Exit this survey ServiceNet Smoking Survey Question Title * 1. What division do you work for? DBIS MHRS Clinical Shelter and Housing Administration Question Title * 2. What is your smoking history? I currently smoke I am a former smoker I never smoked Question Title * 3. If you are a former smoker, how long has it been since you quit smoking? < 3 months 3 months to 1 year 1 year to 2 years 2 years to 5 years 5 years to 10 years 10 years to 20 years 20 years to 30 years Question Title * 4. If you are a former smoker, how did you quit ? Nicotine Replacement Therapy Support group Medication Individual Counseling Quit Buddy Other (please specify) Question Title * 5. If you are current smoker, are you interested in quitting? Yes No Question Title * 6. Have you tried to quit in the past? Yes No Question Title * 7. What is you present motivation to stop smoking? Choose all that apply. My health My family’s health Save money Be a better role model for the people I serve Other (please specify) Question Title * 8. What support would you like to help you quit smoking? Nicotine Replacement Therapy Support group Quit buddy Individual counseling Other (please specify) Question Title * 9. Would you like this support to be provided through ServiceNet? Yes No Question Title * 10. If you think a support group would be helpful, what locations and times work best for you? County Day Time Enter Time Hampshire Franklin Hampden Berkshire Enter Time County menu Monday Tuesday Wednesday Thursday Friday Enter Time Day menu Morning Afternoon Enter Time Time menu Question Title * 11. If you are a former smoker, are you interested in supporting someone who is trying to quit? If so please leave your email or other contact information. Done