Form 1 Survey Instrument

Community Based Health and Needs Assessment PID:

Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*).  Do not return the completed form to this address.

OMB Number: 0925-XXXX

OMB Expiration Date: TBD

Today’s Date

Part 1. Health Information

The next questions are about your health and your health practices. Please answer to your best knowledge.

During the past month, how often did you eat the following? Please fill in the number of times per day, per week, OR per month.

Description	Daily	OR	Weekly	OR	Never	OR	Don’t Know
Breakfast
Breads, cereals, rice, and pasta made of whole grains like whole wheat, oatmeal, rye, pumpernickel, barley, quinoa. Do not include white bread or white rice.	_ _		_ _		_ _		_ _
Red meat, such as beef, pork, ham, or sausage. Do not include chicken, turkey or seafood.	_ _		_ _		_ _		_ _
Processed meat, such as bacon, lunch meats, or hot dogs. Include ham, pastrami, salami, sausages, bratwursts, frankfurters, spam, or corned beef.	_ _		_ _		_ _		_ _
Fried foods. Count chips, french fries, fried meats, fried appetizers, fried pastries.	_ _		_ _		_ _		_ _
Foods prepared outside of the home? Include frozen dinners, pre-packaged meals, take-out, fast food, and meals at restaurants.	_ _		_ _		_ _		_ _
Breakfast, lunch, or dinner in a place such as McDonald’s, Burger King, Wendy’s, Arby’s, Pizza Hut, or Kentucky Fried Chicken	_ _		_ _		_ _		_ _
	_ _		_ _		_ _		_ _
Drink regular soda or pop that contains sugar? Do not include diet soda.
	_ _		_ _		_ _		_ _
Drink sweetened fruit drinks, sports or energy drinks, such as Kool-aid, lemonade, Hi-C, cranberry drink, Gatorade, Red Bull or Vitamin Water? Include fruit juices you made at home and added sugar to. Do not include diet drinks or artificially sweetened drinks
	_ _		_ _		_ _		_ _
Eat cookies, cake, pie or brownies? Do not include sugar-free kinds.

Fruit and Vegetable Consumption

These next questions are about the fruits and vegetables you ate or drank during the past month.

Description	Daily	OR	Weekly	OR	Never	OR	Don’t Know
Drink 100% PURE fruit juices such as orange, mango, apple, grape and pineapple juices? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to.
Eat fruit? Include fresh, frozen, or canned fruit. Do not include juices.	_ _		_ _		_ _		_ _
Eat a green leafy or lettuce salad, with or without other vegetables?	_ _		_ _		_ _		_ _
Eat orange-colored vegetables such as sweet potatoes, pumpkin, winter squash, or carrots?	_ _		_ _		_ _		_ _
Not including green leafy or lettuce salads, orange colored-vegetables, or beans, how often did you eat other vegetables?	_ _		_ _		_ _		_ _
Eat refried beans, baked beans, beans in soup, pork and beans or any other type of cooked dried beans? Do not include green beans.	_ _		_ _		_ _		_ _

Physical Activity

The next few questions are about the time you spend doing different types of physical activity in a typical week. In answering the following questions 'moderate-intensity activities' are activities that require moderate physical effort and cause small increases in breathing or heart rate, vigorous-intensity activities' are activities that require hard physical effort and cause large increases in breathing or heart rate.

1. Does your work involve moderate-intensity activity that causes small increases in breathing or heart rate such as brisk walking [or carrying light loads] for at least 10 minutes continuously?

□Yes □No (Go to Q20) □Don’t know

2. In a typical week, on how many days do you do moderate intensity activities as part of your work?

_ _ Enter number of days □Don’t know

3. How much time do you spend doing moderate-intensity activities at work on a typical day?

Hours: minutes └─┴─┘: └─┴─┘ □Don’t know

hrs mins

4. Does your work involve vigorous-intensity activity that causes large increases in breathing or heart rate like [carrying or lifting heavy loads, digging or construction work] for at least 10 minutes continuously?

