WiSTEM2D Data Collection Form Thank you for participating in Johnson & Johnson's WiSTEM2D (Women in Science, Technology, Engineering, Math, Manufacturing and Design) initiative -- a multifaceted approach that supports and inspires girls and women of all ages in their pursuit of STEM2D studies and careers. Johnson & Johnson recognizes the importance of evaluation and data collection in measuring the impact of the WiSTEM2D Youth Programs. For each WiSTEM2D activity or event, please answer all the questions listed below and submit the completed form. Thank you for living the Credo and using your talent for good. About the STEM2D LeadYour Name* First / Given Name Last / Sur Name Your Role Job Title Organization / Company Your Email* Johnson & Johnson RegionAsia / PacificEurope / Middle East / AfricaLatin / South AmericaNorth AmericaAbout the Activity or EventDateWhen did the STEM2D activity or event occur? MM slash DD slash YYYY LocationWhere did the STEM2D activity or event occur? City State / Province / Region 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 Country TypeWhat type of STEM2D activity or event was held?Activity with studentsActivity with educators / teachers (professional development)Participate in a community event / make a presentationOtherType (Other)Please specify the type of activity or event: Total Number of Students ServedHow many students participated?Total Number of Female Students ServedOf the total number of students listed above, how many female students participated?Age of StudentsWhat was the age group of the students? Under Age 5 Ages 5 - 10 Ages 11 - 14 Ages 15 - 18 Total Educators / Teachers ServedHow many educators / teachers participated?Instructional LevelWhat is the age of the students that the educators / teachers work with? Check all that apply. Under age 5 Ages 5 - 10 Ages 11 - 14 Ages 15 - 18 Estimated Number of Students ReachedHow many students with the educators / teachers impact this year? TIP! Calculate by multiplying the number of participating teachers and the number of students served per teacher.Estimated Number of Female Students ReachedOf the number of students listed above, how many are females?AttendeesHow many people attended the event?Attendees (Female Students)Of the total number of attendees listed above, how many were girls or young women?Age of Attendees (Female Students)What are the ages of the girls or young women attending the event? Check all that apply. Under Age 5 Ages 5 - 10 Ages 11 -14 Ages 15 - 18 Student Activity SeriesDid you use, adapt, download, or share an activity(s) from the WiSTEM2D Student Activity Series, which is available at STEM2D.org? Yes No Student Activity SeriesPlease list the name(s) of the activity(s):Employee EngagementJohnson & Johnson EngagementDid Johnson & Johnson employees volunteer or participate in this activity? Yes No Total VolunteersHow many Johnson & Johnson employees volunteered?Volunteer HoursOn average, how many hours did each Johnson & Johnson employee spend volunteering? List the hours per person, e.g. 1 for 1 hour or 1.5 for 90 minutes.Total Volunteer HoursNote! The total number of volunteer hours is computed automatically based on the specific information previously entered.The total number of volunteer hours for this event or activity is:
