Data Submission Form - The Quilt A Living History of African American Music Step 1 of 15 6% Name(Required) First Last Email(Required) PhoneWhat type of group are you with?(Required) School Nonprofit Organization Religious Group/Organization Government Institution Other Name of Group(Required) Your Position/Role(Required) Group Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands HiddenAre you with a school or learning center? Yes No HiddenName of Company/Organization HiddenHow did you show the film? In-Person Screening(s) Virtual Screening(s) - Livestream Only Virtual Screening(s) (On-Demand, not Live) How many times did you show the film?(Required)Please enter a number from 1 to 100.Total Number of Viewers(Required)This should be the total number of people that watched the film over the course of all times that it was watched.Please enter a number greater than or equal to 1.Viewer Race/Ethnicity (%)(Required)White/CaucasianHispanic/Latino AmericanAfrican AmericanAsian AmericanNative American/Alaskan NativeHawaiian Native/Pacific Islander (#)Other or Multiple Race/EthnicitiesPlease type numerical values only (1,2,3,4, etc.). You may use general demographic information of your group overall.Viewer Gender (%)(Required)MaleFemaleOtherDid not Disclose/UnknownPlease type numerical values only (1,2,3,4, etc.). You may use general demographic information of your group overall. Screening & Use InformationHow many in-person screenings did you have?(Required)12345How many live virtual screenings did you have?(Required)12345How long did your virtual on-demand screening last for?Start Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920End Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 In-Person Screening #1Screening Date(Required) MM slash DD slash YYYY Number of Attendees(Required)Attendee Race/Ethnicity (%)Please type numerical values only (1,2,3,4, etc.)White/CaucasianHispanic/Latino AmericanAfrican AmericanAsian AmericanNative American/Alaskan NativeHawaiian Native/Pacific Islander (#)Other or Multiple Race/EthnicitiesAttendee Gender (%)Please type numerical values only (1,2,3,4, etc.)MaleFemaleOtherDid not Disclose/UnknownAttendee Age Range (%)Please type numerical values only (1,2,3,4, etc.)1-1718-2425-3435-4445-5455-6465+ In-Person Event #2Screening Date(Required) MM slash DD slash YYYY Number of Attendees(Required)Attendee Race/Ethnicity (%)Please type numerical values only (1,2,3,4, etc.)White/CaucasianHispanic/Latino AmericanAfrican AmericanAsian AmericanNative American/Alaskan NativeHawaiian Native/Pacific Islander (#)Other or Multiple Race/EthnicitiesAttendee Gender (%)Please type numerical values only (1,2,3,4, etc.)MaleFemaleOtherDid not Disclose/UnknownAttendee Age Range (%)Please type numerical values only (1,2,3,4, etc.)1-1718-2425-3435-4445-5455-6465+ In-Person Screening #3Screening Date(Required) MM slash DD slash YYYY Number of Attendees(Required)Attendee Race/Ethnicity (%)Please type numerical values only (1,2,3,4, etc.)White/CaucasianHispanic/Latino AmericanAfrican AmericanAsian AmericanNative American/Alaskan NativeHawaiian Native/Pacific Islander (#)Other or Multiple Race/EthnicitiesAttendee Gender (%)Please type numerical values only (1,2,3,4, etc.)MaleFemaleOtherDid not Disclose/UnknownAttendee Age Range (%)Please type numerical values only (1,2,3,4, etc.)1-1718-2425-3435-4445-5455-6465+ In-Person Screening #4Screening Date(Required) MM slash DD slash YYYY Number of Attendees(Required)Attendee Race/Ethnicity (%)Please type numerical values only (1,2,3,4, etc.)White/CaucasianHispanic/Latino AmericanAfrican AmericanAsian AmericanNative American/Alaskan NativeHawaiian Native/Pacific Islander (#)Other or Multiple Race/EthnicitiesAttendee Gender (%)Please type numerical values only (1,2,3,4, etc.)MaleFemaleOtherDid not Disclose/UnknownAttendee Age Range (%)Please type numerical values only (1,2,3,4, etc.)1-1718-2425-3435-4445-5455-6465+ In-Person Screening #5Screening Date(Required) MM slash DD slash YYYY Number of Attendees(Required)Attendee Race/Ethnicity (%)Please type numerical values only (1,2,3,4, etc.)White/CaucasianHispanic/Latino AmericanAfrican AmericanAsian AmericanNative American/Alaskan NativeHawaiian Native/Pacific Islander (#)Other or Multiple Race/EthnicitiesAttendee Gender (%)Please type numerical values only (1,2,3,4, etc.)MaleFemaleOtherDid not Disclose/UnknownAttendee Age Range (%)Please type numerical values only (1,2,3,4, etc.)1-1718-2425-3435-4445-5455-6465+ Virtual Screening - Livestream #1Note that it is understood that data such as race/ethnicity, gender, and age range may not be trackable in this format, so answer to the best of your ability.Screening Date(Required) MM slash DD slash YYYY Total Live Viewers(Required)Please enter a number greater than or equal to 1.Viewer Location (City/State)City/State% of viewers Add RemoveViewer Race/Ethnicity (%)Please type numerical