1. National Client Tobacco Use Survey

The Community Action Partnership (CAP) has designed this survey in collaboration with the Health Education Council's Break Free Alliance and West Virginia University. This is a research study. One goal of Break Free Alliance is to work with national, state and local organizations to provide technical assistance on how to best reach priority populations in addressing tobacco control issues. The purpose of this survey is to gain insight on what current tobacco control efforts are taking place within various CAP facilities across the country. Secondly, we would also like to explore opportunities for collaboration with interested CAP organizations in order to address tobacco use among those you serve.

Please answer the questions to the best of your ability and we welcome any additional thoughts and experiences you would like to share with us. There are no right or wrong answers. Taking part in this survey is voluntary and private. You may skip any questions you wish, end this survey at any time, and there is no penalty to you if you decide not to participate. This survey will take about 10 minutes to complete. You must be at least 18 years old to complete this survey and affiliated with a CAP organization. West Virginia University's Institutional Review Board (IRB)has acknowledgement of this study on file. If you have any questions please contact Joie Brown, Rural Alaska CAP Inc. at 907-865-7356 or Robert Anderson, West Virginia University, Department of Community Medicine at 304-293-1828.

Question Title

* 1. Does your agency/facility routinely ask about client tobacco use?

Question Title

* 2. Do you know approximately what percentage of your clients use tobacco products?

Question Title

* 3. What barriers do clients experience when trying to quit tobacco? (check all that apply)

Question Title

* 4. What type of tobacco use policy does your agency/facility have?

Question Title

* 5. Does your agency/facility provide tobacco education and/or cessation services to clients?

T