Section A

1. Check your present level of education:
_____ 1-6
_____ 7-9
_____ 10-12
_____ other (specify) ___________________________________________

2. Have you used computers?
_____ yes
_____ no

If yes, where?
_____ at home
_____ at work
_____ at school

3. If you have used a computer, describe what you used it for: _______________________________________________________________
_______________________________________________________________

4. How interested are you in learning about new computer technologies, such as Internet and E-mail?
_____ very interested
_____ interested
_____ not interested

Section B

5. Do you or would you feel comfortable using a computer in your classroom?
_____ yes
_____ no

6. Do you think using a computer can help you improve your reading, writing and math?
_____ yes
_____ no
_____ don't know

7. How will learning more about computers help you now and in the future? ________________________________________________________________
________________________________________________________________
________________________________________________________________

Section C

If you are willing to talk to us about using computers, please provide you name and the name of your college, CASP or Literacy Council below and feel free to add any other comments here: ________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Name:___________________________________________________________
College/CASP/Council:______________________________________________
Instructor/Facilitator/Tutor:___________________________________________