Statistics for Action

Your/Organizer's Name

Organization (TAC, BREDL, etc.)

Name of Community Group or Conference Workshop

Date of Meeting/Workshop

Number attending Please note # of men and women, if possible

Tell us about the ethnic/racial groups represented, languages spoken. Tell us about the setting (living room, community meeting room, conference, etc.)

Tell us a little background information about the group campaign or the goal of the workshop.

What SfA materials did you use? What activties did you set up?

What Smart Moves did YOU use? Check all that apply.

What Smart Moves did your AUDIENCE use? Check all that apply.

Any comments on using Smart Moves? (Your own or your audience's)

What was the response? Quotes from participants are especially helpful, even simple statements that reveal attitudes, comfort level, as well as observations about the math, e.g., This was good; I’d like to do this with my sister, son; This is easy; I never knew a gram was so little; I still can’t imagine a milligram, etc.

What connections did you make for participants between their issues and the SfA materials? For example, what community issue prompted you to use this workshop? What reports or additional materials did you bring in, if any?

As facilitator, do you have any feedback for us about the materials? Or any other reflections/comments?

	Toxics Action Center
	Blue Ridge Environmental Defense League
	Little Village Environmental Justice Organization
	New England Literacy Resource Center
	Operation Green Leaves
	Pesticide Watch
	River Network
	B.U. SuperFund Basic Research Program Community Engagement Core
	Global Community Monitor
	Pesticide Action Network, North America

Facilitator Feedback Form

Statistics for Action: Activity Use Feedback Form