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* 1. What is your grade/education level?

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* 2. What school do/did you attend?

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* 3. What is your ethnicity?

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* 4. What culture(s) do you most closely identify with?

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* 5. What types of Media do you use daily?

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* 6. How much would you say that Media has an effect on your values?

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* 7. How much would you say that Media has an effect on your culture's values?

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* 8. Would you say that Media has had an impact on your opinions, norms, values, or beliefs?

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* 9. How has Media impacted you? (optional)

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