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How many hours a week do you spend with screens for entertainment reasons (games, films, surfing the net, television shows, etc)?
 
1-5 hours
 
5-10 hours
 
10-15 hours
 
More than 15 hours
 
 
 
How many times per day do you check your personal e-mail?
 
1-3 times
 
3-5 times
 
5-10 times
 
More than 10 times
 
 
 
How many times per day do you check your screen devices for social media, such as Facebook, Twitter, Instagram, etc?
 
Less than once per day
 
1-3 times
 
3-5 times
 
5-10 times
 
More than 10 times
 
 
 
Please count the number of screens in your daily life, including car, carry-around devices and home?
 
 
 
How many hours do you spend with screens in a day, counting your home and work life?
 
1-3 hours
 
3-6 hours
 
6-8 hours
 
More than 8 hours
 
 
 
How many nights a week do you go to sleep after watching T.V., using a computer, or viewing a screen?
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
 
 
How many hours of screen time per week do you allow your child(ren)?
 
0
 
1-5
 
5-10
 
More than 10
 
 
 
Do you ever feel that screen time takes the place of social interactions in your life?
 
Yes
 
No
 
 
 
Is there anything else that you would like to share about your (or your family's) media consumption?