□Yes □No (Go to Q23) □Don’t know

5. In a typical week, on how many days do you do vigorous intensity activities as part of your work?

_ _ Enter number of days □Don’t know

6. How much time do you spend doing vigorous-intensity activities at work on a typical day?

Hours: minutes └─┴─┘: └─┴─┘ □Don’t know

hrs mins

7. Do you walk or use a bicycle (pedal cycle) for at least 10 minutes continuously to get to and from places?

□Yes □No (Go to Q26) □Don’t know

8. In a typical week, on how many days do you walk or bicycle for at least 10 minutes continuously to get to and from places?

_ _ Enter number of days □Don’t know

9. How much time do you spend walking or bicycling to get to and from places on a typical day?

Hours: minutes └─┴─┘: └─┴─┘ □Don’t know

hrs mins

10. Do you do any moderate-intensity sports, fitness or recreational (leisure) activities that cause a small increase in breathing or heart rate (such as brisk walking, cycling, swimming, volleyball) for at least 10 minutes continuously?

□Yes □No (Go to Q29) □Don’t know

11. In a typical week, on how many days do you do moderate intensity sports, fitness or recreational (leisure) activities? Activities are regarded as moderate intensity if they cause a small increase in breathing and/or heart rate.

_ _ Enter number of days □Don’t know

12. How much time do you spend doing moderate-intensity sports, fitness or recreational (leisure) activities on a typical day?

Hours: minutes └─┴─┘: └─┴─┘ □Don’t know

hrs mins

13. Do you do any vigorous-intensity sports, fitness or recreational (leisure) activities that cause large increases in breathing or heart rate (like running or football) for at least 10 minutes continuously?

□Yes □No (Go to Q32) □Don’t know

14. In a typical week, on how many days do you do vigorous intensity sports, fitness or recreational (leisure) activities? Activities are regarded as vigorous intensity if they cause a large increase in breathing and/or heart rate.

_ _ Enter number of days □Don’t know

15. How much time do you spend doing vigorous-intensity sports, fitness or recreational activities on a typical day?

Hours: minutes └─┴─┘: └─┴─┘ □Don’t know

hrs mins

16. How much time do you usually spend sitting or reclining on a typical day? Consider total time spent at work sitting, in an office, reading, watching television, using a computer, doing hand craft like knitting, resting etc. Do not include time spent sleeping.

Hours: minutes └─┴─┘: └─┴─┘ □Don’t know

hrs mins

17. Over the past month, on average how many hours per day did you sit and watch TV or videos?

• Less than 1 hour

• 1 hour

• 2 hours

• 3 hours

• 4 hours

• 5 hours of more

• I do not watch TV or videos

• Don’t know

18. How many times per week or per month do you do physical activities or exercises to STRENGTHEN your muscles? Do not count aerobic activities like walking, running, or bicycling. Count activities using your own body weight like yoga, sit-ups or push-ups and those using weight machines, free weights, or elastic bands.

_ _ Times per week _ _ Times per month □Never □Don’t know

Tobacco/Drinking History

19. During the past month, how many days per week or per month did you have at least one

drink of any kind of alcoholic beverage such as beer, wine, a malt beverage, or liquor?

_ _ Days per week _ _ Days per month □None □Don’t know

20. Have you smoked at least 100 cigarettes in your entire life? Note: 100 cigarettes is 5 packs

□ Yes □ No □Don’t know

21. Do you now smoke cigarettes every day, some days, or not at all?

□Every day □Some days □Not at all □Don’t know

22. How many cigarettes, cigars, or pipes do you now smoke per day?

______ cigarettes/cigar/pipes □None □ Don’t Know

23. During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?

□ Yes □ No □Don’t know

Overall Health

24. In general, how would you describe your health?

□ Excellent □ Very Good □ Good □ Fair □ Poor

25. Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

_ _ Number of days □None □Don‘t know

26. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

_ _ Number of days □None □Don‘t know

27. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

_ _ Number of days □None □Don‘t know

28. Have you EVER been told by a doctor, nurse, or other health professional that you have high blood pressure/hypertension?

