Conversation Project Reach Tracker Form
We provide all of our materials for free, and in return we ask that you tell us how you are using them. Please fill out this form to the best of your knowledge.

**** If you have done multiple events where you shared the Conversation Project, you can consolidate those into one form for convenience. We are mostly interested in estimating total reach.****

Email address
Who shared The Conversation Project?
Name
Your answer
Organization or affiliation
Your answer
City, State and Zip Code (or country if outside of the US)
Your answer
How did you share The Conversation Project?
How did you share the Conversation Project?
Required
When?
Can be approximate or exact ("October 15, 2016", or "Ongoing since April 2013").
Your answer
Estimated reach or attendance
Please enter your best estimate for the number of individuals you directly reached.
Your answer
Who was your audience?
Ex: Nurses, patients at my hospice, other Conversation Project volunteers
Your answer
If you didn't share the Starter Kit, did you share something else?
Your answer
Thank you!
Anything else?
How did your workshop go? Any feedback about this form?
Your answer
A copy of your responses will be emailed to the address you provided.
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