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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. Adult's 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 occupation?
Leave blank if unemployed.

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* 12. What is your approximate annual household income?

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

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

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* 15. 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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* 16. If you signed up for one of the low-cost home internet options while taking this course, please tell us which one.

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

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* 18. How many internet-capable devices do you have at home?

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* 19. Now that you have completed TGH CHA, which best describes your level of computer skills?

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

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

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* 22. What job skills training would you be interested in taking, if offered?
You may select multiple options.

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* 23. Did TGH improve your relationship with the teachers/staff at the school or community organization?

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

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

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* 26. How would you rate your TGH trainers?

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* 27. How would you rate your overall experience with TGH?

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* 28. What did you most like about participating in TGH?

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

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* 30. If you would like to nominate your trainer(s) as "TGH 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. Which type of Tech Goes Home class have you completed?

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