Safe Screens Healthy Minds Survey

First Name

Last Name

Email Address*

Phone: () -

Home Address

Street 1 Street 2 City State Zip

I am responding as a: Educator
Parent
Mental Health Professional

Other:

If you are a parent, how many children do you have? 1
2
3
4
5+

If you are a parent, how old is your child? Please choose all that apply. Under 8
8 to 10
11 to 14
15 to 17
18+

Do you live in a? City
Suburb/outside the city
Village/town/township

In your home, do you have access to internet? Yes, always
Yes, most of the time
Yes, some of the time
No

How much time does your child/students spend online each day? (This includes all devices) More than 5 hours
1-5 hours
Less than 1 hour
Doesn't have regular access
Unsure
N/A

How does your children/students access the internet? Please choose all that apply. Parents'/guardians' computer at home
Own desktop computer at home
Own laptop
Mobile phone
Game consoles
Friends’ houses
Relatives’ houses
School
Club
Community center
N/A

Other:

Do you have set rules about your internet use with your children? No
Yes, restricted access
Yes, set time limits
Yes, both
N/A

Do your children/students have access to social media platforms? Yes
No
Unsure
N/A

Which of the following platforms do they have access to? Facebook
Instagram
TikTok
X (formerly known as Twitter)
YouTube
Snapchat
Reddit
Pinterest
N/A

Other

How much time does your children/students spend on a social media platform? More than 5 hours
1-5 hours
Less than 1 hour
Doesn’t have regular access
Unsure
N/A

Have your children/students ever discussed with you issues of concerns that they have experience from their use of social media? Please choose all that apply. Bullying or harassment
Unwanted sexual approaches
Viewing sexual images or content
Being sent sexual images or content
Inappropriate use of their photos/images
Threats
N/A

Other:

Have your children/students experienced any of the following: Addiction (any type)
Anxiety
Body image issues
Depression
Drug abuse
Eating disorders
N/A

Other:

Do you believe these experiences are related to their usage of social media? Yes
No
Unsure
N/A

Do you have a specific story/experience of your children’s/students’ negative experience from social media that you would like to share?

Would you be interested in sharing that story/experience publicly? Yes
No
Unsure
N/A

Would you be interested in sharing that story/experience at a legislative hearing? Yes
No
Unsure
N/A

Do you think the government needs to do more to regulate social media platforms when it comes to minors? Yes
No
Unsure

Do you believe the government should do more to inform parents and minors about the potential dangers of social media use? Yes
No
Unsure

Do you believe the government should regulate online privacy data? Yes
No
Unsure

Would you like to sign up for Senator Rezin's E-Newsletter?

YesNo

Would you like to sign up to receive occasional text messages from Senator Rezin?

YesNo