WV Tobacco Cessation Strategies for Healthcare Providers Webinar Registration

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* 1. What is your gender?

Female

Male

Other (specify)

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* 2. Which category below includes your age?

18-20

21-29

30-39

40-49

50-59

60 or older

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* 3. Which of the following categories best describes your employment status?

Dental Hygienist

Dentist

Medical Doctor

University Faculty

Nurse

Advance Practiced Nurse or Physician Assistant

College Student in Healthcare Profession Training Program

Clerical Staff within a healthcare office

Other Healthcare Provider (please specify)

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* 4. What is your race?

White

Black or African-American

American Indian or Alaskan Native

Asian

Native Hawaiian or other Pacific Islander

From multiple races

Some other race (please specify)

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* 5. Which West Virginia Counties do you work in?

Barbour County

Berkeley County

Boone County

Braxton County

Brooke County

Cabell County

Calhoun County

Clay County

Doddridge County

Fayette County

Gilmer County

Grant County

Greenbrier County

Hampshire County

Hancock County

Hardy County

Harrison County

Jackson County

Jefferson County

Kanawha County

Lewis County

Lincoln County

Logan County

Marion County

Marshall County

Mason County

McDowell County

Mercer County

Mineral County

Mingo County

Monongalia County

Monroe County

Morgan County

Nicholas County

Ohio County

Pendleton County

Pleasants County

Pocahontas County

Preston County

Putnam County

Raleigh County

Randolph County

Ritchie County

Roane County

Summers County

Taylor County

Tucker County

Tyler County

Upshur County

Wayne County

Webster County

Wetzel County

Other (please specify)

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* 6. How many years have you been healthcare provider?

0 years - 5 years

6 years - 10 years

11 years - 15 years

16 years - 20 years

21 years - 25 years

26 years or more

N/A - I am not a healthcare provider

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* 7. How did you learn about this training?

Postcard Received in the Mail

Social Media Ad

WV Division of Tobacco Prevention

Other (please specify)

WV Tobacco Cessation Strategies for Healthcare Providers Webinar Registration

Question Title

* 1. What is your gender?

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* 2. Which category below includes your age?

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* 3. Which of the following categories best describes your employment status?

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* 4. What is your race?

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* 5. Which West Virginia Counties do you work in?

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* 6. How many years have you been healthcare provider?

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* 7. How did you learn about this training?

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* 8. If you are a college student in a healthcare training program, please tell us what college and program you are currently enrolled in.