Digital Inclusion Survey

Confidential intake information for Prospective

Participants

We are part of the City of San José Digital Inclusion Association effort that is dedicated to helping San José residents connect to the Internet, protect their devices, and provide basic device training.

Your information is kept confidential.

Once you have completed the survey:
We will assess your needs and connect you with the right resources. We will contact you within 3 business days by phone or text message.

Question Title

* CONTACT INFORMATION

First Name

Last Name

Address

City

State

Zip Code

Email Address

Phone Number where we can reach you?

Question Title

* How did you hear about us?

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* Person Completing this Survey

Self

Staff

Other (please specify)

Question Title

* Age of person applying

18-29

30-39

40-49

50-64

65-74

75+

Question Title

* Household Annual Income

Less than $20,000

$20,000 - $39,999

$40,000 - $59,999

$60,000 - $99,999

$100,000 or more

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* The number of people in your household?

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* Number of Children under 18 in your household?

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* Ethnic Identification

African-American

Asian (Non-Vietnamese)

LatinX (Latina/Latino)

Native American

Vietnamese

White (Non-Latino/Latino or Non-LatinX

Other

Decline to State

Question Title

* Primary Language Spoken at Home

English

Spanish

Vietnamese

Other

Decline to State

Question Title

* What form of Identification do you have? Check all that apply

Valid California Identification or Drivers License with my current address.

Valid US Passport

Matrícula de México

I don't have any form of identification

Another type of identification with a photograph and current address (please specify)

Question Title

* Please select the one that applies to you.

I have a Social Security Number

I have a Taxpayer Identification Number

I do not have a Social Security Number or Tax Identification Number.

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* SERVICES YOU (OR YOUR CHILD) RECEIVE

Medicaid/Medi-Cal

Unemployment Benefits

Low Income Home Energy Assistance Program (LIHEAP)

Supplemental Security Income (SSI)

Federal Public Housing Assistance or Section 8

CalFresh, Food Stamps or Supplemental Nutrition Assistance Program (SNAP)

Women, Infants and Children Program (WIC)

National School Lunch Program (NSL)

Temporary Assistance for Needy Families (TANF)

California Work Opportunity and Responsibility to Kids (CalWORKs)

Stanislaus County Work Opportunity and Responsibility to Kids (StanWORKs)

Welfare-to-Work (WTW)

Greater Avenues for Independence (GAIN)

Tribal TANF

Bureau of Indian Affairs General Assistance

Head Start Income Eligible (Tribal Only)

Food Distribution Program on Indian Reservations

Federal Veterans and Survivors Pension Benefit Program

None of my household or I receive any of these benefits.

Question Title

* Do you need assistance with telephones, computers, or other digital devices to help you with any of these physical impairments?

I am visually impaired and need assistance with proper digital devices.

I am hearing impaired and need assistance with proper digital devices.

I am physically impaired and need assistance with proper digital devices

None of the above

Please elaborate on any needs you may have indicated above

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* Do you have children that live with you, and attend school?

Yes