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Technology for Distance Learning Need Assessment
Information provided through this survey will help determine what resources the family has access to, what resources are near the family, and how to best assist them.
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
-
Area Code
Phone Number
Parent/Guardian Email
*
example@example.com
Parent/Guardian Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Relationship to Student
Mother
Father
Grandfather
Grandmother
Aunt
Uncle
Cousin
Older sibling
Student (self)
Other family
Other guardian
What is the name of your child #1?
*
First Name
Last Name
What is the grade level of your child #1?
*
PK
K
1
2
3
4
5
6
7
8
T9
9
10
11
12
What is the name of your child #2?
First Name
Last Name
What is the grade level of your child #2?
PK
K
1
2
3
4
5
6
7
8
T9
9
10
11
12
What is the name of your child #3?
First Name
Last Name
What is the grade level of your child #3?
PK
K
1
2
3
4
5
6
7
8
T9
9
10
11
12
What is the name of your child #4?
First Name
Last Name
What is the grade level of your child #4?
PK
K
1
2
3
4
5
6
7
8
T9
9
10
11
12
What is the name of your child #5?
First Name
Last Name
What is the grade level of your child #5?
PK
K
1
2
3
4
5
6
7
8
T9
9
10
11
12
Does your child (or children) have access to a device (computer/tablet) at home that is capable of supporting online platforms like Google Classroom or Zoom?
*
Yes
No
Are you currently using a chrome book provided by NOLA Public Schools/Fannie C. Williams Charter?
*
Yes
No
If no, are you using your own device (cell phone, tablet, laptop/chrome book)?
Cell phone
iPad/ Android Tablet
Laptop/chrome book
Do you have internet access at home?
*
Yes
No
If yes, how do you access the internet.
Home WiFi
NOLA-PS Hotspot
Cell Phone Hotspot
If no, select what best fits your situation.
There are no providers in my area
I can’t afford the Internet at the moment
I don’t have the Internet now, but if I qualified for low-cost ($5-10 per month) Internet I would apply
Who is your internet or mobile hotspot provider?
*
Do you have the ability to send and receive emails?
Yes
No
Do you have access to a printer?
Yes
No
During school closures, who will be providing care for your child or children?
Parent/caregiver
Older sibling
Grandparent or relative
Nanny or babysitter
How does your child's caregiver feel about assisting with school work?
1
2
3
4
5
Lacking confidence or time
Very confident and plenty of time
1 is Lacking confidence or time, 5 is Very confident and plenty of time
How does the caregiver feel about assisting with technology?
1
2
3
4
5
Very uncertain
Confident
1 is Very uncertain, 5 is Confident
What method of communication works best for your family?
Class DOJO
Text notifications
Email
Phone call
Which of the following resources would you have access to at home?
Pencils
Art supplies (crayons, markers, colored pencils, etc)
White paper
Lined notebook paper
Scissors
Glue
Ruler
None of the above
If the school provides learning packets (e.g., books, worksheets), how easy would it be for someone to collect these from the school on a regular basis?
Difficult to pick up from the school
Very easy to pick up from the school
Unsure
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