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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. Did you receive information about the Affordable Connectivity Program (ACP) during class?

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* 16. Are you receiving a discount on your internet service through ACP?

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* 17. If you are interested in ACP or discussing other low-cost or no-cost home internet options, do you agree to receive a phone call from a Tech Goes Home staff member?

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

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

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

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

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

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

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

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

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

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

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* 30. 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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* 31. Please select your program location:

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* 32. Prior to this program, what was your experience level using technology
(internet/computers/tablets)?

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* 33. After the program, I feel more knowledgeable about using computers and
technology.

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* 34. After the program, I feel more confident when using computers and technology.

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* 35. I intend to apply what I learned in this program.

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* 36. How often do you use the internet?

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* 37. How would you rate your ability to be safe on the internet?

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* 38. To what extent do you agree or disagree with the following statement: “Using the internet makes me feel more connected to my community.”

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* 39. I plan to access the Internet for the following: (check all that apply)

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* 40. What did you like most about the program? How did the program impact your life?

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* 41. What additional feedback or comments would you like to share about the
program?

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