“The Power Of Two” Community Outreach & Engagement Campaign Post-Viewing Survey
To assist us with information for our grant applications, we would appreciate if you can please fill out this survey after watching, “The Power Of Two.” We would like to record your level of understanding concerning key issues in the film. Please deposit into boxes by the exit following the screening.  Thank you for supporting “The Power Of Two!”

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To which screening does this survey relate? *
Choose the screening you attended from the drop-down list.
I consider myself a _______ :      
(check all that apply)
Clear selection
Are you registered as an organ donor?
Check one
Clear selection
Have you told your family about your decision to register as an organ donor?
Check one
Clear selection
How has your knowledge of the issues below increased following the viewing of this film?
(Check answer in column)
No change
Increased Slightly
Increased Somewhat
Significantly Increased
The genetics and symptoms of those with cystic fibrosis
The medical treatment of those with CF
Ways to cope with having CF
The process of becoming listed for a transplant
Ways to cope with waiting for a transplant
The process of receiving a transplant
Medical treatment of transplant recipients
Cultural & religious beliefs about organ donation
Cystic fibrosis in Japan
Organ donation and transplantation in Japan
Clear selection
Would you recommend this film to others?
(circle your answer)
Clear selection
What was the most important thing you learned from viewing "The Power Of Two"?
If you would like to be on our email list, please provide your name, city and email address:
I am someone who prefers to receive information in a language other than English
If so, which language: ________________________
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