Title VI Evaluation Tool User Guide

 

Overview 

The Administration for Community Living (ACL) encourages all Title VI grantees to participate in regular 

program evaluation. Routinely evaluating your program services and participant satisfaction is important 

to ensure that the services are as effective as they can be. Evaluation can help you identify areas for 

improvement and, ultimately, help you best support your program participants.

This evaluation tool is a ready-to-use product that includes two surveys: one for Part A/B services 

(Nutrition and Supportive Services) and the second for Part C (Caregiver Support) services. Each survey

contains a set of questions designed to gather specific information related to Title VI Part A/B and Part C 

program services from your elders or caregivers. The surveys ask about demographic information (e.g., 

age, gender) as well as elders’ and caregivers’ attitudes, preferences, and satisfaction with program 

services. 

Additionally, the Title VI Survey Response Spreadsheet is an Excel file to help you analyze and use the 

information collected through the surveys. 

 December 2019
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Introduction to the Evaluation Tool

There are two surveys within the evaluation tool. The first survey (Appendix A) is specific for Part A/B 

(Nutrition and Supportive Services) program service delivery, and the second survey (Appendix B) is for 

Part C (Caregiver Support Services) program service delivery. 

Each survey starts with an introduction and asks respondents to share some basic demographic 

information—gender, age, and current living situation. Each survey then leads into the main survey 

questions specific to either Part A/B services or Part C services.

Planning Your Evaluation

1. Get to Know the Survey Tools

The first step in planning your evaluation is to get familiar with 

the surveys. Review the surveys and become familiar with the 

questions. The questions are designed to gather participant 

feedback and satisfaction with your program services. 

After review, determine if you want to use the tool in its 

entirety or select specific sections of the tool to conduct in 

small surveys at different times. For example, you could create 

several two- to three-question surveys that you conduct over

time. 

Steps for Planning Your 

Evaluation

1. Get familiar with the survey tool. 

2. Identify your audience. 

3. Plan how you want to distribute 

the survey. 

4. Set the date and location to 

administer the survey. 

5. Create a survey schedule to 

routinely evaluate your program 

services. 

2. Identify Your Audience

The second step is to determine your audience—who do you want to hear from? Ask yourself the 

following:

• Do you want to survey all elders who participate in your Part A/B services? Or, do you just need to 

hear from a certain group of your elders?

• For the Part C survey, do you want to survey all caregivers or a certain group, like those who are 

raising grandchildren? 

3. Make a Distribution Plan

After you have identified who you want to hear from, think about the best way to present the survey to 

your elders or caregivers. For example, the survey may be given to participants all at once (for example, 

at a congregate meal), or you can break the survey into several “mini-surveys” and conduct them over

time. 

• Decide whether to print the survey on full sheets of paper, on notecards, or as placemats. 

• Be sure to provide pencils and/or pens to help participants complete the survey.
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4. Set a Date and Time to Conduct the Survey

Now that you know how you will present the survey (e.g., at a congregate meal), the next step is to 

select a date and location to administer the survey. Use your knowledge of your program participants to 

help you set a date. For example, if you plan to survey your congregate meal participants, think about 

what days you typically have the best turnout. 

Additional things to consider include: 

• Is there a day of the week that you typically have more turnout 

for your congregate meals or activities? 

• Do you want to conduct the survey before, during, or after a 

congregate meal?

• If you will be surveying home-delivered meal participants, look 

at your meal delivery logs—what days do you typically deliver 

more meals? Those days might be best to deliver the survey 

along with the meal.

Tip: Mark Your Calendar!

Once you have determined the 

date and time you want to 

conduct your survey, make 

reminders on your work 

calendar to help you set aside 

time to prepare for giving the

survey.

5. Setting a Survey Schedule

You have made a plan for conducting the survey—congratulations! Now, it is time to consider how often 

you want to evaluate your program in this way. Routinely asking your program participants for their 

feedback is highly recommended. Some programs may find it helpful to do so once a year; others may 

prefer to evaluate twice a year. You know your program participants and your program services best, so 

consider what will best help your program. A program evaluation schedule will help you routinely 

evaluate your program services and participant feedback. 

