Please answer the following questions based on your recent viewing of XX. Thank you for your participation.
1) Screening Location: ____________________________________________________
2) How would you rate the following in reference to this film?
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5 Excellent |
4 Good |
3 OK |
2 Fair |
1 Poor |
a. Handling of topic presented |
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b. Overall impact of film |
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c. Effectiveness of group discussion (if applicable)
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3) Has this screening provided you with the following?
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Yes, very much |
Yes, somewhat |
No, didn’t make a difference |
Not applicable |
a. Information or tools you can use in your work |
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b. Increased motivation to prevent hate, intolerance, and/or bullying in your community |
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c. Increased motivation to work more closely with schools to prevent hate, intolerance and/or bullying |
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d. New ideas for improving relationships between community members, schools, and law enforcement |
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e. Increased commitment to engage youth in preventing hate, intolerance and/or bullying in their communities |
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4) What opportunities and/or challenges do you anticipate in using this film within your community or agency?
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5) What additional information or supplemental resources would you like to see presented in films and discussions to support your training and outreach efforts?
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6) Additional comments?
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7) Demographic Information
We request the following information to help us understand and better serve our audience. Thank you. |
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a. Gender ☐Male ☐Female ☐ Other |
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b. Age ☐12 or younger ☐13-18 ☐19-25 ☐26-35 ☐36-45 ☐46-55 ☐56-65 ☐66+ |
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e. Constituency ☐Law enforcement ☐Student ☐Educator ☐Community member ☐Civic leader ☐Faith group member ☐Other__________________ |
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f. Occupation |
Would you like to receive more resources or updates from Not In Our Town?
If yes, please provide: Name ________________________________________________
Phone ________________ Email ___________________________
Thank you for your participation!
For more information on how to prevent hate, intolerance, and bullying in your community, please visit the Not In Our Town website at www.niot.org.
The public reporting burden for this collection of information is estimated to be up to 5 minutes per response. Send comments regarding this burden estimate or any other aspects of the collection of this information, including suggestions for reducing this burden, to the Office of Community Oriented Policing Services, U.S. Department of Justice, 145 N Street, N.E., Washington, DC 20530; and to the Public Use Reports Project, Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503.
You are not required to respond to this collection of information unless it displays a valid OMB control number. The OMB control number for this application is XXXX-XXXX and the expiration date is <insert date>.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | gRace Carroll |
File Modified | 0000-00-00 |
File Created | 2021-01-27 |