1.Household Dwelling Information

Name of Head of Household :

Street Address :

Apartment Number :

City :

2.Single Family Dwelling Or Multi Family Dwelling (2 or more units)

Single

Multi-Family

3.Is Dwelling listed above: 

Owned

Housing

Renting

4.How many persons live at this address?

5.How many families live at this address?

6.How many persons are school age or in school (PreK-12) Or taking college classes?

7.Of the school attendees in the household how many computers do you have in your dwelling?

8.How many persons require health monitoring or telehealth (video) consultations?

9.How many persons work from home?

10.Does this household dwelling have internet access?

Wired (Cable or DSL, Great Plains)

Fixed Wireless (Santee Communications)

Mobile Cellular (Version, AT&T, USCelluar, T-Mobile)

Other

11.Does the Internet access have adequate speed?

Yes

No

12.Is the internet access affordable?

Yes

No

13.Is the internet access reliable?

Yes

No

14.How many laptop or desktop computers at this address?

15.How many Tablet computers at this address?

16.How many smartphones, cellphones (internet connected cell phones) at this address?

17.How many smart televisions do you have in the home?

18.Do you stream movies or use streaming apps?

Yes

No

19.What is the age of the most technical person in the household?

20.Do you or someone in the household use on-line Gaming devices like Xbox?

Yes

No

21.Rate Each of the following skillsets or potential training courses as Most important to least important (5 Most important 1 least)

How to operate a cell phone or computer

1

2

3

4

5

22.How to apply for jobs or work from home

1

2

3

4

5

23.How to apply for government services or submit government information

1

2

3

4

5

24.How to do telehealth or research health services

1

2

3

4

5

25.How to order products and/or services online (eCommerce)

1

2

3

4

5

26.How to take online classes or training

1

2

3

4

5

27.How to participate in social media (Facebook, Twitter, Intagram, etc....)

1

2

3

4

5

28.How to select streaming services (E.g., Hulu, Netflix, Apple+, etc....)

1

2

3

4

5

29.Does your household qualify for affordable Connectivity Program benefits? Please check all below that apply to this household.

Supplemental Nutrition Assistance Program (SNAP), formerly known as food stamp

Medicaid

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

Supplemental Security Income (SSI)

Public Housing, and Affordable Housing Programs for American Indians

Veterans Pension and Survivors benefits

Free and Reduced-Price School Lunch Program or School Breakfast Program

Received a Federal Pell Grant in the current award year

Bureau of Indian Affairs General Assistance

Head Start (only households meeting the income qualifying standard)

Tribal temporary Assistance for Needy Families (Tribal TANF)

Food Distribution Program on Indian Reservations