1. 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 to follow up this survey?
If yes, please give us your phone no. and/or address
PHONE NUMBER:
Please turn over

2. 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 this form to
Asian British
Caribbean
Irish
Turkish
Mixed race
Bangladeshi
Chinese
Jewish
Pakistani
White
[This space for additional questions of local interest]