DIRECT COMMUNITY AUDIT FORM: Short Survey

1. Public Media Corps Community Survey

Thank you for taking the time to participate in this brief Public Media Corps survey. Public Media Corps fellows are community media helpers working in schools and community anchor organizations to give parents, students, teachers, and the whole community, improved access to a changing world of Internet connectivity and online communication.

Your information will help our Fellows design events, student, and community activities/training designed to provide basic, and advanced information on connecting to the networked world for relevant and life-improving information.

***PLEASE NOTE THAT YOUR ZIP CODE INFORMATION IS REQUIRED TO MOVE TO THE FINAL PAGE OF THE SURVEY.

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* 1. Please provide us with some identifying information (mostly optional):

Name:

Address (optional):

Address 2:

City/Town:

State:

ZIP (required): *

Email Address:

Mobile Number (optional):

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* 2. Please select your racial/ethnic identification(s):

Asian (please elaborate below)

American Indian or Alaska Native (Print name of enrolled or principal tribe in comments box)

Bi-racial/Multi-racial (please elaborate below)

Black or African American

Hispanic/Latino

Guamanian or Chamorro

Native Hawaiian

Other Pacific Islander (Please print race, for example, Fijian, Tongan, and so on in the comments field below)

Samoan

White/Caucasian

An invitation to self-identify your race or ethnicity (Please elaborate):

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* 3. What is your age range?

18-21

Under 18

21 - 35

36 - 45

46 - 55

56 - 65

66 and over

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* 4. Please select a gender identification:

Male

Female

Gender Non-Conforming

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* 5. Which of the following best describes your Internet access at home?

I do not have Internet Access at Home

I use a Broadband Connection

I Use a Dial-up connection through my phone line

I Use a DSL Connection

I use a mobile device on a 3G or 4G network

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* 6. Who is your Internet service provider?

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* 7. What device do you use to connect to the Internet at home?

Mobile phone

Laptop or netbook

Desktop computer

iPod Device

Gaming Device

iPad

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* 8. If you do not have access to the Internet at home what is your main reason?

Cost

Don't Need/Not Relevant

I do not know how to use a computer

I do not own a computer

I do not have access where I live

I do not have the necessary credit or credit card accounts

Other (please specify)

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* 9. If you use the Internet, how frequently?

Several times a day

Everyday

Every few days

Weekly

Rarely

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* 10. What activities do you use the Internet for the most?

News

General information and research

Music and video

Gaming

Shopping

Social Networking

Work

Email and other communication

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