Date completed:

Length of match:

Age:

Male:     Female:

Community Based: School Based:

White:     Black: Hispanic: Asian: Native American: Multi cultural:

Please describe any changes you’ve observes in your child in the below areas, in the past 12 months. It’s okay to indicate “don’t know” if you have no knowledge about change in a given area. Select the appropriate description from the menus below.

CONFIDENCE
1. Self Confidence:

2. Able to express feelings:

3. Can make decisions:

4. Has interests or hobbies:

5. Personal Hygiene/Appearance:

6. Sense of the future:

COMPETENCE
7. Uses community resources:

8. Uses school resources:

9. Academic performance:

10. Attitude toward school:

11. School preparedness:

12. Class participation:

13. Classroom behavior:

14. Able to avoid delinquency:

15. Able to avoid substance abuse:

16. Able to avoid early parenting:

CARING
7. Shows trust toward you:

18. Respects other cultures:

19. Relationship with family:

20. Relationship with peers:

21. Relationship with other adults:

THANK YOU!