PBS Online Thirteen
Feedback Forms

Individual Evaluation

Stations, organizations, discussion leaders, and participants, please give us your feedback.

Please print this form and return it by mail or fax to: Lennie Duensing, Associate Director of Outreach, Thirteen/WNET, 356 West 58th St., New York, NY 10019. Fax: 212-560-6992.

Neither wNetStation nor PBS Online is collecting these evaluation forms via the Internet.

BEFORE I DIE
Outreach Report
Individual Evaluation

Name:

Address:

Telephone:

1) What was your initial reaction to the videoconference, BEFORE I DIE: A NATIONAL CONVERSATION?






2) How did these issues affect you?






3) Do you have any criticisms or comments about the videoconference?






4) Did you participate in a discussion group following the videoconference?






5) What was the response like?






6) Did you participate in this discussion? What issues were particularly close to you? Did you bring these up during the discussion?









7) How did people react to your comments?






8) Do you feel that you learned a lot from the other participants?






9) Did you exchange numbers or resources with any of the other participants?






10) Did you gather with any of the videoconference participants to watch the broadcast production, BEFORE I DIE: MEDICAL CARE AND PERSONAL CHOICES?






11) What was your initial reaction to the broadcast?






12) Do you have any comments or criticisms about the program?






13) Did you participate in a discussion group following the broadcast?






14) How many people were in your discussion group? Was it a diverse group?






15) Did you participate in any other outreach activities/ events following the broadcast?






16) How did you become involved with your discussion group? Did you go through your local PBS station, a healthcare organization, civic organization, business and professional women's group, medical and allied professional groups, managed care groups, geriatric service organization, bar association, or employee assistance program?






17) How often did the discussion group meet?



18) How many people were in your discussion group on the average?






19) Did you make it a social gathering? For example, did your discussion group convene at a coffee house? Did your discussion group plan any other creative activities?






20) Did your group have a leader?



21) Did he/she emerge or was this the person that put the group together?



22) What were some of the resource material used?






23) Did you find the Viewer's Guide helpful? How?






24) Did you order any of the available videotapes? If you ordered the segmented tape, did you find it particularly useful in your discussions? Was the Resource Kit a good tool?






25) What were some of the interesting dialogue developments?






26) What were some of the themes discussed?



27) Did everyone actively participate?



28) Did you find yourself actively participating?




29) Did all participants fully listen to everyone else?









30) What did you learn from other members of your discussion group?







31) Do you have any suggestions/ comments?









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