• Yes

• Yes, but I am a female told only during pregnancy

• No

• Told borderline high blood pressure or pre-hypertensive

• Don’t know

29. Are you currently taking medicine for your high blood pressure?

□ Yes □ No □Don’t know

30. Cholesterol is a fatty substance found in the blood. Have you EVER had your cholesterol checked?

□ Yes □ No (Go to Q49) □Don’t know (Go to Q49)

31. About how long has it been since you last had your blood cholesterol checked?

• Within the past year

• Within the past 2 years

• Within the past 5 years

• 5 or more years ago

• Don’t know

32. Have you EVER been told by a doctor, nurse or other health professional that your cholesterol is high?

□ Yes □ No □Don’t know

33. Diabetes is when you have high blood sugar, or glucose. Have you EVER had your blood sugar checked or been tested for diabetes?

□ Yes □ No □Don’t know

34. Have you EVER been told by a doctor, nurse, or other health professional that you have diabetes?

• Yes

• Yes, but I am a female told only during pregnancy

• No (Go to Q55)

• Told borderline diabetes or pre-diabetic

• Don’t know

35. How old were you when you were told you have diabetes?

□ [ENTER AGE] _ _ □ Don‘t know

36. Are you now taking insulin?

□ Yes □ No □Don’t know

37. About how many times in the past year have you seen a doctor, nurse, or other health professional for your diabetes?

□ _ _ Number of times □ None □Don’t know

38. Have you ever taken a course or class in how to manage your diabetes?

□ Yes □ No □ Don’t know

Cardiovascular Health

39. Has a doctor, nurse, or other health professional EVER told you that you had a heart attack (also called a myocardial infarction)?

□ Yes □ No □ Don’t know

40. Has a doctor, nurse, or other health professional EVER told you that you had angina or coronary heart disease?

□ Yes □ No □ Don’t know

41. Has a doctor, nurse, or other health professional EVER told you that you had had a stroke?

□ Yes □ No □ Don’t know

_________________________________________________________________________________

Health Care Access and Utilization

42. In the past year, how many times did you go to a hospital, Emergency Room, or ER, for care or treatment?

• 0 times

• 1-2 times

• 3-4 times

• 5-6 times

• 7-8 times

• More than 8 times

• Don’t know

43. Is there one place you usually go for care when you are sick or injured or need medical advice?

□ Yes □ No (Go Q61) □Don’t know

44. Which of the following do you usually go to for medical care or advice?

• Doctor’s office

• Clinic or Health Care Center

• Hospital Outpatient department

• Hospital Emergency Room

• Urgent Care Center

• Other _______________________

• Don’t know

45. What is the main reason you do not have usual source of medical care? (Check one)

• 2 or more usual places

• Have not needed a doctor

• Do not like/trust/believe in doctors

• Do not know where to go

• Previous doctor is not available/moved

• No insurance/cannot afford

• Speak a different language

• No place is available/close enough/convenient

• Other _________________________

• Don’t know

46. In the past year, how many times did you go to any doctor’s office or clinic for care or treatment?

• 0 times

• 1-2 times

• 3-4 times

• 5-6 times

• 7-8 times

• More than 8 times

• Don’t know

47. How would you describe the overall health care you have received in the past year?

• Excellent

• Very good

• Good

• Fair

• Poor

• Not applicable/don’t use any health services

• Don’t know

48. About how long has it been since you last visited a doctor for a routine checkup or general physical exam? Do not include visits for an illness, injury, or medical condition.

