Dialogue Impact Report Form – Days of Dialogue

Dialogue Impact Report Form

Frist Name

Last Name

Email

Dialogue Title

Date of Session

Scribe Name

Quotes

Was the group engaged?

Yes No Somewhat

Any conflicts or tensions?

Yes No

How well did participants connect with the material?

Very Well Moderately Not at all

Scribe Notes (Surprises, Gaps, Questions)

Total Participants

Age Range

Demographics (Gender, Race, Affiliations)