Consent

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

Date:

Age:

Background Information

Name:

Birth Date:

Sex:Select…MaleFemale

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 CollegeFreshmanSophomoreJuniorSenior

If in graduate school, what year? Select…Not in Graduate SchoolFirst YearSecond YearThird YearForth YearFifth YearSixth YearSeventh Year +

Have you completed a master 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

Questions

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.

What is your most common activity when using a computer?  (check ONLY ONE)

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

With what groups do you get along the best?

If in school, what is your grade point average?

How many close friends do you have?
Of these, how many are male? female?

Do you tend to focus your attention and thoughts more to (Choose one)
the future
the present
the past?

Imagine a situation in which you meet someone you would like to know better,  someone who might possibly become a friend.  However, for some reason, the conversation is not coming out as you would like it to.

Do you (check all that apply; for each, choose how much):