Client Intake and Assessment Form Questions
Instructions to Navigator: Use this form to collect client information. Information collected will remain confidential in final reporting. The first section can be filled out by the client or by you having a conversation with the client. Please take care to ensure you are correctly entering data into this form. Fields marked with an asterisk (*) are required.
- Name of Client (First/Last): *
- Client ID: * Automatically Assigned
- Digital Navigator: *
- Language(s) Spoken: *
- Assessment Date (MM/DD/YYYY): *
- Client’s Email Address: *
- Client’s Street Address: *
- Zip Code: *
- Client’s Primary Phone Number: *
- Client’s Secondary Phone Number: *
- Can the Digital Navigator program follow your progress? *
- Are you interested in researching available options for affordable internet connection? *
- How did you hear about this program?
- If “Partnering Organization”, which organization? If “Referral”, please describe
- What type of device(s) do you own? (Check all that apply.) *
- Please describe if “Other”:
- How old is your most recent device? *
- How do you currently access the internet? (Check all that apply.) *
- If “Unsure”, what is your Internet Service Provider (ISP)?
- Does the client qualify for a device from the Digital Navigator program? *
Demographic Information
Use this form to collect information on race, income, head of household, etc. Providing information on race, income, head of household, etc. helps Digital Navigator programs share data on community impact and secure continued funding. All data is de-identified (aggregated) before final submission. Fields marked with an asterisk are required.
- Does the client consent to share demographic information? *
- Please review the following chart with the client and select the income limit that best them. *
- What race/ethnicity best describes you? *
- What is your gender? *
- Do you identify as Hispanic? *
- Are you Head of Household? *
- The Americans with Disabilities Act (ADA) defines disability as a “physical or mental impairment that substantially limits one or more major life activities”. Is the Head of Household a person with a disability? *
- What is your age range?
- What is your highest level of education completed?
- Are you a veteran or an active-duty service member?
- What is your DIGITAL SKILL or INTEREST? On a scale of 1 (Strongly Disagree) to 5 (Strongly Agree), how would you rate the following statements? *
- I am able to manage accounts, usernames, or passwords for the digital resources I use.
- I am able to adapt to new programs or digital resources quickly.
- I am able to use a desktop computer or laptop computer to complete tasks.
- I have access to a working device that suits my needs.
- I am able to maintain applications or programs I download for my device(s) or check for updates.
- I have access to reliable internet service.
- I am able to keep my information safe and secure online.
- I am able to use a smartphone to complete tasks.
- I am able to download new applications or programs for my device(s).
- What are your technology goals? *
- Please review the following. Which topic(s) are you most interested in? (Check all that apply.) *
- Account Management
- Adaptability
- Business
- Career Development
- Computer Skills
- Communication
- Creativity
- Device Access
- E-Commerce
- Education
- Email
- Entertainment
- Finance
- General Interest
- Government Services
- Hardware
- Health and Wellness
- Internet Access
- Research
- Safety and Security
- Smartphone Skills
- Social Media
- Software
- Tablet Skills
- Video Conferencing
