Learner Intake Form

Please do not share this form with others. Please do not share this form with learners directly.

If submitting this form results in an error, please do not re-submit. Contact Pat Jew.

Questions marked with an * are required.

Who is submitting this form?

PartnerdigitalLIFT

Program Name

Is the learner a direct referral to digitalLIFT and not referred by a partner organization?

YesNo

Program Enrollment Date

Learner First Name

Learner Last Name

Learner contact phone number

No parentheses, spaces, or dashes

Class Location

IT Bookman Community CenterSAHA - MonarchSAHA - SAM

SCRIPT

Hi my name is [name] and I’m calling from digitalLIFT in response to your application for the [name of program]. We are following up to assess how we can help you use your device.

I want to take a few minutes to verify the information we received, ask a few additional questions, and then let you know what you can expect from us and your trainer.

Contact Attempts

**DO NOT ATTEMPT a fourth contact unless instructed to do so.**

Contact Attempt

FirstSecond

Result

Contact MadeContact made but information not verifiedNo Contact

Learner ID

Which Learners are you reporting on? Click HERE for active learners. Please COPY and PASTE the ID from the document. If you cannot locate your learners in the file skip this question.

Learner ID

Which Learners are you reporting on? Click HERE for active learners. Please COPY and PASTE the ID from the document.

Are you a graduate of the Home Connect program and have completed your 5, 1-hour lessons of training OR a graduate of the Digital Equity program?

YesNo

Learner Information

Basic Information

What is the learner's birth date?

Is the learner age 60 or older?

YesNo

What is the learner's birth year?

YYYY

What is the learner's preferred language of instruction?

Learner's spoken language(s)

Note: to select multiple, hold down the Ctrl or Cmd key while clicking on selections.

Other Language

How does the learner prefer to be contacted?

Note: to select multiple, hold down the Ctrl or Cmd key while clicking on selections.

What is the best number to reach the learner at?

Please provide the learner's mailing street address.

Is this a housing site?

YesNo

Unit#

Please provide the learner's mailing city.

Is the mailing city San Francisco?

YesNo

Please provide the learner's mailing state.

Please provide the learner's mailing county.

Please provide the learner's mailing zip code.

Get Care ID

Does the learner participate in any government assistance program?

Note: to select multiple, hold down the Ctrl or Cmd key while clicking on selections.

Demographic Information

Next, I'm going to ask a few questions about your demographic. This is to help us understand whom we serve in the community. Your personal information will remain confidential within our organization. All of these questions are optional. If you prefer not to answer any of them, it will not have a negative impact on the services we provide to you.

Is the learner a veteran?

Does the learner have a disability or learning difficulty?

What is the learner's ethnic identity?

Please specify

What is the learner's current residence status in the U.S.?

Other status

What is the learner's gender identity?

What is the learner's sexual orientation?

What is the learner's marital status?

What is the learner's living status?

What is the learner's income level?

Does the learner own a device (in addition to any device received through this program)?

YesNo

If the learner has an email account, do they know the password?

Yes, know the passwordYes, but forgot passwordNo email

Learner email address

Learner Technical Experience

If the learner has used a smartphone or tablet before, which features have they used?

Note: to select multiple, hold down the Ctrl or Cmd key while clicking on selections.

Has the learner used a laptop or desktop computer?

YesNo

Services

What device would the learner like to receive?

AndroidiPad

Has the learner received their device from us or from our partner agency?

YesNo

Has the learner received a training booklet?

YesNoNot Sure

Does the learner need assistance setting up their supplied device?

YesNo

What kind of assistance does the learner need?

Note: to select multiple, hold down the Ctrl or Cmd key while clicking on selections.

What other tablet setup assistance does the learner need?

digitalLIFT offers lessons at no charge, would the learner be interested?

YesNo

Does the learner needa device or use their own device?

The learner needs a deviceThe learner will use their own device

For SF Digital Connections lessons are 5 1-hour lessons with an Instructor

What type of service does the learner need?

1:1 VirtualGroup In-person

At what location is the learner planning to attend group sessions?

Here's a list of site addresses

What type of service does the learner want?

1:1 TutoringGroup Workshop
Both

Training

Which topics would the learner like to cover with their trainer?

Note: to select multiple, hold down the Ctrl or Cmd key while clicking on selections.

Which topics would the learner like to cover with their trainer?

Note: to select multiple, hold down the Ctrl or Cmd key while clicking on selections.

Additional Topics requested

Please select all days and time that the learner would be available to attend classes. (Select all that apply.)

To Staff member - enter estimated hours needed for instruction.

Maximum is 5 hours for ATT and Sourcewise.

The lessons will be done over the phone and a screen sharing app so that our instructor will be able to see your screen and guide you through the training. Does your device have this app installed? If not, we will request the device supplier to add this screen sharing tool on your device.

Permission GivenPermission Refused

Does the learner need any special accommodations to use the device?

YesNo

What special accommodation does the learner need?

We offer group Q&A sessions, would the learner like to be included on the invitation list?

YesMaybe / Not sureNo

For your Digital Coach to best support you throughout your lessons, they will need to have remote access to your device via TeamViewer QuickSupport or AnyDesk. One of these applications must be downloaded on your device prior to pairing you with your coach. We've created video tutorials on how to download each platform. If you are unfamiliar in downloading applications to your device, you can either visit us at our main digitalLIFT office or the closest senior center open to the public. Which would you prefer?

Receive email containing video tutorials for self downloadVisit the main digitalLIFT officeVisit closest community center

Does the learner want 1:1 lessons with a Digital Coach volunteer?

YesNo**NOTE**: Learner must meet the minimum age for the Digital Coaching program.

Device Info

Did the learner receive a device

YesNo

Device Info

TeamViewer ID

AnyDesk ID

Digital Coaching Lesson Pathways

Answering the following questions will help us match you with your Digital Coach.

(For Devices other than the digitalLIFT distributed Lenovo Tablet) We want to pair you with a coach who has the most knowledge and understanding of your device. Can you provide me with additional information about your device like the model year?

Which topics would you like to cover with your Digital Coach?

A Digital Coach is available to offer support in 4, 8, or 12, 1-hour weekly sessions. Which lesson timeline would you commit to?

4, 1-hour Weekly Sessions8, 1-hour Weekly Sessions12, 1-hour Weekly Sessions

Thank you for taking the time out of your [afternoon/evening] to answer these questions. We will be processing the information you provided in order to best pair you with a Digital Coach.

Referring Organization

First Name of Interviewer

Last Name of Interviewer

Email Address of Interviewer

Is the interviewer also the instructor for this learner?

YesNo

Was this intake performed during an activity session?

YesNo

How much time did it take to interview the learner?

Notes

Contact Information

	Monday	Tuesday	Wednesday	Thursday	Friday
Afternoon (between 12:30 and 4:30pm)
Evening (between 5 and 8pm)