Questionnaire:
Social Interaction and Technology Use

SHYNESS INSTITUTE
2000 Williams
Palo Alto, CA 94306
650-493-6398; www.shyness.com

Please do not this submit this questionnaire more than once.

Consent

I, , hereby consent to participate in the project described above.  I have read and understand this statement.

Date:

Age:

Background Information

Name:

Date:

Sex: Select... Male Female  

Are you in school? Yes No
          If so, are you in grades 1 through 12? Yes No

What grade are you in?

If you are in college, what year? Select... Not in College Freshman Sophomore Junior Senior

If in graduate school, what year? Select... Not in Graduate School First Year Second Year Third Year Forth Year Fifth Year Sixth Year Seventh Year +

Have you completed a master,s degree? Yes No

Completed Ph.D.?  Yes No

Working? Yes No
          If so, are you working full time? Yes No  

Working in a technical field? Yes No   

Activities Questionnaire

Listed below are some activities that people do, both alone and with others. For each item, select the category that shows how often you engage in this activity.

Do you use the internet more or less than your friends? 
more  less  same as

How many hours a week do you spend doing the following activities:  

Where is the computer in your house (i.e. what room)?

Do you have one in your bedroom? Yes No

If you are at home, do parents limit the time you spend using computers? Yes No

Are there consequences if you break the limits? Yes No

Do your parents use technology as a reward? Yes No

Do your parents use technology as a punishment? Yes No

(Rank the following four questions in this order: 1 = most, to 4 = least)  
If you need to talk to someone about something personal, do you prefer to

1st most likely thing to do (please only choose one):
email them  write a letter telephone them   speak to them in person

2nd most likely thing to do (please only choose one):
email them  write a letter telephone them   speak to them in person

3rd most likely thing to do (please only choose one):
email them  write a letter telephone them   speak to them in person

4th most likely thing to do (please only choose one):
email them  write a letter telephone them   speak to them in person

If you have a fight with a friend, what do you prefer to do most?
email them  write a letter  telephone them  speak to them 

If something important comes up in a relationship, what are you most likely to do?
email them  write a letter  telephone them  speak to them in person

In general, would you rather talk to someone via email or on the telephone?
email them   telephone them