One Small Step Questionnaire – Brave Coalition Step 1 of 5 0% Contact InformationName First Last Location (City, State, ZIP) City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address Preferred phone numberHow did you find out about the opportunity to participate in StoryCorps' One Small Step?RadioA friend, family member, or colleagueSocial mediaEmailFlyer, postcard, or other print advertisementEventAnother organizationA different way not listed herePlease specifyIf scheduled, your One Small Step recording will take place online. Do you have access to a computer or mobile device (iPad, tablet, etc.) and reliable wifi?YesNoIf StoryCorps is unable to make a match for you, would you like us to share your information with on-campus group BridgeND?BridgeND is a student-run group that will be holding a conversation event called ConvergeND later in the fall. You can find out more about it at http://bridgeusand.weebly.com/ or by emailing [email protected] If you aren't matched by StoryCorps, they will make an effort to include you in their event. Yes, please share my infoNo, thank you Your IdeologyWhere on this scale would you place your thinking on social issues? I would not place myself on this scale.Please briefly describe your thinking on social issues.Where on this scale would you place your thinking on economic issues? I would not place myself on this scale.Please briefly describe your thinking on economic issues.How important is your social/political ideology to your identity as a person?How important is religion in your life?How accurate are the following statements about you?Not at allSometimesConsistentlyI vote in electionsI am dedicated to following the newsI discuss politics with my friendsI am actively engaged in local politics The One Small Step conversationIs there someone in the Make America Dinner Again Community who you would like to be matched with for this conversation?NoYesPerson's namePlease note that while we cannot guarantee it, we will do our best to match you with them if possible.Do you know someone you would like to speak with for One Small Step?If you have a conversation partner in mind, we will get in touch with you for further details.NoYesPerson's name, and relationship to youWhat one thing do you most want to achieve by participating in a One Small Step interview?Give voice to my point of view / tell my storyTry to understand a point of view that is different or difficult for meExperience or practice talking to someone with whom I may not agreeMeet and connect with someone unlike most people I knowHave a potentially difficult conversation in a structured settingRe-connect in a structured setting with someone that I knowNot listed abovePlease specifyPlease describe your ideal conversation partner for a One Small Step conversationIf you have any concerns about being part of a One Small Step conversation, what is the one thing that most concerns you?The conversation may escalate to a point that makes me uncomfortableThe other person might say something that is troubling or disturbing to meI will be unable to express myself as well as I'd wantI will get angry or upset at the other personThe other person will get angry or upset at meWe will have trouble taking turns speaking, and one person will get to express themselves more than the otherNone of these things concern meNot listed abovePlease specify Some more information about youProviding StoryCorps with this demographic information is optional. Having more information about you will help us match you with an interview partner, so we encourage you to provide as much as makes you comfortable.AgeGender Female / Woman Male / Man Another gender identity Please specifyRace / Ethnicity American Indian or Alaska Native Asian Black or African American Hispanic or Latino/a/x Native Hawaiian or Pacific Islander White/Caucasian Not listed above Please specifyReligious affiliation Buddhist Christian Hindu Jewish Muslim Secular/Atheist/Agnostic Unitarian Universalist Not listed above Please specify Introduce YourselfIf you’re chosen to participate, we’ll share what you write below with your conversation partner a few days before you meet. Write a few details that give a sense of who you are, where you're from, the big life events that shaped you (e.g. the birth of children, or losing a loved one), and any issues that are especially important to you.