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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


EMPLOYMENT & SCHOOL

Employer Site
Do you have Internet access at work?

9 Yes

9 No

Do you have remote access to your employers computer system?

9 Yes

9 No

Do you have e-mail at work?

9 Yes

9 No

If so, does your employer monitor your use?


(NOTE: This information may be verified.)

9 Yes

9 No

Must you use unique passwords to gain access to work


computer, your employers network, and/or the Internet?

9 Yes

9 No

Are you currently enrolled in an education program?

9 Yes

9 No

As a result, do you have Internet access through the schools system?

9 Yes

9 No

Do you have e-mail through the schools 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 schools network, and/or the Internet?

9 Yes

9 No

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

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

School Site

What requires you to have access to the schools computer and/or Internet access?
Name of e-mail account(s) at school.

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Computer & Internet Use Questionnaire

NDCA
(08/2008)

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, Amazon.com), even if you only use the account to buy
items. If additional space is needed, attach a separate sheet.

Provider

Screen Name

Password

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Purpose

Computer & Internet Use Questionnaire

NDCA
(08/2008)

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

Provide complete details regarding any storage locations that are not reflected above.
Remote Storage
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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Computer & Internet Use Questionnaire

NDCA
(08/2008)

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)

Computer & Internet Use Questionnaire

Additional Page

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