1.01 Internet Service at Home
 1.05 Work Impact: Have you been unable to
Do you have Internet service at home?
complete work due to lack of Internet access?

No, Internet is not available where I live

Yes, many times

No, but I would consider getting Internet if Yes, sometimes

barriers were removed

No, never

No, I just don’t want or use Internet at home

I do not use the Internet for work

Other, please explain _____________________

1.06 Schoolwork Impact: Have you been unable to

1.02 Internet Barriers (mandatory? yes) (check all complete schoolwork due to lack of Internet access?

that apply)
 Yes, many times

Which of these conditions are a barrier for you to get Yes, sometimes

Internet service at home? No, never

Price
I do not use the Internet for schoolwork

Not available

Credit check or deposit

1.07 Health Impact: Have you been unable to
Long-term contract
access health support or social services due to lack
Other, please explain _____________________
 of Internet access?

Yes, many times

1.03 Internet Access
 Yes, some times

Where do you go most often to access the Internet? No, never

(check all that apply)

I do not use the Internet for health and social
Library
services

School

Work
1.08 Computer Skills: Which of the following can
Community center
you do? (check all that apply)

Senior center
Create a document

Local business or coffee shop

Upload and download a document

Relative or Friend’s home

Send and receive an email

Public hotspot
Share photos

Other, please explain _____________________
 Watch a video

Search for information online

1.04 Internet Opportunities Access health services

Would you like to use the Internet for any of the Order something online

following? (check all that apply)
1.09 Improve Computer Skills

Education - remote learning or teaching, online Do you need or want to strengthen your ability to use
training Business
the Internet and a computer?
Business - remote working, business tasks,
marketing, online sales or store Yes

Telehealth - physical and mental health support, No

appointments, prescriptions

Household - pay bills, look for services, online 1.10 Age: What is your age range?

shopping, online banking Social

Under 18
Social - connecting with family and/or friends, 18-29
email, social media 30-39
Entertainment - music, movies, TV, video games
40-49
Civic - Civic duties, register to vote, serve as 50-59
juror, find government agencies 60-69
70-79
80 +
 Doña Ana Broadband



1.11 Community: Are you a member of any of the 1.13 Race and Ethnicity
following groups? (choose all that apply)
How would you best describe yourself?
Live in Dona Ana County
Check all that apply:
Student
American Indian or Alaska Native

Teacher
Asian

Parent Black or African American

Senior
Hispanic, Latino or Spanish origin

Employee
Native Hawaiian or Pacific Islander

Business owner
White

Veteran
 Prefer not to answer

A race/ethnicity not listed. Please explain:


1.12 Household Income: What is the range of your ________________________________

annual household income?

Under $21,000 per year

1.14 Cell Phone

$21,000 - - $34,999 per year
Do you have a cell phone?
$35,000 - $ 49,999 per year
(e.g. Verizon, T-Mobile, Sprint, AT&T, etc.)

$50,000 - $99,999 per year

Yes, for voice calls only

$100,000 - - $249,999 per year

Yes, for Internet data only

More than $250,000 per year

Yes, for voice calls and Internet data

I don’t know
No, I do not have a cell phone
Prefer not answer


1.15 Address Enter your address. The street address of your home or business is critical to helping
identify areas without adequate internet service. Personal Information will not be shared but locations
may be gathered together to find areas that lack Internet service and need improvement.


Street ____________________________________________________________________________


City ___________________________________State ___________ Zip Code____________________


Please
Place
Stamp
Here