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* 1. Site Name:

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* 2. Your name: 

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* 3. Email:

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* 4. Please complete the following statements by picking the most appropriate response:

  5-Strongly Agree 4- Somewhat Agree 3- Neither agree nor disagree 2- Somewhat disagree 1. Strongly Disagree
I feel comfortable and at ease facilitating creative movement activities in my classroom
I feel creative movement is an important part of my classrooms learning environment
I regularly incorporate creative movement activities in my classroom as part of my curriculum
I am knowledgeable in creative movement terminology
I feel comfortable and at ease with developing a movement activity to support executive function
I know how to adapt an activity I already do in the classroom to further support executive function

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* 5. Based on what you know of your students’ abilities, please complete the following statements by picking the most appropriate response:

  4- Very proficient 3- Somewhat proficient 2- Somewhat not proficient 1- Not proficient
Demonstrate working memory (staying on task)
To follow 2+ step directions
Demonstrate cognitive flexibility
Demonstrate inhibitory control
To start and stop on cue
To wait their turn before moving
To respect other people's personal space boundaries
To understand that dance/creative movement can express ideas and emotions
Ability to portray the meanings of words through movement
Ability to keep a steady beat
Ability to keep a rhythmic pattern

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* 6. Please list 3 important reasons for using creative movement and dance in your classroom.

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* 7. In what ways do you think creative movement can help your classroom? (Classroom management, transitions, etc)

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* 8. If you are facing a challenge in your classroom, how might you use a creative movement activity to help you overcome the situation?

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* 9. Describe a moment of growth for one of your students because of this program.

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* 10. What challenges or struggles did you face during this program? What suggestions can you offer PBT for improving this program for the future?

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* 11. Any additional comments about the program?

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* 12. By completing all paperwork for the residency, you will receive a gift bag of approximately $25 for your classroom! Please choose a few items you would like for your classroom from the choices below:

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