DIGITAL EQUITY SURVEY
2021-2022
PARENT/GUARDIAN
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First Name
Last Name
Email
*
example@example.com
Phone Number
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-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Name - Please list all children currently attending Nettleton (You only need to fill out one form for all students.)
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1. Does this child have Internet Access at home?
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Yes
No
2. If there is no Internet Access, what is the reason this child does NOT have Internet access? (If you chose Yes on #1, choose N/A here)
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Not Available
Not Affordable
Other
N/A
3. What type of Internet Access does this child have? (Select one of the following)
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Residential Broadband
Cellular Network
Hotspot
Community Provided WI-FI
Satellite
Dial-up
Other
None
Unknown
4. Is the Internet Performance acceptable for learning activities? (Select one of the following)
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Yes - experiences very few or no interruptions in learning activities caused by poor internet performance in the primary place of residence
Sometimes - regularly experiences interruptions in learning activities internet caused by poor internet performance in their primary place of residence
No - unable to complete learning activities due to poor internet performance in their primary place of residence
5. What type of device does this child use most often to complete learning activities away from school? (Select one of the following)
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Desktop Computer
Laptop Computer
Tablet
Chromebook
Smartphone
None
Other
6. What is the source of this primary learning device? (Select one of the following)
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District Provided
Personal
Other
7. What is the child's access to this primary learning device? (Select one of the following)
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Shared
Not Shared
Submit
Should be Empty: