Complete both sides of this survey for a chance
to win a $100 Amazon gift card! Provide your email
address on page 2 to enter the prize drawing.
Winners will be announced [January 2016].
AUDIENCE SURVEY
PART 1 (Before the Film)
Your feedback will help us understand if we are meeting our mission of engaging with diverse audiences, and will help us
shape future events to better serve community needs. Your responses will remain confidential. Thank you for your time!
1. Location of Screening Event (City/State): ___________________________________
2. Are you a member of your local PBS station?
3. What is your current age group?
4. What is your gender?
[ ] Under 18
[ ] Female
[ ] Male
[ ] yes
[ ] no
[ ] 18 – 34
[ ] not sure
[ ] 35 – 49
[ ] 50 – 69
[ ] Over 70
[ ] Other: _____________________
5. How would you describe yourself?
[ ] Latino/Latina [ ] African American [ ] Asian American/Pacific Islander [ ] Middle Eastern
[ ] Native American/Native Alaskan [ ] Caucasian [ ] Multiracial [ ] Other: _____________________
6. What is the highest level of formal education you have completed?
[ ] Elementary School [ ] Middle/High School [ ] College/University [ ] Graduate School
[ ] Vocational/Technical School [ ] Not Applicable [ ] Other: _____________________
7. What is your home zip code? __________________________
8. Which of the following best describes your main means of watching films and video? Select no more than two:
[ ] Watch live broadcast television
[ ] Watch on an “over-the-top” device (Apple TV, Roku, Google TV, etc.)
[ ] Watch recorded television (e.g. DVR or TiVo) [ ] Watch online, on a computer (Netflix, Hulu, Amazon, etc.)
[ ] Other: ________________________________
9. Have you ever attended an Indie Lens Pop-Up event before?
[ ] Yes [ ] No [ ] I'm not sure
10. Had you heard of the PBS series Independent Lens prior to attending today’s event?
[ ] Yes [ ] No [ ] I'm not sure
11. How would you rate your current level of awareness about [film issue]? (1 = not at all aware; 5 = very aware)
1
2
3
4
5
12. At this moment, on a scale of 1-5 (1 = not at all likely; 5 = very likely) how likely are you to…
Take time to learn more about [film issue here]
1
2
3
4
5
Do something to get involved locally around [film issue here]
1
2
3
4
5
Donate to or become a member of your local PBS station
1
2
3
4
5
1
AUDIENCE SURVEY
PART 2 (After the Film)
Complete both sides of this survey for a chance
to win a $100 Amazon gift card! Provide your email
address on page 2 to enter the prize drawing.
Winners will be announced [January 2016].
Please complete this side of the survey at the conclusion of the event
1. Your email address (optional): _________________________________________________________
2. How would you rate your current level of awareness about [film issue]? (1 = not at all aware; 5 = very aware)
1
2
3
4
5
Please explain:
3. At this moment, how likely are you to… (1 = not at all likely; 5 = very likely)
Take time to learn more about caregiving for people with disabilities
1
2
3
4
5
Talk to friends or family about caregiving for people with disabilities
1
2
3
4
5
Get involved in and/or take action on caregiving for people with disabilities
1
2
3
4
5
Donate to, or become a member of your local PBS station
1
2
3
4
5
Watch Mimi and Dona when it airs on PBS
1
2
3
4
5
Attend future Indie Lens Pop-Ups
1
2
3
4
5
4. If you are likely or very likely to get involved locally around caregiving for people with disabilities, please tell
us what action you are considering taking:
5. Please feel free to share additional comments about Mimi and Dona and today’s event:
6. Would you like to receive the Independent Lens e-newsletter to receive updates on upcoming films?
[ ] yes
[ ] no
2