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NDCA (08/2008)

Computer & Internet Use Questionnaire

Name:

USPO:

Complete this form in full and return to your U.S. Probation Officer within seven days. If you are unsure about

what to report, ask your U.S. Probation Officer. If you need additional space, write on a separate sheet of paper

referencing the item. If an item does not apply mark "not applicable" or "N/A".

Where do you use a computer and/or access the Internet?

9 Home 9 School 9 Work 9 Other (Specify) Do you use a computer to operate/host a website, electronic bulletin board, list serve, or e-mail service?

9Yes (Explain) 9 No

Do you use a computer to write or publish material for distribution to the public?

9Yes (Explain) 9 No

Do you use a computer to sell merchandise over the Internet?

9Yes (Explain) 9 No

Estimate how often you access your computer.

9 0 to 5 times a week 9 6 to 10 times a week 9 11 to 15 times a week 9 More than 15 times a week

Estimate how many hours a week you are on the Internet?

9 0 to 10 hours a week 9 11 to 15 hours a week 9 16 to 20 hours a week 9 More than 20 hours a week

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NDCA (08/2008)

Computer & Internet Use Questionnaire

Employer Site

EMPLOYMENT & SCHOOL

Do you have Internet access at work?

Do you have remote access to your employer's computer system?

Do you have e-mail at work?

If so, does your employer monitor your use? (NOTE: This information may be verified.)

Must you use unique passwords to gain access to work computer, your employer's network, and/or the Internet?

How do your duties at work require computer and/or Internet access?

9 Yes 9 Yes 9 Yes 9 Yes

9 No 9 No 9 No 9 No

9 Yes 9 No

Name of e-mail account(s) at work:

School Site

Are you currently enrolled in an education program?

9 Yes 9 No

As a result, do you have Internet access through the school's system?

9 Yes 9 No

Do you have e-mail through the school's system?

9 Yes 9 No

Do they monitor your use? (NOTE: This information may be verified.)

9 Yes 9 No

Must you use unique passwords to gain access to the computer, your school's network, and/or the Internet?

9 Yes 9 No

What requires you to have access to the school's computer and/or Internet access?

Name of e-mail account(s) at school.

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NDCA (08/2008)

Computer & Internet Use Questionnaire

RESIDENCE

Internet Service Provider(s) (ISP): If you use more than one ISP, list all and indicate which screen names/e-mail

addresses correspond with the appropriate ISP. If additional space is needed, attach a separate sheet.

ISP

Screen Name

E-mail

Passwords

Who Has Access

How Paid?

E-mail Accounts: List any and all e-mail accounts not reflected above. Examples of such accounts are Hotmail and

Yahoo. If additional space is needed, attach a separate sheet.

Provider

Screen Name

Password

Purpose

Chat Room/Internet Relay Chat/Instant Messages, etc. List any and all forms of electronic communication

not reflected above. If additional space is needed, attach a separate sheet.

Provider

Screen Name

Password

Purpose

Seller Accounts: List all seller accounts you maintain (eBay, ), even if you only use the account to buy

items. If additional space is needed, attach a separate sheet.

Provider

Screen Name

Password

Purpose

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NDCA (08/2008)

Computer & Internet Use Questionnaire

Social Networking Accounts: List all social networking (i.e. My Space) accounts you maintain.

Provider

User Name

Password

Purpose

Websites List any and all websites and/or locations you have privileges to receive, send, and/or store information to. If additional space is needed, attach a separate sheet.

Name

Domain Registered to

IP Address

Purpose

Remote Storage

Provide complete details regarding any storage locations that are not reflected above.

Information to include: Location (be specific), how much storage space you have, method for paying for space, purpose

of having this storage space, and password to access location.

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NDCA (08/2008)

Computer & Internet Use Questionnaire

EDUCATION Provide complete details regarding any certifications you have received (i.e., MCSE).

Certification Title

Date Received

Training Facility

Provide complete details regarding any degrees you have received.

Degree

Date Received

Institution

Provide complete details regarding any other educational information.

To the best of my knowledge and belief, the information I have provided in this statement is true, correct and complete. I understand that a false statement on this form may result in a violation of supervision or a separate charge of false statements under 18 U.S.C. ?1001 (up to five years imprisonment, a fine of $250,000, or both).

Signature

Date

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NDCA (08/2008)

Additional Page

Computer & Internet Use Questionnaire

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