• Within past year (anytime less than a year ago)

• Within past 2 years (1 year but less than 2 years ago)

• Within past 5 years (2 years but less than 5 years ago)

• Never

• Don’t know

49. In the past year, did you miss medical appointments because you didn’t have a way to get there?

□ Yes □ No □ Don’t Know

50. Was there any time in past 12 months that you needed to see a doctor but could not because of cost or because you were not covered by health insurance?

□ Yes □ No □ Don’t Know

51. Which of the following kinds of health care coverage or insurance are you now covered by? (check all that apply)

• No insurance

• HMO or other private insurance

• Medicare

• Medicaid

• Military/VA sponsored

• Other _______________

52. When you think about doctors and the medical professionals in general, do you…

• Trust them completely

• Trust them partially

• Not Trust them at all

• Don’t know

Weight History

Look at the following drawings, and circle the one you would most want to look like (women should choose from the top, and men from the bottom).

53. Circle the drawing that is closest to how you think you look (omen should choose from the top, and men from the bottom).

54. Fill in the three blanks with the letters for the drawings that represent your 3 closest same sex friends. You may use the same letter more than once. (Women should choose from the top, and men from the bottom) ­­ ­____ ____ ____­

^{1 2 3}

55. Do you consider yourself now to be …

• Overweight

• Underweight

• About the right weight

• Don’t Know

56. Would you like to weigh …

• More

• Less

• Stay about the same

• Don’t Know

57. How much would you like to weigh?

_ _ _ Enter weight in pounds □ Don’t Know

58. How much do you weigh now?

_ _ _ Enter weight in pounds □ Don’t Know

59. How much did you weigh a year ago? [If you were pregnant a year ago, how much did you weigh before your pregnancy?]

_ _ _ Enter weight in pounds □ Don’t Know

60. Do you now weight more, less, or about the same as you did a year ago?

□ More □ Less □ About the same □ Don’t Know

61. During the past year, have you tried to lose weight?

□ Yes □ No (Go to Q80) □ Don’t Know

62. In the past year, how did you try to lose weight?

• Ate less food (amount)

• Exercised

• Ate “Diet” foods or products

• Joined a weight loss program

• Ate more fruits, vegetables, salads

• Ate less sugar, candy, sweets

• Ate less junk food or fast food

• Don’t know

63. In the past year, did you seek help to lose weight?

• Yes, from a Personal trainer

• Yes, from a Dietitian

• Yes, from a Nutritionist

• Yes, from a Doctor or other health professional

• No

• Don’t Know

64. During the past year, have you done anything to keep from gaining weight?

□ Yes □ No □ Don’t Know

65. What did you do to keep from gaining weight?

• Ate less food (amount)

• Exercised

• Ate “Diet” foods or products

• Joined a weight loss program

• Ate more fruits, vegetables, salads

• Ate less sugar, candy, sweets

• Ate less junk food or fast food

• Don’t know

66. What is the most you have ever weighed ­AND how old were you then? [Do not include any times when you were pregnant.]

_ _ _ Enter weight in pounds AND _ _ Enter age in years □ Don’t Know

67. Has a doctor, nurse, or other health professional talked with you about changing your diet or eating habits?

□ Yes □ No □ Don’t Know

68. Has a doctor, nurse, or other health professional talked with you about physical activity or exercise?

□ Yes □ No □ Don’t Know

69. Has a doctor, nurse, or other health professional talked with you about losing weight?

□ Yes □ No □ Don’t Know

70. How concerned are you about excess weight and heart health for yourself?

• Extremely concerned

• Somewhat concerned

• Not concerned

• Don’t know

71. How concerned are you about excess weight and heart health in your family?

• Extremely concerned

• Somewhat concerned

• Not concerned

• Don’t know

72. What do you believe are the biggest challenges to maintaining a healthy weight and healthy lifestyle? Write response (ex. money, diet, exercise, time, motivation, support, etc.)

