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CULTIVATING CODERS INITIAL SURVEY
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Student Contact Information
Name
*
Your answer
Address
*
Your answer
Email
*
Your answer
Phone number
*
Your answer
Class Information
Leave blank if this is a general inquiry
Location
Your answer
Start Date
MM
/
DD
/
YYYY
End Date
MM
/
DD
/
YYYY
Existing Knowledge
Please rank your knowledge of the following from 1-10 with 1 being no knowledge and 10 being extremely proficientl
General Computer Knowledge
1
2
3
4
5
6
7
8
9
10
Clear selection
Coding
1
2
3
4
5
6
7
8
9
10
Clear selection
HTML
1
2
3
4
5
6
7
8
9
10
Clear selection
CSS
1
2
3
4
5
6
7
8
9
10
Clear selection
Website Design
1
2
3
4
5
6
7
8
9
10
Clear selection
Javascript
1
2
3
4
5
6
7
8
9
10
Clear selection
General Information
What do you hope to learn from this program?
Your answer
Have you attended other computer classes?
Yes
No
Clear selection
If yes, please describe your experience.
Your answer
Are you currently employed?
Yes
No
Clear selection
If yes, what's your current job?
Your answer
Gender
Male
Female
Other:
Clear selection
Ethnicity
Your answer
If Native American, please indicate tribe affiliation.
Your answer
Number of household members (including yourself)
1
2
3
4
5
6
7
8
9
10
Clear selection
Annual household income
Your answer
Do you currently receive government assistance?
Yes
No
Clear selection
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