What is your UW Affiliation (please choose only one): 
Student Staff Faculty Community Alumni

Ethnicity: Select only one American Indian or Alaskan Native Asian American or Pacific Islander African American/ Black (not of Hispanic origin) Hispanic/ Chicano/a White (not of Hispanic origin) Other/ Bi-racial/ Multi-ethnic

Program/ Class Name:

Date of Program/ Class:

What did you think of the program/ class (on a scale of 1-5)?
Select one 5 = Excellent 4 = Good 3 = Average 2 = Below Average 1 = Poor

Would you attend another program (or be interested in another class) like this in the future?
Yes No Maybe

Would you recommend our programs (or class lectures) in the future?
Yes No Maybe

Any other suggestions/ comments?

Optional:
Name:
Contact info (e-mail, phone, etc):

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