______________________________________________________________________________________________________________________________________________________

73. Should the church offer health programs to its members or congregants?

□Yes □No □ Don’t Know

74. If you were participating in a weight management program as a part of your church health program, what health topics and activities would be like to see? Mark all that apply.

• Healthy Eating Out

• Eating Healthy on a Budget

• Shopping for healthy foods

• Reading food labels

• Portion control

• Making recipes healthier

• Food demonstrations

• Exercise classes and demonstrations

• Calories and Energy Balance

• Tips for healthy weight loss and maintenance

• Heart Disease

• Diabetes

• High Blood Pressure

• Cholesterol

• Stress management

• Setting goals and monitoring health

• _______________________

• _______________________

• _______________________

75. List what resources, knowledge, skills, or tools that you think the church can provide for managing weight and promoting a healthy lifestyle.

1.____________________________________________________________

2.____________________________________________________________

3.____________________________________________________________

Part 2. Other Information

.

Social Support

76. For each of the following, indicate how much you think each is true for you. For each statement, check one box to indicate your answer choice.

	Not True	Somewhat True	Very True	Don’t Know
You’re trying to take on too many things at once.	□	□	□	□
There is too much pressure on you to be like other people.	□	□	□	□
Too much is expected of you by others.	□	□	□	□
You have to go to social events alone and you don’t want to.	□	□	□	□
Your friends are a bad influence.	□	□	□	□
You don’t have enough friends.	□	□	□	□
You don’t have time for your favorite leisure time activities.	□	□	□	□

Social Isolation

77. I am alone too much.

□Not true □Somewhat true □Very true □Don’t know

78. For the following statements, indicate how often over past year you feel the way described. For each statement, check one box to indicate your answer choice.

Statement	Never	Rarely	Sometimes	Often
1. I feel in tune with the people around me	□	□	□	□
2. I lack companionship	□	□	□	□
3. There is no one I can turn to	□	□	□	□
4. I do not feel alone	□	□	□	□
5. I feel part of a group of friends	□	□	□	□
6. I have a lot in common with the people around me	□	□	□	□
7. I am no longer close to anyone	□	□	□	□
8. My interests and ideas are not shared by those around me	□	□	□	□
9. I am an outgoing person	□	□	□	□
10. There are people I feel close to	□	□	□	□
11. I feel left out	□	□	□	□
12. My social relationships arc superficial	□	□	□	□
13. No one really knows me well	□	□	□	□
14. I feel isolated from others	□	□	□	□
15. I can find companionship when I want it	□	□	□	□
16. There are people who really understand me	□	□	□	□
17. I am unhappy being so withdrawn	□	□	□	□
18. People are around me but not with me	□	□	□	□
19. There are people I can talk to	□	□	□	□
20. There are people I can turn to	□	□	□	□

79. Choose the option you most agree with. For each statement, check one box to indicate your answer choice.

	Not at all or less than one day last week	1-2 days last week	3-4 days last week	5-7 days last week	Nearly every day for 2 weeks
1. My appetite was poor.	□	□	□	□	□
2. I could not shake off the blues.	□	□	□	□	□
3. I had trouble keeping my mind on what is doing.	□	□	□	□	□
4. I felt depressed.	□	□	□	□	□
5. My sleep was restless.	□	□	□	□	□
6. I felt sad.	□	□	□	□	□
7. I could not get going.	□	□	□	□	□
8. Nothing made me happy.	□	□	□	□	□
9. I felt like a bad person.	□	□	□	□	□
10. I lost interest in my usual activities.	□	□	□	□	□
11. I slept much more than usual.	□	□	□	□	□
12. I had trouble keeping my mind on what I was doing.	□	□	□	□	□
13. I felt fidgety.	□	□	□	□	□
14. I wished I were dead.	□	□	□	□	□
15. I wanted to hurt myself.	□	□	□	□	□
16. I was tired all the time.	□	□	□	□	□
17. I did not like myself.	□	□	□	□	□
18. I lost a lot of weight without trying to.	□	□	□	□	□
19. I had a lot of trouble getting to sleep.	□	□	□	□	□
20. I could not focus on the important things.	□	□	□	□	□

80. The questions in this scale ask you about your feelings and thoughts during the last month. In each case, check one box to indicate how often you felt or thought a certain way.

