Assisted Suicide Presentation Feedback Form Phone Sex * Female Male Age * School Name * Religion (if any): On a scale of 0 to 10, please select the number which best identifies your view on assisted suicide BEFORE the presentation. ( 0 = always SUPPORT | 10 = always OPPOSE) * 5 Please explain your view: * On a scale of 0 to 10, please select the number which best identifies your view on assisted suicide AFTER the presentation ( 0 = always SUPPORT | 10 = always OPPOSE ): * 5 Please explain your view: * What do you remember most about the presentation? * Did you find anything confusing in the presentation?: * Yes No If yes, what was it?: Do you have any questions about assisted suicide that weren’t answered during or after the presentation? * Yes No If yes, what are they?: Did this presentation motivate you to take action on assisted suicide? * Yes No Please briefly explain: * Speaker’s Name: * Please rate the speaker: * Would you recommend this presentation to someone else? * Yes No Are there any further comments you wish to share? Please proceed to the end of the feedback form to submit. For more information on how you can get involved, such as volunteer opportunities, please sign up below (OPTIONAL): First Name Last Name Email Address Phone Number How can we best reach you? Email Text Facebook Instagram
