Request for educational presentation or guest speaker (needs assessment)
A needs assessment is an approach to determine the state of knowledge, ability, interest and attitude of the group we will be presenting to. With this information we will be able to tailor your learning experience. Please complete the attached, it should take you about 10-15 minutes. If you have any questions please email us at education@pflagdurhamregion.com
Email address *
Needs Assessment
Date - please suggest 3 possible dates
Suggested Date - 1 *
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Suggested Date - 2
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Suggested Date - 3
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Time - please suggest 3 possible times
Suggested time - 1 *
Time
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Suggested time - 2
Time
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Suggested time - 3
Time
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Contact Details
Contact Name/Title: *
Your answer
Telephone: *
Your answer
Email *
Your answer
Organization: *
Your answer
Are you a PFLAG member?
Your answer
Presentation Details
Scheduled Length of the Presentation? *
Your answer
Will we run into a meal time?
Your answer
Will the participants require a break?
Your answer
Audience
Who is our audience? *
Your answer
What is the audience's group identity?
Your answer
To what extent are they educated, informed or experienced on issues of sexual orientation and/or gender identity? Have they had previous training?
Your answer
Are the participants using personal or work time?
Your answer
Is participation mandatory or volunteer?
Your answer
How many people should we expect? *
Your answer
What is the age group of participants?
Your answer
Organization Culture
Does the current environment support sexual orientation and gender diversity?
Please explain:
Your answer
Is the presentation proactive or reactive? *
Please explain:
Your answer
Anticipated Outcomes or Goals
What are your goals? What knowledge, understanding and/or information do we wish to impart?
Your answer
Why will audience members want to attend?
Your answer
What are they expecting to learn? *
Your answer
Promotion
How will the presentation be promoted?
Your answer
Space and Equipment:
Additional Details:
Your answer
Equipment Available:
Additional Details:
Your answer
Where is the presentation room located?
Your answer
Is the space barrier-free?
Your answer
What is the earliest we can access the room?
Your answer
Where are the washrooms located in relation to the presentation room?
Your answer
Content Suggestions
Introduction:
Your answer
Lecture:
Your answer
Experimental Learning:
Your answer
Review:
Your answer
Discussion/Questions: *
Your answer
Suggested Donation
Train the Trainer: $250/person
LGBTQ 101: $50/person
Trans 101: $50/person
Building Compassion for LGBTQ Seniors: $50/person
Positive Space $75/person

If cost is prohibitive, please discuss this with the Executive Director or Education Director.

Thank you for completing this needs assessment. We will be in contact with you shortly to discuss next steps.
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This form was created inside of PFLAG Canada Durham Region.