This free survey is powered by
0%
Questions marked with an * are required Exit Survey
 
 
* Your child uses technology only when permitted.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child stops using technology when requested.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child goes through periods of heavy technology use.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child spends increasing amounts of time on technology.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child will sneak use of the technology.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child gets up early in the morning or stays up late at night to use technology
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child seems to lose track of time when using the technology.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child begs or almost craves more time with the technology.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* You have made attempts to limit your child’s use.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child’s grades have started to slip due to incomplete homework, failing on tests, or sleeping through classes.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* The first and last thing your child does every day is use the technology.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child has given up previously enjoyed hobbies, e.g., sports, dramatics, music, outdoor recreation, etc.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child’s use of technology causes arguments in your family.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child completes their daily/weekly chores.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
* Your child appears awake in the morning.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child engages in physical activities on a regular basis.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child has dark circle under their eyes or bloodshot eyes.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child is constantly tired and easily falls asleep e.g., when riding in a car, sitting in an office waiting for an appointment, etc.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child consumes energy drinks or other caffeinated drinks to stay awake.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* You notice your child squinting or straining to look at things.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child complains of pains in their hands, wrists, or arms.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child complains of back problems or shoulder aches.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child eats well balanced meals.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child showers every day.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child brushes their teeth regularly.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child puts effort in to grooming.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Generally speaking your child is happy.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child demonstrates a normal variation in their mood.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child seems to enjoy life’s experiences.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child is demonstrating depression either in the form of sadness or anger.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child appears sullen or somber.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child presents with anxiety either in the form of nervousness, agitation, or hyper vigilance when they are away from their technology.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child demonstrates rage when technology is taken away.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child demonstrates dramatic mood swings.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child no longer demonstrates any emotions and their moods seem to be “flat”.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child’s mood improves when engaged in technology.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child interacts with friends without the use of technology.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child will stop using their electronic device to be with their friends.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child goes to their friends’ homes and they come to yours.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* You know at least a handful of your child’s friends or at least their close friends.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child maintains good interpersonal skills during conversations (e.g., good
eye contact, appropriate nonverbal skills, speaks clearly or with enough volume).
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child spends time alone in their bedroom.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Most of your child’s friends are online friends.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child neglects their friends.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Most of your child’s conversations occur via chatrooms/chatlines/texting/instant messaging.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child lies about his or her use of technology.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child no longer wants to be involved in family functions and if they reluctantly participate they do not interact with family members.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA
 
 
 
* Your child can go for periods of time without checking their electronic device or social networking site.
 
1 Rarely
 
2 Occasionally
 
3 Frequently
 
4 Often
 
5 Always
 
6 Unknown/NA