ACRN-IAP SELF-SCREENING QUESTIONNAIRE
This Inter-Action Project (IAP) is sponsored by the African-Canadian Resource Network (ACRN), a Saskatchewan non-profit organization and the Government of Canada through the Department of Canadian Heritage. The project seeks to address the HUMAN, SOCIAL AND ECONOMIC cost of the intersection of OPPRESSION based on PERCEIVED "RACE", GENDER AND RELIGIOUS DIFFERENCES experienced by Canadians of African Descent in Manitoba, Saskatchewan and British Columbia towards positive change.

This purpose of the pre-self-screening questionnaire is to self- assess your readiness for a) positive change and b) level of risk involved for self before engaging in deep critical self-reflection about past experiences of oppression and you being in an oppressor role (i.e. individual’s and related social intervening conditions).
Participants in this study will be requested to share only information that they are comfortable with for the purpose of exploring, improve understanding and overcoming oppression.
Completing this questionnaire will take you 15 minutes or less, however, it may require some time of reflection. The questionnaire should be collected the next day after the initial contact for those who choose to reflect on the decision.

-READINESS FOR CHANGE: (-description to assess attitude about change, awareness of change, desire to change improve; time commitment, willingness to take a challenge to overcome…grow if supported.

The project goal is to recruit 80 to 90 provincial participants comprising of 40 men and 40 women, 50% of which will be between the ages of 19 to 35 (to be classified as youth). They will attend a minimum of three discussion workshops held on Saturdays in Regina and Saskatoon during the months of January –February 2019 (a total of 20 hours). They will also attend the project conference to be held in Regina during May 23-25, 2019 weekend. Meals transport and child-care costs related to participating in this 8 to 10 months of anti-oppressive practice intervention program will be covered by the project

By completing this self screening questionnaire, you agree that African Canadian Resource Network (ACRN) reserves the right to use any photograph/video taken at these Inter-Action Project workshops or sessions, without the expressed written permission of those included within the photograph/video. ACRN may use the photograph/video in publications or other media material produced, used or contracted by ACRN including but not limited to: brochures, invitations, books, newspapers, magazines, television, websites, etc.

Email address *
Your Location *
1. After some critical self-reflection about your life –in the past, where you are now and where you’d like to be five years from now- state in three short sentences why you are interested in this project. *
Your answer
2. Gender *
3. Religion
4. Age *
5. Official Language and Fluency *
6. What is your attitude or state of mind in respect to past and current experience of the oppression (discrimination) and in relation to general changes in life? Please state your response by completing the sentences below. *
7. What is your current state of mind (attitude) in relation to aspect of your life that you can influence /or believe you are able to control? *
Your answer
8. Within the context of oppression based on perceived “race”, gender and religious differences, do you have any recent incident(s) in your life in the last 1-2 years where you felt that your safety is threatened *
9. If Yes - has the issue(s) been resolved? If No, Ignore this question and proceed to the next
10. Within the context of oppression based on perceived “race”, gender and religious differences, do you have any recent incident(s) at the family level where you felt that your safety is threatened? *
11. If Yes, has the issue(s) been resolved? If No, Ignore this question and proceed to the next
12. Within the context of oppression based on perceived “race”, gender and religious differences, do you have any recent incident (s) at the larger public sector level where you felt that your safety is threatened? *
13. If Yes, has the issue(s) been resolved? If No, Ignore this question and proceed to the next
14. In general - do you have past incident (s) that you still feel threaten your safety?If yes – can you briefly state the context of the ones you are ready to resolve? *
Your answer
A copy of your responses will be emailed to the address you provided.
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