Conducting Your Survey

Once you have determined how and when you want to implement your survey, it is time to conduct the 

survey. Anytime you are conducting a survey, it is important to share with your participants why you are 

asking for their feedback. Let them know their feedback is important to you and that you appreciate 

their assistance. 

Example Announcement Language:

“We want to hear from you! Your feedback helps us better understand who is using 

our program and your satisfaction with the services. Please take a few minutes to 

complete the survey in front of you. When you are done taking the survey, turn your 

survey over and leave it on the table. We will collect all of the surveys. We appreciate 

your help.”
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If you have chosen to distribute the survey during a congregate meal or activity, consider placing a copy 

of the survey at each seat with a pencil or pen so that when the elders or caregivers arrive, the survey is 

in front of them. Once everyone has gathered and you are about to start the meal or activity, you can 

make the announcement about the survey and thank them for their assistance and time.

If you have chosen to distribute the survey in the mail or during meal deliveries, consider adding a 

message attached to the survey that tells the elder or caregiver why you are asking for their feedback 

and that you appreciate their assistance. Also include information in the message on when you plan to 

collect the feedback.

Example Message Announcement:

“Hello! We want to hear from you to help us better understand who is using our 

program services and your satisfaction with the services. Please give your completed 

survey to the driver at your next meal delivery. We appreciate your help in completing 

the survey and thank you for your time.”

Collection and Analysis Guidance

Collecting and Storing Completed Surveys 

Once participants have taken the survey, it is time to collect the completed surveys and begin to analyze 

your program participants’ responses. Make sure to: 

• Collect completed surveys as soon as possible—ideally directly following the congregate meal, 

group activity, training, or meal delivery where you asked program participants to take the survey. 

• Store all completed surveys in one location. For example, put them in an envelope and then in a

drawer or desk basket in your office where you can easily access them once you are ready to begin 

entering the survey responses into the analysis spreadsheet. 

Preparing to Enter Survey Data

When you are ready to enter your survey data, these steps will help you complete the process:

• Take the envelope of completed surveys and place it on your desk, next to your computer for easy 

access during the data entry process. 

• On your computer, open the Title VI Survey Response Spreadsheet.

• At the bottom-left side of the screen, select the tab that matches the survey that you want to enter 

responses for (Part A/B or Part C). 
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Select Part A B Survey 

or Part C Survey

• Once you have the correct tab open on your screen that matches the completed surveys, enter the 

date that the survey was conducted at the top of the spreadsheet. 

Enter the date 

of your survey. 

• After entering the date, save the spreadsheet as a new file. Click on the File tab at the top-left 

corner of the screen and select “Save As” from the dropdown menu to save the file on your 

computer in the folder of your choice. 

o Consider naming your new file “Title 6 Survey Responses MMDDYYYY” (for example, 

“Title 6 Survey Responses 101119”). By including the date in your file name, you can 

easily go back in your files and compare survey responses over time. Remember to 

keep a blank copy of the Survey Data Response Spreadsheet to use as a template 

each time you have survey data to enter.
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Click on the “File” tab 

and select “Save As.” 

Entering Survey Responses

• Take the completed surveys from your desk and, using a marker, number each of them. For 

example, the first survey on the pile will be marked “1”, the second “2”, and so on until every 

survey has been given a number. Starting with the first completed survey, write the number “1” at 

the top of the survey. This numbering system will help you if you need to go back and double-check 

data entry for a specific survey or re-enter data if an error was made.

• Once all of the paper surveys are numbered, you are ready to begin entering all of the surveys into 

the spreadsheet. Be sure to enter the responses for each survey in the appropriate cells on the 

spreadsheet. For example, the survey you marked “1” should be entered in the row for survey 

number 1. 
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Be sure to enter the survey 

you marked “1” in the line for 

survey 1. 

• As you enter the survey responses, note that many of the questions have dropdown menus to 

select from. Look to see if there is an arrow within the cell, as shown below. If there is a dropdown 

menu option, select the answer from the dropdown list that matches the answer on the completed 

survey. If there is not a dropdown menu, enter the answer that the respondent has selected or 

written on the survey. 
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Click on the little arrow to 

show the dropdown menu 

of response options. 

