This was used as an assessment to analyze, summarize, and lead up to compare/contrast of two Carl Sandburg poems. I also used it with two Robert Frost poems when teaching a younger grade. Due to copy write issues I cannot attach those poems, but any two poems would work by the same author, and it could be adapted to summarize simply one poem if desired.
It is to be used AFTER all poetry analysis instruction has been given and you want to see if students can synthesize their learning and summarize via writing. I did several with them using the exact same form but different poems (Homework, Oh Homework, If, etc) so they wouldn't be scared by writing about their analysis and summarizing.