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Needs Assessment Questionnaire

Contact and Event Information

*E-mail (required):

Name:

Company Name:

Event Date:

Event Day:

Beginning Time: Ending Time:

Number of Attendees:

Audience Demographic Information

Age: Sex:
Average Income: Education:

Cultural Mix:

Should the message be tailored to one group?
yes no

If yes, which group?

What occupation or occupations will be represented in the audience?

What frustrations do they experience in their work?

What are the sensitive issues in your organization's work environment?

Are there controversial issues that should be avoided?
yes no

If yes, which group?

Other Relevant Demographic Information:

Meeting Information

Are there specific issues you want Burnette to address
in her presentation?

What three points of information do you want Burnette to
address at this particular meeting?

Please suggest two or three speech titles or ideas that might
be compelling to your audience.

Does your meeting have a theme? yes no If yes, what is it?

Does your meeting have a slogan? yes no If yes, what is it?

What industry jargon do you want used during the presentation?

Are there common sayings in your organization that might be
effectively employed?

How do you want your people to feel when they leave the
speaker's presentation?

What events are occuring immediately before and
after Burnette speaks?

What's the appropriate dress code for the presentation? (Formal, business, casual, etc.)

What other information might be helpful for the speaker to know?

Speaking Information:

What is the name and telephone number of the person that will be introducing Burnette Clingman?
Introducer's name:

Introducer's Phone:

Please provide names, title, and telephone numbers of three key individuals in your organization that will be in Burnette's audience. To further customize Burnette's presentation, we would like to contact them to get additional information.

1a.	Name:
1b.	Title:
1c.	Phone:

2a.	Name:
2b.	Title:
2c.	Phone:

3a.	Name:
3b.	Title:
3c.	Phone:

Please send BCE the following:

An agenda of the meeting/program
Relevant past meetings brochures
List of presenters who will be speaking before Burnette

Send to the attention of Burnette Clingman:

Fax: (937) 835-9868
E-mail: bclingman@aol.com

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