Interaction Form
Today's Date
*
Date Format: MM slash DD slash YYYY
Estimated Time Spent (in minutes)
*
Please enter a number from
0
to
120
.
How did you hear about Digital Literacy?
*
Choose
Community Flyer/Sign
Computer Help Sign
Friend/Family
Librarian
Referral From Agency/Organization
Repeat Customer
Volunteer Initiated
Referral Agency/Organization
Location
*
Choose
Arnett Library
Lincoln Library
Literacy Rochester
Mary's Place
Maplewood Library
OACES
R-H-R
Did you receive a Library Card today?
Choose
Yes
No
Already a library cardholder
Did you come to the Library with your children?
Choose
Yes
No
Computer Helper
*
Choose
Alajah D
Betsy G
Briana B
Chris P
Chuck V
Delia J
Edward C
Emily K
Emily Y
Emmy T
Erin C
Gail D
Hannah W
Isabella S
Jasmine K
Jason T
Jim B
Joe P
John O
Kamaiya B
Kami T
Kat F
Katie H
Kendall G
Laura R
Lisa R
Liz R
Lue H
Mary M
Megan M
Michael E
Michael T
Michelle P
Mike L
Nancy B
Rachel S
Rebekah W
Tom H
Tricia L
Wendy A
Person Completing this form
*
Choose
Computer Help Volunteer
Customer/Patron/Student
Other
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 NAME, DATE OF BIRTH and ZIP CODE for these forms to help support the funding and continuation of the program. If you do not wish to share, please place an X in those fields so that the volunteer may still record their work with you today.
Name
*
First
Last
Zip Code
*
Date of Birth
*
MM
DD
YYYY
Gender
*
Choose
Female
Male
Non-binary
Race
*
Choose
African American
African Native
Afro-Carribean
Alaska Native/Pacific Islander/Other
Asian
Caucasian
Native American
Ethnicity
*
Choose
Hispanic/Latino/a
Non Hispanic/Latino/a
Highest Education Level
*
Choose
Elementary
Some High School, diploma not received
High School/GED/TASC
Some college, degree not received
2-yr college
4-yr college
Advanced Degree (PHD, MBA, MS, etc.)
Did Not Respond
Employment Status
*
Choose
Working/Employed
Self-Employed
Student
Retired
Unemployed, seeking work
Unemployed, NOT seeking work
Unable to work, Disability or Illness
Did Not Respond
I am a(n)...
Immigrant (regardless of citizenship)
Refugee (regardless of citizenship)
US Military Veteran
OACES Student (Current)
Section 2: What Was Accomplished Today
Community
Located and/or used community agencies or services
Awareness of local community information
Applied for Services
Choose
Subsidized Housing
Child Health Plus
Healthy New York Insurance
SNAP (Food Stamps) Benefits
HEAP (Home Energy Assistance Program)
Unemployment Benefits
Other (Please Specify)
Other (Service Application)
Number of job application(s) submitted
Please enter a number from
1
to
10
.
Workforce Readiness Part 1
Read and Understand Help Wanted Ads
Filled out a Job Application
Submitted a Job Application
Workforce Readiness
Create or update a resume
Create employment correspondence
Read and understand work-related documents
Read and understand training materials
Obtain information about college or training or jobs
Apply online for education or training
Create Job site Account*
Complete Job Skills Assessment*
Citizenship
Register to vote
Join a community-based organization (Church, PTSA, Neighborhood Watch, etc.)
Financial Literacy
Complete loan/credit application
Open or access a checking account
Open or access a savings account
Understand banking and/or credit process
Health Literacy
Use digital medical resources (WebMD/Telemedicine)
Use health care facilities and services
Legal
Complete a legal document
Seek legal advice when necessary
Seek online information on employment rights
Seek online information on housing rights
Social Services
Complete benefit form(s)
Access online resources (ex. mybenefits.ny.gov)
Communicate with a government agency/representative
Computer Literacy
Create an email account
Create, edit, or save a digital document
Learn new smartphone skill
Join social media group
Complete an online search and/or navigate a website*
Learn Microsoft/Google Suite Skills*
Recover an online account (e.g., reset password)*
Upload a document to email or Drive*
Utilize Print/Fax/Scan services*
Other computer skill (not listed): briefly describe
Additional Outcomes
Enhance Citizenship skills / Community involvement
Attain Basic Digital Literacy Skills
Interpret Signage
Section 3: Overall Experience
Please describe the interaction.
*
Choose
Minimal Assistance, Customer performed task(s)
Some Instruction, Customer performed task(s)
Significant Instruction, Customer performed task(s)
Customer viewed once, then performed task(s)
Volunteer completed, Customer was unable/unwilling to perform task(s)
Please describe the level of help you received.
*
Choose
Minimal Assistance
Some Instruction
Significant Instruction
Viewed volunteer one time, then was able to do it myself
Volunteer completed, I was unable to complete task(s)
Was the outcome(s) achieved?
*
Choose
Yes, the outcomes(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
Yes
No, previously received a USB
Referred to OACES
*
No
Yes, Created an OACES account
Yes, Liked OACES on Facebook
Yes, Flash drive with OACES literature was given
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?
*
Choose
Yes, I will complete the contact information below
No. I do not wish to share my story publicly
Not at this time, but I am willing to be contacted in the future to share the outcomes of my work with the volunteer
I have already submitted my story/contact information
Phone
*
Email
*
Please share some details about yourself and what your goals or successes are.
Some ideas: Job searches and employment opportunities, education goals achieved, learning a new language, finding better housing, applying to a program or service and being accepted, community involvement, etc.
Username or Email Address
Password
Remember Me
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