TECHNOLOGY QUESTIONNAIRE

STUDENT NAME DATE

1. Do you have access to a computer at home? Yes No *

* If No, where do you plan to access a computer? (check all that apply)
Library
Work
A friend/relative’s house
School
Other ____________

2. Do you have Internet access at home? Yes No *

3. If so, what type of connection do you have?
Dial-up
Cable/DSL/ other high-speed connection (i.e. FIOs)
Don’t know

4. How often do you use a computer to access the Internet? (Choose one)
A few times a day Once a week
Once a day A few times a month
Several times a week Never

For each item, check the box that best describes your familiarity with the following technology tasks.
NONE AT ALL A LITTLE FAIRLY EXTREMELY
General computer use (basic functions, mouse, etc.)
File management
Sending email
Sending email attachments
Instant messaging (IM)
Texting (SMS)
General web use (browsing)
Web searching
Word processing (i.e. Microsoft Word)
Creating spreadsheets (i.e. Microsoft Excel)
Creating presentations (i.e. Microsoft PowerPoint)
Taking pictures with a digital camera
Downloading pictures from a digital camera to a
computer
Creating web sites
Blogging
Computer programming (C+, HTML, SQL, etc.)

Application Addendum I
 PERSONAL STATEMENT

STUDENT NAME DATE

Please use the space below to tell us why you are interested in participating in the PlugGED In program. In your
statement, please address the following questions:

• why you are interested in enrolling in a GED-technology employment class like PlugGED In
• what you expect to gain from participating in the program
• what are your education and employment goals once you complete the program (i.e. get a job, go to college,
etc.)

Application Addendum III

 REFERRAL FORM

Return to: Linda Allen

Southwest Regional Adult Education
1 School Board Drive
P.O. Box 8
Lebanon, VA 24266
APPLICANT INFORMATION (TO BE COMPLETED BY PLUGGED IN APPLICANT)

Last Name First Name MI

Address
City State Zip
Email address __ Phone ( ) _____________

This applicant above is applying to enroll in PlugGED In, an innovative six-month long course that prepares
participants to earn their GED credential and Career Readiness Certificate (CRC) as well as valuable technology
certifications and workplace readiness skills. This curriculum will prepare the applicant for an entry-level position in a
technology sector industry or for admission into additional post-secondary education and training.

REFERRER’S INFORMATION
Name
Title
Address
City State Zip
Email address Phone (__ )

1. How long have you known the above applicant? _____________

2. Briefly describe how you know the applicant: _________________ ________________________

3. Please use the scale below to rate the applicant in the following areas
EXCELLENT GOOD AVERAGE POOR DON’T
KNOW
Dependability
Independence
Motivation
Perseverance
Academic potential
Teamwork skills
Leadership ability
Work/study habits
Creativity

4. Overall, do you recommend that the applicant be accepted into the PlugGED In program?
Highly recommend Recommend Do not recommend Do not know

Application Addendum IV