	Never	Almost Never	Sometimes	Fairly Often	Very Often
1. In the last month, how often have you been upset because of something that happened unexpectedly?	□	□	□	□	□
2. In the last month, how often have you felt that you were unable to control the important things in your life?	□	□	□	□	□
3. In the last month, how often have you felt nervous and “stressed”?	□	□	□	□	□
4. In the last month, how often have you felt confident about your ability to handle your personal problems?	□	□	□	□	□
5. In the last month, how often have you felt that things were going your way?	□	□	□	□	□
6. In the last month, how often have you found that you could not cope with all the things that you had to do?	□	□	□	□	□
7. In the last month, how often have you been able to control irritations in your life?	□	□	□	□	□
8. In the last month, how often have you felt that you were on top of things?	□	□	□	□	□
9. In the last month, how often have you been angered because of things that were outside of your control?	□	□	□	□	□
10. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?	□	□	□	□	□

Spirituality

81. For each statement, check one box to indicate your answer choice on a scale from “strongly disagree” to “strongly agree”.

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
1. Through my faith in God, I can stay healthy	□	□	□	□	□
2. If I lead a good spiritual life, I will stay healthy	□	□	□	□	□
3. If I stay healthy, it’s because I am right with God	□	□	□	□	□
4. Living the way the Lord says I’m supposed to live means I have to take care of myself	□	□	□	□	□
5. Even though I trust God will take care of me, I still need to take care of myself	□	□	□	□	□
6. God gives me the strength to take care of myself	□	□	□	□	□
7. I rely on God to keep me in good health	□	□	□	□	□
8. God works through doctors to heal us	□	□	□	□	□
9. Prayer is the most important thing I do to stay healthy	□	□	□	□	□
10. If I stay well, it is because of the grace of the good Lord	□	□	□	□	□
11. It’s ok not to seek medical attention because I feel that God will heal me	□	□	□	□	□
12. There is no point in taking care of myself when it’s all up to God anyway	□	□	□	□	□
13. God will heal me	□	□	□	□	□
14. God and I share responsibility for my health	□	□	□	□	□

Neighborhood Environment

82. How long have you lived in your neighborhood?

_ _ Years _ _ Months □Don’t know

83. For each of the following statements about your current neighborhood, please choose whether you strongly disagree, disagree, feel neutral, agree, or strongly agree.

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
This is a close-knit neighborhood.	□	□	□	□	□
People around here are willing to help their neighbors.	□	□	□	□	□
People in this neighborhood generally don’t get along with each other.	□	□	□	□	□
People in this neighborhood can be trusted.	□	□	□	□	□
People in this neighborhood do not share the same values.	□	□	□	□	□

84. During the past year, how often did you see or hear about (or read about):

Often Sometimes Rarely Never Don’t Know

a. a fight in your neighborhood in

which a weapon was used? □ □ □ □ □

b. a violent argument between neighbors? □ □ □ □ □

c. gang fights? □ □ □ □ □

d. a sexual assault or rape? □ □ □ □ □

e. a robbery or mugging? □ □ □ □ □

85. How safe from crime do you consider your neighborhood to be? Please rate the level of safety on a scale of 1 to 5, with 1 being very safe, and 5 being not at all safe.

• 1 (Very safe) □ 2 □ 3 □ 4 □ 5 (Not at all Safe)

86. How serious do you think the following problems are for your neighborhood as a whole? For each statement, check one box to indicate your answer choice.

	Not At All Serious	Minor Problem	Somewhat Serious	Very Serious
a. Excessive noise	□	□	□	□
b. Heavy traffic or speeding cars	□	□	□	□
c. Lack of access to adequate food shopping	□	□	□	□
d. Lack of recreation areas (parks or playgrounds)	□	□	□	□
e. Trash and litter	□	□	□	□
f. No sidewalks or poorly maintained sidewalks	□	□	□	□
g. Violence	□	□	□	□

Utilization of Technology

87. Can you access email and internet websites at least once per week, from home,

work, or elsewhere, if it is necessary for this project?

□Yes □No □Don’t Know

88. The following questions are about a variety of computer, email and web-related tasks.

For each statement, check one box to indicate your answer choice.

	Not at all	Not so well	Okay	Well	Very Well
I can switch a computer on	□	□	□	□	□
I can restart a computer	□	□	□	□	□
I can begin typing a new document	□	□	□	□	□
I can open a previously saved file from any drive/ directory	□	□	□	□	□
I can use “save as” when appropriate	□	□	□	□	□
I can print a document	□	□	□	□	□
I can open an email program	□	□	□	□	□
I can read new email messages	□	□	□	□	□
I can open a file attached to an email	□	□	□	□	□
I can delete read email messages	□	□	□	□	□
I can send an email message	□	□	□	□	□
I can use the “reply’ and “forward” features for email	□	□	□	□	□
I can use a browser such as Internet Explorer, Firefox, or Google Chrome to navigate the World Wide Web (www.)	□	□	□	□	□
I can open a web address directly	□	□	□	□	□
I can identify the host server from the web address	□	□	□	□	□
I can use “back” and “forward” to move between web pages	□	□	□	□	□
I can use search engines such as Yahoo and Google	□	□	□	□	□

89. Do you own or regularly use a cell phone, or mobile phone?

□Yes □No □Don’t Know

90. On a typical day, how much time do you spend on your cell or mobile phone TO MAKE OR ANSWER CALLS?

• Less than 30 minutes

• From 30 minutes to 1 hour

• From 1 to 2 hours

• From 2 to 3 hours

• More than 3 hours

91. On a typical day, how much time do you spend doing each of the following using your cell or mobile phone?

	Don’t use it	Less than 30 min	From 30 min to 1 hour	From 1 to 2 hours	From 2 to 3 hours
Taking or looking at pictures
Internet browsing/applications
Gaming
Text messaging
Other applications

92. Which of these is your favorite feature on your mobile phone?

• Camera

• Internet Browsing/ applications

• Gaming

• Text Messaging

• None of these

Part 3. Basic Information

93. What is your date of birth? Month_________ Day _____ Year _______

94. Are you: □ Male □ Female

95. How many children under the age of 18 years live with you? ___________# of children

96. What is your marital status or living situation?

□ Married □ Single

□ Divorced

□ Widow

□ Separated

□ Unmarried couple

97. What is the highest level of education that you have completed?

□ Less than high school (grades K-8) □ College Degree

□ Some high school (grades 9-11) □ Technical Degree

□ High school diploma/GED (12) □ Some Graduate/ Professional School

□ Some college □ Graduate/ Professional School Degree

98. Are you now a student, either full or part time? □ Yes □ No

99. Are you now employed for wages?

□ Yes, Part-time □ Yes, Full-time

□ No, unemployed □ No, retired □ Other_____________

100. What is your best estimate of the total income of all family members in your household from all sources, before taxes, in [last calendar year]?

□ Less than $10,000 □ $10,000 - $19,999 □$20,000 - 29,999 □$30,000 - 39,999

□ $40,000 - $49,999 □$50,000 - $59,999 □ $60,000 - $69,999 □ $70,000 -79,999

□ $80,000 - $89,999 □$90,000 - $99,999 □ ≥ $100,000 □ Don’t know

Please remember to turn over to fill out questions on the back.       Page 23 of 23