YOUR VIEWS ARE VITAL TO US – PLEASE TAKE A COUPLE OF MINUTES TO FILL OUT THIS FEEDBACK FORM   1. Date and time of screening Date:  AM/PM please circle 2. Was this part of a staff training or development event?    Yes No 3. Did you attend an Audience Dialogue? 4. Do you or a family member have dementia? 5. Do you work with people with dementia? Paid work Volunteer 6. Please tell us what you think of the show in general: 7. If you know or work with people with dementia, what messages will you take away from seeing Inside Out of Mind? 8. Overall, how did you enjoy the screening of the play? please circle Not at all Moderately Very much 9. May we contact you again by phone or email to follow up this survey? If yes, please give us your phone no. and/or email address PHONE NUMBER: EMAIL: Please turn over

PLEASE TELL US ABOUT YOURSELF    [This space for additional questions of local interest] 11. Your home postcode PLEASE TELL US ABOUT YOURSELF 12. Your age group please circle 14-19 25-64 20-24 65+ 13. Do you consider yourself have a disability? Yes No 14. Are you deaf? 14. Are you: Female Male 15.Your ethnic group African Black British Indian Kurdish Vietnamese THANK YOU FOR YOUR RESPONSES Please e-mail this form to ioom@nottingham.ac.uk Asian British Caribbean Irish Turkish Mixed race Bangladeshi Chinese Jewish Pakistani White [This space for additional questions of local interest]