Section 1 of 3
ACP Navigator Services
To assess the impact of the project, partner programs will document and share information on the services provided and their impact.
Referral Source (Branch Location or outside agency)
Referral Source (Branch Location or outside agency)
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Short answer
Paragraph
Multiple choice
Checkboxes
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Checkbox grid
Date
Time
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Referred through other program inquiry or assistance?
Referred through other program inquiry or assistance?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
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File upload
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Checkbox grid
Date
Time
SNAP
WIC
School Lunch Program
Housing Assistance
Medicaid
Other
N/A
Add option
or
add "Other"
…
Answer key
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Please enter time
Please enter time
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Please enter the time at the start of the call or consultation.
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Learner's name
Learner's name
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Whats your name?
Answer key
(0 points)
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Does the learner need help in a different language?
Does the learner need help in a different language?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
I can get someone to help you in your own language. Do you want me to find someone to help you?
1.
Yes
Continue to next section
2.
No
Continue to next section
3.
Add option
…
Answer key
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Section 2 of 3
Language Access
Language access is important. It allows people with limited English proficiency to use and benefit from these services.
If yes, what language?
If yes, what language?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
What language do you speak?
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Learner's phone number
Learner's phone number
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
What is your phone number? I will get someone to call you back.
Answer key
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Section 3 of 3
Digital Navigator Services (cont.)
Learner's phone number
Learner's phone number
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
What is your phone number? I will call you back if we get disconnected.
Number
Text
Length
Regular expression
Greater than
Greater than or equal to
Less than
Less than or equal to
Equal to
Not equal to
Between
Not between
Is number
Whole number
Answer key
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Learner's zipcode
Learner's zipcode
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
What's your zipcode?
Answer key
(0 points)
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How did you hear about the ACP?
How did you hear about the ACP?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Radio
TV
Social Media
Friend/Family
Flyer
Organization
Other…
Add option
…
Answer key
(0 points)
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Which of the following does the learner have?
Which of the following does the learner have?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
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Checkbox grid
Date
Time
Which of the following do you have? Select all that apply.
A smart phone
A tablet, Ipad, eReader
A laptop
A desktop computer
An email account
A social networking site (Facebook, Instagram, Linkedin)
A blog
A microblog (Twitter, tumblr)
Add option
or
add "Other"
…
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Learner's Email
Learner's Email
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Contact by email permission
Contact by email permission
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Can we email you more information or contact you again by email?
Yes
No
Add option
or
add "Other"
…
Answer key
(0 points)
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Reason for calling?
Reason for calling?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Thank you for calling. How can I help you today?
Internet connection
Devices
Digital skills
Online learning
Other…
Add option
…
Answer key
(0 points)
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Why is the learner interested in this service?
Why is the learner interested in this service?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
What is your motivation for obtaining (internet connection, access to devices, digital skills, online learning, search for jobs, etc)?
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Referrals offered?
Referrals offered?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Please name all the referrals made to the learner
Answer key
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Following up
Following up
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Can we contact you again to check on your progress?
Yes
No
Other
Add option
or
add "Other"
…
Answer key
(0 points)
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End time
End time
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Please enter time at the end of the call or consultation.
Answer key
(0 points)
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