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* 1. First Name

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* 2. Last Name

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* 3. Please provide the following contact information:

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* 4. Date of Birth (MM/DD/YYYY)

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* 5. What is your age?

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* 6. What is your gender?

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* 7. With which group do you most identify?

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* 8. What is your highest educational level?

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* 9. What is the primary language spoken in your household?

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* 10. What is your employment status?

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* 11. What is your approximate annual household income?

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* 12. How many members are in your household (including yourself)?

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* 13. Which best describes your internet access at home?

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* 14. If you do not have and do not plan to get internet access at home, why not? (You may select more than one option.)

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* 15. Do you know where you can go to access free wireless Internet in the community?

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* 16. How many internet-capable devices do you have at home? (For example, cell phone, tablet, desktop computer, laptop computer, Kindle, smart TV, etc.)

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* 17. Now that you have completed the Tech Goes Home class, which best describes your level of computer skills?

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* 18. How do you access the internet?
You may select multiple options.

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* 19. What further training would you take advantage of, if offered?
You may select multiple options.

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* 20. Did the Tech Goes Home class improve your relationship with the staff at the community organization or senior center where you have taken the class?

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* 21. Do you plan to participate in future activities at this community organization or senior center?

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* 22. Would you recommend the Tech Goes Home class to others?

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* 23. How would you rate your Tech Goes Home trainers?

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* 24. How would you rate your overall experience in the Tech Goes Home class?

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* 25. What did you most like about participating in the Tech Goes Home class?

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* 26. Do you have any suggestions for how we might improve the class?

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* 27. If you would like to nominate your trainer(s) as "Tech Goes Home Trainer of the Year," please provide their name(s) and tell us why.
If you do not wish to nominate your trainer(s), leave the space blank.

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* 28. Please select your program location:

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