Please circle the number that best describes your experience by using “1” to strongly disagree and “5” to strongly agree. If the question does not apply to the dialog you experienced please circle N/A.

		1	2	3	4	5	N/A
1)	I am more aware of the many ways power and privilege exists in today’s society.
2)	I have more understanding about the legacy of race and the racial hierarchy in the United States.
3)	I am more aware of the ways in which power and privilege show up in my daily experiences.
4)	I am more aware of language and terminology regarding the racial, ethnic and cultural identity of myself, and others.
5)	I am willing to explore ways to increase my cultural competency and deepen my insight to how I can use my power and privilege to make positive change in my community.
6)	I am more informed about what an ally is and how to be one.
7)	I have more strategies and language to talk to children about race.
8)	I understand the value of Anti-Bias Education and I am interested to learn more.
9)	I have more language and resources to support positive racial and ethnic identity in children.
10)	I have access to more resources to further my work around Anti-Bias Education and understanding power and privilege.
11)	I can apply what I learned to my work or parenting.
12)	I would recommend Start Dialog to friends and community members.
13)	Something I appreciated and found useful was
14)	Something I would like to dialog more about is
15)	Something I would like to share with Tarah is
16)	Location and Date of Dialog
17)	Ethnic identification (Optional)