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How do you finish your Homework? (Please check all that apply.)
 
Sitting at table in front of the television.
 
Sitting at table in a room with door shut
 
Sitting at table in a room with the radio or television on in the back ground
 
On the floor in front of the television.
 
On the floor in a room with door shut
 
On the floor in a room with the radio or television on in the back ground
 
On your bed in your bedroom with door shut
 
On your bed in your bedroom with the radio or television on in the back ground
 
On your bed in your bedroom in front of the television
 
 
 
What is your GPA?
 
4.0 to 3.8
 
3.8 to 3.5
 
3.5 to 3.0
 
3.0 to 2.5
 
2.5 to 2.0
 
2.0 to 1.5
 
1.5 to 1.0
 
0.9 or below
 
 
 
Which cartoons do you recognize?
 
Scooby Doo
 
Space Ghost
 
Bugs Bunny
 
Teen Titans
 
Huckleberry Hound
 
Woody Woodpecker
 
Batman
 
Bart
 
Homer
 
All above
 
None
 
 
 
Note: This is a sensitive question that can help to understand the needs of students--it is not intended to offend.
Are you impaired or have ADD or AD/HD? (Please check all that apply.)

 
Rather not say
 
Vision impaired
 
Hearing impaired
 
Have ADD
 
Have AD/HD

 
 
 
How frequently do you do Homework at home?
 
Daily
 
Twice a week
 
Three times a week
 
Less than once a week
 
Never
 
 
 
From school
 
Daily
 
Twice a week
 
Three times a week
 
Less than once a week
 
Never
 
 
 
From other places


 
Daily
 
Weekly
 
Monthly
 
Less than once a month
 
Never
 
 
 
Which of the following best describes your Subject in school?
 
P.E.
 
Math
 
English
 
Science
 
Art
 
Music
 
Drama
 
 
 
Can you do your Homework with the Television on?
 
Yes
 
Sometimes
 
Maybe
 
Not really
 
No
 
 
 
How many Hours a day do you watch television?
 
less than 30 mins
 
30 mis to 1 hour
 
1 hour to 2 hours
 
2 hours to 3 hours
 
3 hours to 4 hours
 
over 4 hours
 
Do not know
 
Rather not say
 
 
 
What is your sex?
 
Female
 
Male
 
 
 
Note: Although this is a sensitive question, the answer can help to understand the needs of students. It is not intended to offend.
How would you classify yourself?
 
Rather not say
 
Caucasian/White
 
African American
 
Indigenous or Aboriginal Person
 
Asian/Pacific Islander
 
Hispanic
 
Latino
 
Multiracial
 
Other
 
 
 
What is the current marital status of your house?
 
Rather not say
 
Divorced
 
Living with another
 
Married
 
Separated
 
Single
 
Widowed
 
 
 
Do you feel that Television is a distraction from your Homework?
 
Yes very much
 
Yes
 
Yes sometimes
 
a little
 
No not really
 
No not at all
 
 
 
Which of the following best describes the area you live in?
 
Urban
 
Suburban
 
Rural
 
 
 
How many children under 16 years old live in your household?
 
None
 
1
 
2
 
3
 
4 or more
 
 
 
Please indicate how many Televisions you have?
 
Rather not say
 
1
 
2
 
3
 
4 or more
 
 
 
What is your age?
 
Under 16
 
16
 
17
 
18
 
19 or above
 
 
 
What is your Grade level?
 
8
 
9
 
10
 
11
 
12
 
Do not know
 
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