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VirtuVisit: Participant Intake Form

Thank you for your interest in participating in the VirtuVisit Program. We look forward to partnering you with a tech-buddy volunteer who will assist you in connecting with friends and family members via a video call. As a participant in this program you will be assigned to a volunteer who will support you in setting up a tech device, answer questions and guide you through your first several video calls. Your tech-buddy will support you through the program until you are comfortable making video calls on your own.

We need some general information to ensure you are eligible for the program.

1. Provide your First and Last Name. *This question is required.

2. How can we contact you?

Provide your home address. This program is currently available to residents of Fort Collins. *This question is required.

3. Provide your email address.

4. Provide your phone number. This question requires a valid number format.

5. Provide your birthdate (MM/DD/YYYY). This question requires a valid date format of MM/DD/YYYY.

calendar

6. Do you have a family member that we can work with to help you get set up on your device?

7. What is the name and phone number of this family member?

7. Can our volunteers call you?

7. Can our volunteers text you?

7. Indicate how often each of these statements are descriptive of how you feel during COVID-19. Check all that apply.

Space Cell	I often feel this way	I sometimes feel this way	I rarely feel this way	I never feel this way
I feel isolated from others	I feel isolated from others: I often feel this way	I feel isolated from others: I sometimes feel this way	I feel isolated from others: I rarely feel this way	I feel isolated from others: I never feel this way
I no longer am able to visit with family and friends	I no longer am able to visit with family and friends: I often feel this way	I no longer am able to visit with family and friends: I sometimes feel this way	I no longer am able to visit with family and friends: I rarely feel this way	I no longer am able to visit with family and friends: I never feel this way

8. Access to Wi-Fi and Computer Knowledge

Do you have access to the internet (Wi-Fi) in your residence? *This question is required.

9. Do you know the internet (Wi-Fi) password?

9. Do you have a Facebook account? *This question is required.

10. Do you have Facebook Messenger? *This question is required.

11. Do you have a WhatsApp account? *This question is required.

12. Can we create a Facebook account for you?

Having a Facebook account allows you to use more devices and better maintain your contacts for making video calls to friends and family.

12. Do you have a smartphone? (e.g. iPhone, Android)

13. Please tell us how comfortable you are using technology/computers. This will help us tailor your training.

Space Cell	Very Comfortable	Comfortable	Not Comfortable	Very Uncomfortable
Using the internet and browsing websites	Using the internet and browsing websites: Very Comfortable	Using the internet and browsing websites: Comfortable	Using the internet and browsing websites: Not Comfortable	Using the internet and browsing websites: Very Uncomfortable
Using technology to connect with family and friends	Using technology to connect with family and friends: Very Comfortable	Using technology to connect with family and friends: Comfortable	Using technology to connect with family and friends: Not Comfortable	Using technology to connect with family and friends: Very Uncomfortable

14. Would you like to be able to use Zoom?

15. Please tell us what you want to gain from the VirtuVisit Program and what interests you.

16. How did you hear about VirtuVisit?