The Courseware Accessibility Study

Distance Education Survey

(CCE and EvNet)

[Return to Appendix]
NOTE: this form is a copy of the original and is non-functional. You will not be able to submit this form.

Part F: Personal Information

Please answer the following questions about yourself. Indicate your response by either choosing of the appropriate selection, or by filling in the blank space provided.

Enter your Participant ID

1. What is your sex?
	I am a Female I am a Male

2. What is your age group?
	16 - 18 years	19 - 20 years	21 - 22 years
	23 - 24 years	25 - 34 years	35 - 44 years	45 years and over

3. What is the language you first learned as a child?
	English	French	Other (Specify)

4. What is the language you are most comfortable with today?
	English	French	Other (Specify)

5. What is your marital status?
	Single	Married or Common-Law
	Divorced/Separated	Other (Specify)

6. Are there children living at home?
	No, I have no children at home
	Yes I have children at home --If Yes, how many?
	Please list their ages

	How many hours per week do you estimate you personally spend caring for children for which you do not receive any pay?

7. What is the highest level of education you have already completed?
	Less Than High School	High School
	Community College	University (Certificate/Diploma)
	University (Undergraduate Degree)	University (Graduate Degree)
	Other Post-Secondary (Please specify)

8. What is your most recent Job Title ? (Please be specific)
	What is the type of workplace? (ie., hospital, bank, police dept.)
	Approximately how many employees work there?
	What were your THREE most important job duties at work?
		1.)
		2.)
		3.)

9. How many total hours per week do you estimate you work for a wage, salary, or other form of income?
The average number of paid hours I work in a week is

10. How many hours per week do you estimate you personally spend doing household chores (e.g. washing the dishes; cleaning; fixing things in the house; laundry; etc?
The average number of hours per week I spend doing household chores is

11. How many hours per week do you estimate you personally spend in extra-curricular or volunteer activities for which you do not receive any pay?
The average number of hours per week I spend in extra-curricular activities is

13. How long can you comfortably work in front of a computer without needing to take a break (ie., due to eye strain, back pain, fatigue, etc.)?

The number of minutes I can work in front of a computer without taking a break is

This form is now ready to send Yes