WCCS is participating in a smoke-free and tobacco-free community college grant initiative through the Truth Initiative Grant Program.  The grant is aimed at involving students, faculty, and staff in an effort to create an awareness of the dangers of smoking and using tobacco products as well as implement a smoke-free and tobacco-free policy at the College.  This survey does not necessarily represent the views of Truth Initiative, its staff and or Directors.

Direction:            Please complete the form using responses that best represent you or your situation/position:

* 1. WCCS E-mail address:

Other E-mail address:

* 2. Identify factors related to smoking that most concern you.  (May select more than one)

* 3. Identify yourself:

* 4. Sex:

* 5. Race (choose one):

* 6. What is the highest grade of school that you have completed? (Select the response that describes your situation)

* 7. Do you smoke or use tobacco products?

* 8. Do you want to quit smoking or stop using tobacco products?

* 9. What is the one most important reason you want to quit using tobacco? (Select Only One)

* 10. How would you rate your motivation today to stop using tobacco?

* 11. How many cigarettes do you usually smoke per day?

* 12. In the past 7 days, I have seen someone using tobacco on campus.

* 13. How concerned are you about the health consequences of second-hand smoke on this campus?

* 14. If you used tobacco, would you be interested in help to quit?

* 15. How did you learn about this awareness program?

* 16. How much has your motivation to stop using tobacco changed as a result of the Truth Initiative Awareness program?

* 17. What is one thing that you have learned during this awareness program that will help you stop using tobacco?

* 18. What was the most useful part of the awareness program?

* 19. Place an "X" in the box that most closely represents your opinion.

  Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree
19a. The material was easy to understand.
19b. I increased my knowledge about quitting tobacco.
19c. I am more motivated to quit using tobacco.
19d. I learned new tools to quit using tobacco.
19e. I will use new ideas to quit using tobacco.
19f. Overall, the awareness program was helpful.