PSA Teaching and Action Guide - Users Feedback Form Survey

Jane Doe Inc. (JDI) is always looking for ways to improve and evaluate the work we are doing. Your input is valuable and we appreciate it. Please complete this form and submit to our (website). Thank you.

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* 1. Your Position:

Counselor/Advocate

Educator

Executive Director

Program Director

Other (please specify)

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* 2. Your Organization:

Middle School

High School

College

SA or DV Program

Faithbased Organization

Governmental

Other (please specify)

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* 3. For JDI Members, your organization type:

Domestic Violence

Sexual Assault

Dual

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* 4. What audience have you used this with?

Middle School

High School

College

Faith Group

Fathers Group

Other (please specify)

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* 5. Briefly Describe Your Audience:

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* 6. Evaluate the Facilitators Instructions (page 3-4)

	1:Strongly disagree	2:Somewhat disagree	3:Neutral	4: Agree	5:Strongly Agree
The Facilitator Instructions were very useful:	The Facilitator Instructions were very useful: 1:Strongly disagree	The Facilitator Instructions were very useful: 2:Somewhat disagree	The Facilitator Instructions were very useful: 3:Neutral	The Facilitator Instructions were very useful: 4: Agree	The Facilitator Instructions were very useful: 5:Strongly Agree

Comment:

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* 7. Activity 1: Put Yourself in Their Shoes

	1:Strongly disagree	2:Somewhat disagree	3:Neutral	4: Agree	5:Strongly Agree
Generated active participation from your audience?	Generated active participation from your audience? 1:Strongly disagree	Generated active participation from your audience? 2:Somewhat disagree	Generated active participation from your audience? 3:Neutral	Generated active participation from your audience? 4: Agree	Generated active participation from your audience? 5:Strongly Agree
Identified models of healthy relationships?	Identified models of healthy relationships? 1:Strongly disagree	Identified models of healthy relationships? 2:Somewhat disagree	Identified models of healthy relationships? 3:Neutral	Identified models of healthy relationships? 4: Agree	Identified models of healthy relationships? 5:Strongly Agree

Comment:

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* 8. Activity 2: Getting Outside the Box

	1:Strongly disagree	2:Somewhat disagree	3:Neutral	4: Agree	5:Strongly Agree
Generated active participation from your audience?	Generated active participation from your audience? 1:Strongly disagree	Generated active participation from your audience? 2:Somewhat disagree	Generated active participation from your audience? 3:Neutral	Generated active participation from your audience? 4: Agree	Generated active participation from your audience? 5:Strongly Agree
Identified the constraints of gender roles?	Identified the constraints of gender roles? 1:Strongly disagree	Identified the constraints of gender roles? 2:Somewhat disagree	Identified the constraints of gender roles? 3:Neutral	Identified the constraints of gender roles? 4: Agree	Identified the constraints of gender roles? 5:Strongly Agree

Comment:

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* 9. Content and Skills Development

	1:Strongly disagree	2:Somewhat disagree	3:Neutral	4: Agree	5:Strongly Agree
The content presented can be applied or be adapted to work within heterosexual, gay, lesbian, bisexual, and transgender communities.	The content presented can be applied or be adapted to work within heterosexual, gay, lesbian, bisexual, and transgender communities. 1:Strongly disagree	The content presented can be applied or be adapted to work within heterosexual, gay, lesbian, bisexual, and transgender communities. 2:Somewhat disagree	The content presented can be applied or be adapted to work within heterosexual, gay, lesbian, bisexual, and transgender communities. 3:Neutral	The content presented can be applied or be adapted to work within heterosexual, gay, lesbian, bisexual, and transgender communities. 4: Agree	The content presented can be applied or be adapted to work within heterosexual, gay, lesbian, bisexual, and transgender communities. 5:Strongly Agree
The content presented can be applied or be adapted to work within multicultural communities, incorporating issues of culture, race, and disability.	The content presented can be applied or be adapted to work within multicultural communities, incorporating issues of culture, race, and disability. 1:Strongly disagree	The content presented can be applied or be adapted to work within multicultural communities, incorporating issues of culture, race, and disability. 2:Somewhat disagree	The content presented can be applied or be adapted to work within multicultural communities, incorporating issues of culture, race, and disability. 3:Neutral	The content presented can be applied or be adapted to work within multicultural communities, incorporating issues of culture, race, and disability. 4: Agree	The content presented can be applied or be adapted to work within multicultural communities, incorporating issues of culture, race, and disability. 5:Strongly Agree

Comment:

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* 10. To what degree did you find that this guide:

	1:Low amount	2:	3:	4:	5:High amount
Promotes healthy masculinities (manhood)?	Promotes healthy masculinities (manhood)? 1:Low amount	Promotes healthy masculinities (manhood)? 2:	Promotes healthy masculinities (manhood)? 3:	Promotes healthy masculinities (manhood)? 4:	Promotes healthy masculinities (manhood)? 5:High amount
Increases boys understanding of gender?	Increases boys understanding of gender? 1:Low amount	Increases boys understanding of gender? 2:	Increases boys understanding of gender? 3:	Increases boys understanding of gender? 4:	Increases boys understanding of gender? 5:High amount
Promotes equity and healthy relationships for boys?	Promotes equity and healthy relationships for boys? 1:Low amount	Promotes equity and healthy relationships for boys? 2:	Promotes equity and healthy relationships for boys? 3:	Promotes equity and healthy relationships for boys? 4:	Promotes equity and healthy relationships for boys? 5:High amount
Helps boys feel appreciated as whole persons?	Helps boys feel appreciated as whole persons? 1:Low amount	Helps boys feel appreciated as whole persons? 2:	Helps boys feel appreciated as whole persons? 3:	Helps boys feel appreciated as whole persons? 4:	Helps boys feel appreciated as whole persons? 5:High amount
Offers ways to imagine manhood?	Offers ways to imagine manhood? 1:Low amount	Offers ways to imagine manhood? 2:	Offers ways to imagine manhood? 3:	Offers ways to imagine manhood? 4:	Offers ways to imagine manhood? 5:High amount

Comment:

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* 11. Please share any additional comments

Thank you for completing this survey!
To learn more about Jane Doe Inc, please visit http://www.janedoe.org/