• If a respondent did not answer a question, leave the corresponding cell in the spreadsheet blank 

and move on to the next question.

• Enter all completed surveys into the spreadsheet. 

Tip: Save as You Enter! 

 It is recommended to routinely “save” 

your work as you enter the survey 

responses. Consider saving after you 

have entered each survey in case you 

get interrupted or need to stop and 

then resume data entry at a later time.
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Analyzing Your Data

Once you have entered and saved all of your survey responses, it is time to take a look at the results.

The Title VI Survey Response Spreadsheet is designed to automatically calculate your survey responses. 

The spreadsheet will automatically generate data visualization charts that can help you “see” your 

results. 

• At the bottom of the spreadsheet, you will see multiple tabs. There is a Part A/B Graphs tab and a 

Part C Graphs tab.

 

Select the Graphs tab that matches the survey you entered.

• As you will see, charts for specific questions have been automatically generated based upon your 

survey responses. 

Your survey 

data 

visualizations 
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Sharing Your Data

Your program data visualizations are a great way to share your program’s story with others, including 

your Tribal or Governing Council. Take time to review the graphs in the Graphs tab. Getting familiar with 

what your survey data shows will help you better understand your program participants’ feedback and 

help you share this information with others.

• You can “cut and paste” your survey data visualizations into a Word document or PowerPoint 

presentation. To do so:

o Right click on the chart you want to copy and select “Copy.” 

o To paste the chart into your chosen document, select “Paste Special—keep 

formatting and embed workbook.” 

Sample Survey Data Visualizations 
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Saving a new version of the Title VI Survey Response Spreadsheet each time you have a completed 

survey is an important step. For example, if you conduct a Part A/B Survey in October and then another 

in April, you then would have two completed survey spreadsheet files, Title VI Survey Responses

10112019 and Title VI Survey Responses 04112020, plus the original blank template file. Having a 

separate Survey Response file for each completed survey will allow you to compare results over time. 

Saving Your Work 

Example File Names and Storage

Comparing Results Over Time

Comparing survey results over time can help you identify changes in your program participation and 

program satisfaction, as well as any program needs that may develop. For example, if you plan to 
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conduct a Part C survey with your caregivers every six months, you can compare survey responses and 

look to see what has changed, remained the same, or might need some further attention. Below are a 

few questions to keep in mind as you look at your survey results over time.

• Has your program participant demographic changed? In other words, are participants older, 

younger, or about the same? Has there been a change in the kinds of caregivers you are 

supporting?

• Are survey participants participating in the same level of services? Are some services that were 

once popular no longer as commonly used? Are some services being used more? 

• Is the level of satisfaction for specific services staying about the same or changing?

Additional Resources

In addition to this survey tool and instruction guide, there are a number of other free, online resources 

that can assist you with your program evaluation. Below are several resources that ACL and ICF 

recommend.

Evaluation Planning

• Evaluation is designed for people interested in learning about program evaluation and how to apply 

it to their work. Evaluation is a process, one dependent on what you’re currently doing and on the 

direction in which you’d like go. 

https://vetoviolence.cdc.gov/apps/evaluaction 

Evaluation Methods Data Collection Surveys/Questionnaires

• Data Collection Methods for Program Evaluation: Questionnaires: 

https://www.cdc.gov/healthyyouth/evaluation/pdf/brief14.pdf

• Increasing Questionnaire Response Rates: 

https://www.cdc.gov/healthyyouth/evaluation/pdf/brief21.pdf

Sharing Findings

• Evaluation Reporting: A Guide to Help Ensure Use of Evaluation Findings. Atlanta, GA: Centers for 

Disease Control and Prevention, US Dept. of Health and Human Services; 2013. 

https://www.cdc.gov/dhdsp/docs/Evaluation_Reporting_Guide.pdf. 

• Disseminating Program Achievements and Evaluation Findings to Garner Support: 

https://www.cdc.gov/healthyyouth/evaluation/pdf/brief9.pdf 
Title VI Nutrition and Supportive Services Survey

This survey is an opportunity for you to share your feedback about the services that you 

receive through our program. Your feedback is important to us and we appreciate your 

willingness to complete this survey. Thank You.

