SECTION I: DEMOGRAPHIC INFORMATION

DIRECTIONS: Please WRITE IN or CHECK one answer for each of the following
questions in this section.
1. Age years:
2. Gender □ Male □ Female
3. Level of education
□ Intermediate □ Graduate □ Post Graduate
4. Department:
□ Social sciences □ Humanities □ Natural sciences □ Formal sciences
□ Others………………………………….
SECTION II: PATTERNS OF INTERNET USE
DIRECTIONS: Please respond to EACH of the following questions in this section by
indicating WHAT YOU USUALLY DO when you use the Internet.
5. Do you have internet 24/7?
□ Yes □ No
6. Do you prepare your assignment without internet?
□ Yes □ No
7. Where do you USUALLY access/use the Internet?
□ Home □ Class room □ Library□ □ Public area
□ Other…………………………………………………. (Please specify)
8. Is there anyone else in the room during the time that you USUALLY access/use
the Internet on that computer?
□ Yes □ No
9. For HOW MANY years have you used the Internet? (Please
SPECIFY the length of time you have used the Internet)
___________NUMBER OF YEARS
10. HOW MANY HOURS in a typical day do you USUALLY stay on the internet?
______________NUMBER OF HOURS PER DAY (Please specify, 0 up to 24 hours in
any one day).
11. Do you USUALLY use the Internet late at night (e.g., after 9:00 PM)?
□ Yes □ No
12. Do YOU use the Internet for following these reasons? Yes No
a) Emailing current friends?

b) preparing presentations?

c) accessing educational websites

d) Talking in chat rooms

e) Creating or maintaining a personal Web page

f) Information Surfing for study

g) Information Surfing for personal interests

h) Watching TV on the Internet

i) Listening to music on the Internet

j) Downloading music/movies from Internet

k) Shopping online

l) Accessing unethical websites

m) Playing Web games

13 POTENTIAL IMPACT OF INTERNET NEVER OFTEN ALWAYS

USES
How often do you form new relationships with online
users?
How often do your grades suffer because of the amount
of time you spend online?
How often do you lose sleep due to late-night log-ins?

How often do you feel depressed, moody or nervous

when you are offline, which goes away once you are
back online?
How often do you try to cut down the amount of time
you spend online and fail?
How often do you fear that life without the Internet
would be boring, empty, and joyless?
 Impact of internet and consequences Yes No
Use of the Internet can positively and negatively affect
people lives
Do you believe that YOUR use of the Internet affects
your physical health
Do you believe internet cause anxiety and stress
Do you believe internet negatively effects academic
performance
Do you believe internet negatively effects ethical
behavior
Do you believe that YOUR use of the Internet affects
your mental health (e.g. feelings of happiness,
enjoyment/pleasure in life; confidence, sense of control,
loneliness, anxiety, depression, etc?

SECTION III: POTENTIAL IMPACT OF INTERNET USE

DIRECTIONS: PLEASE ANSWER EACH APPLICATION ITEM.
16. Often people use the Internet for long periods of time. We are interested in learning
more about how YOUR Internet use may affect YOU and those around you. Please
answer, Occasionally, Often, or Always EACH item in the table
below.
1. How often do you for Never, Rarely find that you stay online longer than you intended?
2. How often do you neglect household chores to spend more time online?
3. How often do you prefer the excitement of the Internet to spending time with
your friends in person?
4. How often do you form new relationships with fellow online users?
5. How often do others in your life complain to you about the amount of time you
spend online?
6. How often do your grades or schoolwork suffer because of the amount of time
you spend online?
7. How often do you check your Email before something else that you need to do?
8. How often does your job performance or productivity suffer because of the
Internet?
9. How often do you become defensive or secretive when anyone asks you what
you do online?
10. How often do you block out disturbing thoughts about your life with soothing
thoughts of the Internet?
11. How often do you find yourself anticipating when you will go online again?
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12.
13. How often do you snap, yell, or act annoyed if someone bothers you while you
are online?
14. How often do you lose sleep due to late-night log-ins?
15. How often do you feel preoccupied with the Internet when offline, or fantasise
about being online?
16. How often do you find yourself saying "just a few more minutes" when online?
17. 18. How often do you try to hide how long you've been online?
19.
20. How often do you use the Internet to escape from other problem in your life?
SECTION IV: IMPACT OF INTERNET USE AND INTERVENTIONS
: their
schoolwork, their physical and mental health, and their personal relationships. We
would like to learn more about how YOUR use of the Internet MAY affect your life and
relationships. Please answer each of the following questions with your own words.
17. Do you believe that YOUR use of the Internet affects your grades or your school
work (such as students skipping classes in order to stay online; receiving poor grades
because of being online too much, stopped or cut back on school activities; improved
grades because of better access to information from the Web; etc)?
□ Yes, go to 17a. □ No, go to 18
17a. IF YES, please list ALL of the ways you think your grades/schoolwork are
POSITIVELY AND NEGATIVELY affected by your use of the Internet?
.............................................................................................................................................
.............................................................................................................................................
18 (e.g.,
experience back pain, headaches, eye strain, weight gain or loss, strain on hands/arms,
etc.
□ Yes, go to 18a., 18b. and 18c. □ No, go to 19
18a. IF YES, please describe/discuss ALL of the ways you think your physical health is
POSITIVELY AND NEGATIVELY affected by your use of the Internet?
.............................................................................................................................................
.............................................................................................................................................
18b.
□ Yes □ No
18c. After being online for an extended period of time, DO YOU take sleeping pills
to help you go to sleep?
□ Yes □ No
19
□ Yes, go to 19a. □ No, go to 20
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19a. IF YES, please describe/discuss ALL of the ways you think your mental health is
POSITIVELY AND NEGATIVELY affected by your use of the Internet?
.............................................................................................................................................
.............................................................................................................................................
Some people believe that Internet use causes problems, especially for high school and
younger students. We would like to learn more about what effect using the Internet has
on YOU and YOUR friends.
20. Do you think that Internet use may cause problems for secondary school students?
□ Yes, go to 20a., 20b., 20c., 20d., and 20e. □ No, go to 21
20a. IF YES, Please explain what YOU think the problems are that Internet use can
cause for secondary students like YOU and YOUR FRIENDS?
.............................................................................................................................................
.............................................................................................................................................
20b. What strategies would YOU suggest that students like YOU can do to help
students who may have problems from Internet use (e.g., set specific time limits for use
of the computer, put in a specific room where parents usually are, make students
promise to only use computer for a little while etc.). PLEASE LIST ALL THE WAYS
YOU THINK THAT WOULD HELP?
.............................................................................................................................................
.............................................................................................................................................
20c. What strategies would YOU suggest that and parents like YOURS can do to help
students who may have problems from Internet use? PLEASE LIST ALL THE WAYS
YOU THINK THAT WOULD HELP?
.............................................................................................................................................
.............................................................................................................................................
20d. WHO ELSE would you suggest could have a role in helping students like YOU
who may have a problem with Internet use (e.g., your secondary school? The
government? Others?
.............................................................................................................................................
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20e. What do you think those groups can do to help these students?
.............................................................................................................................................
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21. What POSITIVE results has being able to use computers and access the Internet
done for YOU?
.............................................................................................................................................
22. Is there anything else YOU would like us to know about the use of the Internet by
secondary school students that we may not have asked that YOU think is important?