UPSHIFT Soronko Pilot Baseline Form
The following questionnaire will only take a few minutes to complete. All information will be kept confidential. You can choose to opt out. However the dat collected is to help us with some details as well as a baseline for your participation in the UPSHIFT Pilot. THANK YOU FOR YOUR TIME!
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1). What is your name?
2). How old are you (Age)? *
3). Please specify your ethnicity *
4). Do you have any visual, hearing, physical or cognitive impairments? *
5). If you answered yes to Question 4, Please specify.
6). Are you married? *
7). Do you have children or are you expecting? *
8). If you answered yes to Question 7, How many children?
9). How many people live in your household? *
10). How many siblings do you have? *
11). Are you still in or attending school? *
12). If you answered Yes to Question 11, What is the name of your school and what grade are you in?
13). If you answered No to Question 11, What is the reason not to attend school?
Clear selection
14). If you are in SHS, what subject/course are you studying in school? (Course of study)
Clear selection
15). What is the highest educational level? *
16). What is your current employment status? *
17). If employed, what is your type of employment?
Clear selection
18). If Formal Sector, Please specify the sector or industry you work in
19). If Informal Sector, Please Specify the number of businesses and monthly turnover.
20). Please state your place of birth. *
21). Please state your address (region and location) *
22). Which languages are you capable of speaking fluently? *
Required
23). Does your household have a toilet facility?
Clear selection
24). Do you own a TV?
Clear selection
25). If attending school, what do you usually do after school? Check all that apply
26). What religious family do you belong to or identify yourself most close to? *
26). What religious family do you belong to or identify yourself most close to? *
27). What is your level of computer skills? (Computer Literacy)
Clear selection
28). Access to Electronic Devices (Check all that apply)
29). Do you go online regularly or have access to the internet regularly?
Clear selection
30). Where do you have access to internet.(Check all that apply)
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