1 Small Step membership application

1. 1 Small Step membership application

This is a simple survey to help us check that you fall within our research boundaries and to help us get a good mix of people in the community. Please answer every question possible and we will be in contact (via the email address you supply) with you in the coming weeks.

Please note: The participants we are looking for will be male or female, aged 50+, and live either permanently or temporarily in Eastbourne.

If you have any further questions please contact us at 1smallstep@qubemedia.net or call 01273 689672.

Thank you for you time.

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* 1. Are you available to participate in the project 21 May-15 Jun 2012?

Yes

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* 2. First Name

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* 3. Last Name

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* 4. Gender

Male

Female

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* 5. Age

50-59

60-69

70+

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* 6. Employment

Employed

Unemployed

Retired

Unable to work

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* 7. Email Address

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* 8. Post Code

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* 9. How do you rate your computer skills?

Excellent

Good

Not familiar

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* 10. Can you have daily access to a computer and the internet for this project?

Yes

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* 11. Which of the following social networks do you use?

Facebook

Twitter

Youtube

Flickr

Blogs

Forums

Other (please specify)

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* 12. How often do you use social sites such as Facebook, Blogs or Forums?

	1 - Never	2 - A few times a year	3 - Weekly	4 - Most Days	5 - Everyday
Time spent	Time spent 1 - Never	Time spent 2 - A few times a year	Time spent 3 - Weekly	Time spent 4 - Most Days	Time spent 5 - Everyday

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* 13. What type of physical activity do you enjoy?

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* 14. How many times a week are you physically active?

Almost none

Once a week

2-3 times a week

4-6 times a week

Every day

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* 15. Where did you hear about this project?

We will be in contact (via the email address you supplied above) with you in the coming weeks.