R.P.D.S. Questionnaire
Name in Full (Disabled):
Age:
Address:
Post Code:
Phone:
Email:
Carer:
Disability (Must be mobility disabled)
Housebound ?
Yes
No
Pension or Disability Support Pension?
Type of computer/modem in house (if any?)
Are you connected to the Internet?
Yes
No
What ISP do you use?
Monthly Internet costs?
Are you comfortable using a computer?
Yes
No
Have you had any computer training?
Yes
No
What do you currently want out of Internet access?
Will you connect to a commercial ISP with monthly access cost Ave $25 up to $40 for unlimited use, and also the telephone access call costs?
Yes
No
Would you prefer $10 per month for 2 hours per day access from RPDS?
Yes
No
Check the following items of interest:
Contact Disability Support Groups :
Yes
No
Self Education :
Yes
No
Chat :
Yes
No
Access Government services :
Yes
No
Home Shopping :
Yes
No
Newspapers :
Yes
No
Leisure items :
Yes
No
Simply surf the net :
Yes
No
E-mail :
Yes
No
TAFE Course :
Yes
No
Others - List :
Is there anything you want to learn about (ie languages, computers, writing, disability support etc)?
Can you afford $10 per annum per person non-voting membership fee (we can't function without some financial resources)?
Yes
No
Can you introduce family members and carers to RPDS ?
Yes
No
Do you have any ideas where we can obtain donated PC's & modems or cash donations to fund PC upgrades / repairs?
Yes
No
Can you help with contacting organisations for donated computer equipment ?
Yes
No
Do you want to be in the pilot program ?
Yes
No
If our group becomes large enough to obtain buyer discounts would you use it as your whitegoods purchaser? (if N, why?)
Yes
No
No - Why?
Any other comments you have:
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