Tobacco Cessation Survey 2016

Copy of page: Tobacco Cessation Survey

The City of Winston-Salem Human Resources Department division of Employee Medical Services is dedicated to providing assistance to those employees who desire to stop using tobacco products. If you would like to participate in the tobacco cessation program through the City, please provide your information.

Question Title

* 1. Please provide your information:

First and Last Name: *

Employee Number (or SSN if retiree): *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Personal Telephone Number: *

Email Address: *

Department

It is important to note that biometric screening participants who test positive for nicotine can still qualify for the Wellness premium discount by completing one of two city approved Tobacco Cessation curricula. Even individuals who are unsuccessful in their attempt to quit using tobacco may qualify for the Wellness premium discount by successfully completing Tobacco Cessation classes either on-site or online. Once nicotine testing is done during biometric screening, additional retesting will no longer be performed.

1.) Curriculum One is a 5 week series of classes held one hour weekly on-site at Employee Medical Services.
2.) Curriculum Two is a telephonic program that allows BCBSNC members to receive 4 telephone coaching/counseling sessions with QuitlineNC, a state-based tobacco-cessation.

Question Title

* 2. Which Tobacco Cessation Program would you like to be enrolled in?

A five (5) week series ON-SITE at Employee Medical Services (32 W. 32nd Street)

Four (4) TELEPHONIC counseling sessions via QuitLine NC (a state-based tobacco-cessation program) [out of state callers will be redirected to North Carolina QuitLine]

I am undecided at this time, but I will contact Employee Medical Services (336-727-2305) for more information and to enroll. [by selecting this option, you acknowledge that you are responsible for contacting Employee Medical Services]