Customer Interaction Form – Finger Lakes
Customer Interaction Form FLX
Today's Date
(Required)
MM slash DD slash YYYY
Estimated time spent
(Required)
Minutes
How did you hear about Digital Literacy?
(Required)
Choose one
Community flyer or sign
Computer help sign
Friend/Family
Librarian
Referral from agency/organization
Repeat customer
Volunteer initiated
Prefer not to say
Location
(Required)
Choose one
Chosen Spot Senior Community
Ferris Hills at West Lake
Macedon Public Library
Naples Public Library
Newark Public Library
Ontario Public Library
Palmyra Community Library
80 Parrish St
Quail Summit
Sodus Community Library
Victor Farmington Library
Wood Library
Computer Helper
(Required)
Person Completing the Form
(Required)
Choose one
Computer Help Volunteer
Customer/patron/student
Other
Other person or agency completing this form
Section 1: Customer Information
This information is to track the effectiveness of our work in the community and to demonstrate the need for our services. The personal information below is not viewable by outside individuals or agencies. We need age and ZIP code for these forms to help support the funding and continuation of the program. If you do not wish to share, please select the prefer not to say in those fields so that the volunteer may still record their work with you today. All the questions with drop-down answers have a "prefer not to say" option as well.
Name
First
Last
ZIP Code
(Required)
Untitled
(Required)
18-29
30-39
40-49
50-59
60-69
70-79
80-89
90+
Prefer not to say
Hidden
Year of Birth
Gender
(Required)
Choose one
Male
Female
Non-binary
Prefer not to say
Race
(Required)
Choose one
African American
African Native
Afro-Caribbean
American Indian/Alaska Native
Asian
Caucasian
Indian
Latino/Latina
Middle Eastern
Native Hawaiian/Pacific Islander
2 or more
Prefer not to say
Hidden
Ethnicity
Choose one
Hispanic/Latino
Non-Hispanic/Latino
Prefer not to say
Highest Education Level
(Required)
Choose one
Elementary
Some High School, diploma not received
High School/GED/TASC
Some college, degree not received
2-year college
4-year college
Advanced degree (PhD, MBA, MS, etc.)
Prefer not to say
Employment Status
(Required)
Choose one
Working/Employed
Self-Employed
Student
Retired
Unemployed, seeking work
Unemployed, NOT seeking work
Unable to work, Disability/illness
Prefer not to say
I am a(n)...
Immigrant (regardless of citizenship)
Refugee (regardless of citizenship)
US Military Veteran
Active Reserve/Guard
Recently Incarcerated
Adult Student
Hidden
I am a(n)...
Immigrant (regardless of citizenship)
Refugee (regardless of citizenship)
US Military Veteran
Active Reserve/Guard
Adult Student
Prefer not to say
Section 2: What was Accomplished Today
Which areas were worked on?
Computer Literacy
Social Services
Applied for Services
Workforce Readiness
Northstar Digital Literacy
Citizenship
Consumerism
Financial Literacy
Health Literacy
Legal
Computer Literacy
Learn/Attain Basic Digital Literacy Skills
Create an email account
Create or navigate a social media account
Create, edit, or save a digital document
Learn new smartphone/tablet skill
Complete an online search and/or navigate a website
Learn Microsoft Office/Google Workspace/LibreOffice
Recover an online account (e.g. reset password)
Upload a document to email, Google Drive, or iCloud
Utilize print/fax/scan services
Digital photo manipulation (e.g. cropping, editing)
Access library catalog or services
Device Management (Installing, deleting, locating, and using software)
Other (please specify)
Other computer skill (not listed)
Briefly describe
Social Services
Complete benefit form(s)
Access online resources (e.g. mybenfits.ny.gov)
Communicate with a government agency/representative
Other (please specify)
Other service (briefly describe)
Briefly describe
Applied for Services
Lifeline
Unemployment Insurance Benefits/ID.me (Digital Identity Verification)
Subsidized Housing
Child Health Plus/Healthy New York
Supplemental Nutrition Assistance Program (SNAP)
Home Energy Assistance Program (HEAP)
Other (please specify)
Other service (briefly describe)
Briefly describe
Workforce Readiness
Create or update a resume
Applied for jobs/submitted resumes
Create employment correspondence
Read and understand work-related documents
Read and understand training materials
Obtain information about college, trainings, or jobs
Apply online for education or training
Create job site account
Complete job skills assessment
Other (please specify)
Number of job applications submitted
Other workforce readiness (briefly describe)
Briefly describe
Northstar Digital Literacy
Basic Computer Skills
Internet Basics
Email
Windows
macOS
Microsoft Word
Microsoft Excel
Microsoft Powerpoint
Google Docs
Social Media
Information Literacy
Career Search Skills
Your Digital Footprint
Telehealth
Citizenship
Register to vote
Join a community-based organization (e.g. church, PTA, neighborhood watch)
Other (please specify)
Other citizenship (briefly describe)
Briefly describe
Consumerism
Participate in online shopping
Compare and contrast products
Other (please specify)
Other consumerism (briefly describe)
Briefly describe
Financial Literacy
Complete loan/credit application
Open or access a checking/savings account
Understand banking and/or credit process
Other (please specify)
Other financial literacy (briefly describe)
Briefly describe
Health Literacy
Use digital medical resources (e.g. WebMD, telemedicine, MyChart, MyCare)
Use health care facilities and services
Other (please specify)
Other health literacy (briefly describe)
Briefly describe
Legal
Complete a legal document
Seek legal advice when necessary
Seek online information on employment rights
Seek online information on housing rights
Other (please specify)
Other legal (briefly describe)
Briefly describe
Section 3: Overall Experience
Hidden
Please describe the interaction
Minimal assistance
Some instruction
Significant instruction
Viewed volunteer one time, then customer was able to complete task(s)
Volunteer completed; customer was unable to complete task(s)
Was the outcome(s) achieved?
Yes, the outcome(s) was achieved
Requires more time, customer will complete it independently
Requires more time, customer will return for more help
No, could not find a solution to achieve the outcome(s)
Received USB drive
No, not required
No, previously received a USB drive
Yes
Volunteer Comments
Customer Comments
Section 4: Sharing Your Success
We would like to highlight the work our program and our volunteers are doing to support the individuals in our community. Please consider sharing your success to help others see why we do what we do. You measure your own success; we are here to help you get there.
Would you be willing to share your story?
No, I do not wish to share my story publicly
Yes, I will complete the contact information below
Not at this time, but I am willing to be contacted in the future to share the outcome of my work with the volunteer
I have already submitted my store/contact information
Phone
Email
Please share some details about yourself and what your goals or successes are
E.g. job searches, employment opportunities, education goals achieved, learning a new language, finding better housing, applying to a program or service, community involvement
Name
This field is for validation purposes and should be left unchanged.
Username or Email Address
Password
Remember Me
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