values only (1,2,3,4, etc.)White/CaucasianHispanic/Latino AmericanAfrican AmericanAsian AmericanNative American/Alaskan NativeHawaiian Native/Pacific Islander (#)Other or Multiple Race/EthnicitiesViewer Gender (%)Please type numerical values only (1,2,3,4, etc.)MaleFemaleOtherDid not Disclose/UnknownViewer Age Range (%)Please type numerical values only (1,2,3,4, etc.)1-1718-2425-3435-4445-5455-6465+ Virtual Screening - Livestream #2Note that it is understood that data such as race/ethnicity, gender, and age range may not be trackable in this format, so answer to the best of your ability.Screening Date(Required) MM slash DD slash YYYY Total Live Viewers(Required)Please enter a number greater than or equal to 1.Viewer Location (City/State)City/State% of viewers Add RemoveViewer Race/Ethnicity (%)Please type numerical values only (1,2,3,4, etc.)White/CaucasianHispanic/Latino AmericanAfrican AmericanAsian AmericanNative American/Alaskan NativeHawaiian Native/Pacific Islander (#)Other or Multiple Race/EthnicitiesViewer Gender (%)Please type numerical values only (1,2,3,4, etc.)MaleFemaleOtherDid not Disclose/UnknownViewer Age Range (%)Please type numerical values only (1,2,3,4, etc.)1-1718-2425-3435-4445-5455-6465+ Virtual Screening - Livestream #3Note that it is understood that data such as race/ethnicity, gender, and age range may not be trackable in this format, so answer to the best of your ability.Screening Date(Required) MM slash DD slash YYYY Total Live Viewers(Required)Please enter a number greater than or equal to 1.Viewer Location (City/State)City/State% of viewers Add RemoveViewer Race/Ethnicity (%)Please type numerical values only (1,2,3,4, etc.)White/CaucasianHispanic/Latino AmericanAfrican AmericanAsian AmericanNative American/Alaskan NativeHawaiian Native/Pacific Islander (#)Other or Multiple Race/EthnicitiesViewer Gender (%)Please type numerical values only (1,2,3,4, etc.)MaleFemaleOtherDid not Disclose/UnknownViewer Age Range (%)Please type numerical values only (1,2,3,4, etc.)1-1718-2425-3435-4445-5455-6465+ Virtual Screening - Livestream #4Note that it is understood that data such as race/ethnicity, gender, and age range may not be trackable in this format, so answer to the best of your ability.Screening Date(Required) MM slash DD slash YYYY Total Live Viewers(Required)Please enter a number greater than or equal to 1.Viewer Location (City/State)City/State% of viewers Add RemoveViewer Race/Ethnicity (%)Please type numerical values only (1,2,3,4, etc.)White/CaucasianHispanic/Latino AmericanAfrican AmericanAsian AmericanNative American/Alaskan NativeHawaiian Native/Pacific Islander (#)Other or Multiple Race/EthnicitiesViewer Gender (%)Please type numerical values only (1,2,3,4, etc.)MaleFemaleOtherDid not Disclose/UnknownViewer Age Range (%)Please type numerical values only (1,2,3,4, etc.)1-1718-2425-3435-4445-5455-6465+ Virtual Screening - Livestream #5Note that it is understood that data such as race/ethnicity, gender, and age range may not be trackable in this format, so answer to the best of your ability.Screening Date(Required) MM slash DD slash YYYY Total Live Viewers(Required)Please enter a number greater than or equal to 1.Viewer Location (City/State)City/State% of viewers Add RemoveViewer Race/Ethnicity (%)Please type numerical values only (1,2,3,4, etc.)White/CaucasianHispanic/Latino AmericanAfrican AmericanAsian AmericanNative American/Alaskan NativeHawaiian Native/Pacific Islander (#)Other or Multiple Race/EthnicitiesViewer Gender (%)Please type numerical values only (1,2,3,4, etc.)MaleFemaleOtherDid not Disclose/UnknownViewer Age Range (%)Please type numerical values only (1,2,3,4, etc.)1-1718-2425-3435-4445-5455-6465+ Virtual Screening (On-Demand) - Additional InformationNote that it is understood that data such as race/ethnicity, gender, and age range may not be trackable in this format, so answer to the best of your ability.Total View Count(Required)Viewer Location (City/State)City/State% of viewers Add RemoveViewer Race/Ethnicity (%)Please type numerical values only (1,2,3,4, etc.)White/CaucasianHispanic/Latino AmericanAfrican AmericanAsian AmericanNative American/Alaskan NativeHawaiian Native/Pacific Islander (#)Other or Multiple Race/EthnicitiesViewer Gender (%)Please type numerical values only (1,2,3,4, etc.)MaleFemaleOtherDid not Disclose/UnknownViewer Age Range (%)Please type numerical values only (1,2,3,4, etc.)1-1718-2425-3435-4445-5455-6465+ Event Pictures or VideoWe would appreciate if you share any pictures from your Quilt screenings/workshops/classes that we can highlight! Drop files here or Select files Max. file size: 50 MB. Reviews/Comments About the FilmWe appreciate any impactful statements about the film that we can share! Please write the name of the person and/or organization making the statement so that we can recognize them properly. Having Trouble?Email the Marketing Director