1. Gender: Male Female Other

  

2. Age: 

a.  Younger than 55

b.  55-65

c.  66-75

d.  76-85

e.  86-95

f.  Over 95

3. Check the statement that best matches your current living situation:

a.  I live alone

b.  I live with my partner or significant other

c.  I live with my child/children or other family

d.  I live with a friend

e.  I live in an assisted living facility or community

f.  Other (please share):
2

Nutrition Services: In this section, we want to learn about the meal services you participate in 

and how well the services support your needs.

4. Do you participate in the meal program provided by the Senior Center? Yes No

 

5. If you selected “yes” to question number four, check the statement that best applies to 

how you participate in the meals:

 I attend the congregate (group) meal. 

 I have meals delivered to my home. 

 I have both home-delivered and congregate meals depending on my health/how 

I am feeling. 

6. If you participate in the congregate (group) meal at the Senior Center, how often do you 

attend (select one answer that best applies to you)?

 Every day that meals are offered

 Once a week

 A few times a month

 Only on special occasions/events
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7. How did you hear about the meal program (check all that apply)?

 a. Family member or friend

 b. Senior Center staff member

 c. Flyer, in the newspaper, or other written announcement

 d. Senior Center website

 e. Another Tribal or community agency

(Write in name of other agency): 

_____________________________________________

 f. Other (please tell us how you learned about the program): 

8. What are the main reasons you participate in the meal program? (check all that apply)

 a. The meals help me get the vitamins and nutrients I need.

 b. The prepared meal makes life easier (e.g., I don’t have to worry about cooking). 

 c. I get to socialize with others.

 d. I am on a limited budget and the meal helps with lowering my food costs.

 e. Other (please share): 
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9. Thinking about the meal program, please select whether you strongly disagree, disagree, 

agree, or strongly agree with each statement. (Select one response for each statement)

 

Program Activities: In this section, we want to learn about the other activities you participate in 

through the Senior Center.

Strongly

Disagree Disagree Agree

Strongly 

Agree

N/A

a. The meals taste good.     

b. The meals are the right amount of food 

for me.

    

c. The monthly menu has a good variety of 

options.

    

d. Having meals prepared for me is a big 

help.

    

e. Participating in the meal program helps 

me feel connected to my community.

    

f. I enjoy the time I get to spend with 

other elders.

    

g. The staff care about me.     

h. If I have a question about the meals, I 

know who to ask.

    

10. I participate in the following program activities: (check all that apply)

 a. Bank/Bill Paying Trips

 b. Grocery Shopping Trips

 c. Group Exercise Classes

 d. Group Games (bingo, cards, puzzles)

 e. Crafting (sewing, beading, painting, drawing)

 f. Trainings/ Lunch and Learn Presentations

 g. Other (please share):
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11. How often do you go to the Senior Center to socialize/ exercise / participate in activities 

other than a congregate meal? (Please select one answer)

 Every day that meals are offered

 Once a week

 A few times a month

 Only on special occasions/events

 I only go to the Senior Center for congregate meals

12. To help us understand your transportation needs, please select how you typically get around 

for things like shopping, doctors’ appointments, and go to the Senior Center to visit, or attend 

congregate meals. For each, indicate if you strongly disagree, disagree, agree, or strongly agree.

Strongly

Disagree Disagree Agree

Strongly 

Agree

a. I know how to arrange transportation 

through the Senior Center.

   

b. The transportation service through the 

Senior Center is easy to use.

   

c. I rely on the transportation service through 

the Senior Center to get me where I need to 

be (e.g., shopping, congregate meals, medical 

appointments, group outings.)

   

d. I walk or drive myself where I need to go 

(e.g., shopping, congregate meals, medical 

appointments, group outings.)

   

e. I rely on my family or friends to transport me 

to places where I need to be (e.g., shopping, 

congregate meals, medical appointments, 

group outings.)

   

f. I have trouble arranging transportation to get 

myself where I need to be.

