For Me For Us Video Feedback
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1
. Gender
Gender
Male
Female
2
. Age
Age
Under 18
18-45
46-64
65 and older
3
. Race/Ethnicity (You may check more than one.)
Race/Ethnicity (You may check more than one.)
Native Hawaiian
Tongan
Samoan
Other Pacific Islander
American Indian/Alaskan Native
Asian
Black/African American
Hispanic/Latino
White/Caucasian
4
. Where do you live?
Where do you live?
Utah
Other (please specify)
5
. Which versions of the “For Me, For Us” video have you seen? (Check all that apply.)
Which versions of the “For Me, For Us” video have you seen? (Check all that apply.)
Samoan Language Version
Spanish Language Version
Tongan Language Version
English Language Version for African Americans
English Language Version for Hispanics/Latinos
English Language Version for Pacific Islanders
English Language Version for General Population
6
. How did you find out about this video?
How did you find out about this video?
Church
Community-Based Organization
Friend or Relative
Health Department or Public Health Worker
Hospital or Clinic
Internet Search
Utah Department of Health website
YouTube
Other (please specify)
7
. Do you feel that the information in the video was useful?
Do you feel that the information in the video was useful?
Yes
No
8
. Was the video easy to understand?
Was the video easy to understand?
Yes
No
9
. Was the video enjoyable to watch?
Was the video enjoyable to watch?
Yes
No
10
. Did you learn any new information by watching this video?
Did you learn any new information by watching this video?
Yes
No
11
. Were you motivated to change any health behaviors because of watching this video?
Were you motivated to change any health behaviors because of watching this video?
Yes
No
12
. Would you recommend this video to a friend or relative?
Would you recommend this video to a friend or relative?
Yes
No
13
. Overall, how do you rate the video?
Poor
Fair
Good
Excellent
*
Overall, how do you rate the video? Poor
Fair
Good
Excellent
14
. Do you have any comments about the video?
Do you have any comments about the video?
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