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Screening Participant Follow-Up Survey
1.
I attended the following screening of
Connecting The Dots
Screening Date:
Host Organization:
2.
Please enter your name (*
Optional. You can respond to this survey anonymously.)
First Name
Last Name
3.
Country:
Afghanistan
Albania
Algeria
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia (Plurinational State of)
Bosnia and Herzegovina
Botswana
Brazil
British Virgin Island
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte D'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic People's Republic of Korea
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea Bissau
Guyana
Haiti
Holy See
Honduras
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People’s Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia (Federated States of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Republic of Korea
Republic of Moldova
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
State of Palestine
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Tajikistan
Thailand
The former Yugoslav Republic of Macedonia
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United Republic of Tanzania
United States of America
Uruguay
Uzbekistan
Vanuatu
Venezuela (Bolivarian Republic of)
Vietnam
Yemen
Zambia
Zimbabwe
4.
Email address:
5.
I attended the event in my capacity as (choose one that applies the most):
A parent
A peer supporter/youth advocate
A student
A teacher
A person with lived experience/client
A mental health practitioner/professional
A paid staff member at an organization focused on youth mental health
A volunteer at an organization focused on youth mental health
General Interest
6.
Age:
Under 18
18-24
25-34
35-44
45-54
55-64
65+
7.
After the screening of Connecting the Dots my awareness and understanding of youth mental health issues was:
Greatly deepened
Deepened a little bit
I didn’t learn anything knew
8.
The scene/theme I appreciated the most in the film was:
9.
The one thing that impacted me the most in the film was:
10.
This screening event improved my personal overall wellbeing:
Yes
No
Unsure
N/A
Please elaborate:
11.
What did you think of the post screening discussion and activities?
Very useful and interesting
Somewhat useful and interesting
Not useful or interesting
N/A (not applicable)
12.
What did you learn from the post screening discussion and activities? Can you elaborate?
13.
The screening event has inspired me to become an advocate for youth mental health or play a new role in supporting and improving youth mental health in my community?
Yes
No
Please elaborate:
14.
If you could implement one specific change in the way youth mental health is addressed in your community what would that be?
15.
Would you recommend the film to someone you know?
Yes
No
16.
Any other comments about the film or the event you would like to share with us?
17.
Can we share your written responses?
Yes, you can share them and attribute to my name
Yes, you can share them but anonymously
No, please don’t share them
18.
In what country do you currently reside?
United States
Other (please specify)
Current Progress,
0 of 18 answered