   
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13. To help us plan future trainings and activities, please select whether you would be 

interested in each of the following. Please select not at all interested, somewhat 

interested, interested, or very interested.

Not 

Interested 

Somewhat 

Interested Interested

Very 

Interested

a. Health Information / Disease 

Prevention

   

b. Information on community services 

and resources

   

c. Traditional Language / Culture / 

Tribal History

   

d. Personal Safety and Emergency 

Preparedness

   

e. Exercise / Physical Fitness    

f. Wellness / Stress Management/ 

Relaxation

   

g. Other (please share):

Thank You!
This survey is an opportunity for you to share your feedback about the caregiver supportive 

services that you receive through our program. Your feedback is important to us. We 

appreciate your willingness to complete this survey. Thank You.

1. Gender: Male Female Other

   

2. Age: 

 18-20  21-40  41-60 

 61-80  Over 80

3. I am the primary caregiver for:

 An adult child who is mentally or physically disabled

 My grandchild or grandchildren

 My parent(s) or grandparent(s)

 Spouse or life partner

 Other (please share) 

Title VI Caregiver Support Services Survey
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4. If you are a caregiver for an elder or adult with a disability, please mark what services 

they participate in:

Yes No

a. Participates in the congregate meals provided by the Senior Program  

b. Receives a home delivered meal provided by the Senior Program  

c. Participate in activities and events at the Senior Center  

d. Attends trainings provided by the Senior Center  

e. Attends outings provided by the Senior Center  

f. Other. (please specify):

Caregiver Services: In this section, we want to learn about the caregiver services you

participate in and how well they support your needs.

5. What types of information or services do you receive through the Senior Center 

program?

Yes No

a. Information about available services to support me as a 

caregiver

 

b. Assistance in gaining access to other services that can help me as 

a caregiver

 

c. Individual counseling or a caregiver support group  

d. Trainings on topics including health, nutrition, and financial 

literacy to help me make decisions and solve problems as a 

caregiver

 

e. Respite care so I can get a break from my caregiving 

responsibilities

 

f. Supplemental services such as gloves, incontinence supplies, 

walkers, backpacks, school supplies, bunkbeds, etc.

 

g. Congregate meals for yourself provided by the Senior Center  

h. Home delivered meals for yourself provided by the Senior 

Program

 

i. Activities and events that you attend at the Senior Center  

j. Outings provided for caregivers by the Senior Center  
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6. Thinking about the caregiver services, please select whether you strongly disagree, 

disagree, agree, or strongly agree with each statement. (Select one response for each 

statement)

Strongly

Disagree

Disagree Agree Strongly 

Agree

N/A

a. The information I receive about 

caregiver services is helpful.

    

b. Program staff are able to help 

connect me with other services to 

help me as a caregiver.

    

c. The individual counseling or caregiver 

support group helps me be a better 

caregiver.

    

d. The trainings I attend are educational 

and support me as a caregiver.

    

e. The respite care allows me to get rest 

and/or have personal time.

    

f. I enjoy the time I get to spend with 

others.

    

g. The supplemental supplies I receive 

help me provide care for others.

    

h. If I have a question about caregiver 

services, I know who to ask.

    

i. The congregate or home delivered 

meals make it easier for me by being 

one less meal I have to prepare for 

myself or the person I care for.

    

j. The Senior Center outings are a good 

social break for me.

    

k. Other (please specify):
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7. To help us plan future trainings, activities, and resources to better support caregivers 

like you, please select whether you would be interested in each of the following. 

Please select not interested, somewhat interested, interested, very interested, or does 

not apply to me.

Not 

Interested

Somewhat 

Interested

Interested Very 

Interested

N/A

a. Information on caring for children / 

young adults 

    

b. Training on specific topics related to 

caring for a child / young adult

    

c. Supplies that would help me care for 

a child / young adult

    

d. Support group for caregivers hosted 

by the Senior Center

    

8. If you are interested in a support group for caregivers, what time of day would be 

easiest for you to attend:

Morning



Afternoon



Evening



9. Please share any additional comments or suggestions on how the caregiver program 

could better support you as a caregiver:

Thank You!