Inform, Transform, Inspire Presentation Feedback

Thank you for being an ambassador for culture change! We appreciate you taking the time to give us some feedback about your presentation. If you have additional questions or comments, please contact Sonya Barsness at sonya.barsness@pioneernetwork.net.

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* 1. Please tell us about yourself!

Name:

Company:

City/Town:

State:

Email Address:

Phone Number:

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* 2. When was the presentation held?

Date of presentation

Date

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* 3. Where was the presentation held?

Site of presentation (e.g. home, faith community, community center, office, etc.)

City

State

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* 4. About how many people attended your presentation?

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* 5. How would you describe the audience? (check all that apply)

Consumers

Individuals seeking information about care for their family members

Individuals seeking information about care for themselves

Residents currently living in long-term care

Professionals in long-term care

Ombudsman

Policymakers

Researchers

Other (please specify)

Inform, Transform, Inspire Presentation Feedback

Question Title

* 1. Please tell us about yourself!

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* 2. When was the presentation held?

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* 3. Where was the presentation held?

Question Title

* 4. About how many people attended your presentation?

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* 5. How would you describe the audience? (check all that apply)

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* 6. If your audience had questions, what were their questions about?

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* 7. What other comments did you hear from the audience regarding the topic?

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* 8. If plans were made to meet again, or to follow up with the audience, please describe your plans: