ConnectHome Baseline Survey

OMB #2528-0308

Expires: XX-XX-XXXX

Internet Access Survey

Do you (or anyone living in your household) have Internet access in your home (including by smart phone)?
Yes		No

If Yes

If No

How do you (or anyone living in your household) access the Internet in your home? Please check all that apply. Through a high-speed Internet subscription (for example: Comcast, Cox, AT&T, Verizon, CenturyLink, Charter) Who is your provider? Through a smartphone data plan (for example: Sprint, Verizon, AT&T, T-Mobile) Who is your provider? Through a dial-up connection Through WiFi based outside of your home (for example: public access or from a neighbor) Other:

If you don’t have Internet access in your home, what are the reasons? Please check all that apply. Cost for Internet access Cost for devices (desktop computers, laptops, etc.) My housing unit or building isn’t wired for service Tried to sign up for service but couldn’t Not comfortable using computers or Internet Not interested in using the Internet I access the Internet outside of my home Other:

Which devices do you (or anyone living in your household) use to access the Internet in your home? Please check all that apply. Smart phone Desktop computer Laptop, Notebook, or Netbook (for example: Chromebook, HP Mini, Macbook, Dell Inspiron) Tablet (for example: iPad, Samsung Galaxy Tab, Kindle Fire) Gaming console Smart TV or device that connects TV to the Internet Other:

If you don’t currently have Internet access in your home, have you ever had Internet access in your home? Yes No

Have you heard of ConnectHome, a program that brings free or low cost in-home high-speed Internet to residents of public housing?

Yes No I don’t know

If you have Internet in your home, is it free or low-cost through ConnectHome?

Yes No I don’t know I don’t have Internet

Paperwork Reduction Act Notice. Public reporting burden for this collection of information is estimated to be .083 hours (5 minutes) per PHA resident, and includes time for reviewing the instructions, and completing and reviewing the responses. Your completion of this information collection is voluntary. HUD may not collect this information, and you are not required to complete this form, unless it displays a current, valid OMB control number.

Community Name [HH ID]