1. Employee Health and Smoking Screener (Fire Fighter Version)

This page contains 33 questions. To record your answers, you must click "Submit" button at end of page 2.

This survey was developed to determine information on smoking status and is voluntary. Do not write your name on this survey. The information you provide will be collected and analyzed by a third party that will not be able to determine your individual identity. Your privacy is completely protected. The results will be reported for the entire PA Fire Fighters Association in total; no individual results will be reported. You are providing your permission for third party analysis by completing this form. The data will be used to support further health education to Fire Fighters.

* 1. Year of Birth: (type 4 digits - e.g., 1960)

* 2. Gender:

* 3. In which local are you a Fire Fighter? (type number of local)

* 4. Are you currently a smoker?

* 5. Have you smoked in the last 2 months?

* 6. If you have ever smoked, how many years have you smoked altogether? (if never, type 0)

* 7. Does anyone in your household smoke cigarettes, cigars, or pipes?

* 8. Do you currently use chewing tobacco, snuff, or snus (a Swedish word used to describe a moist, smokeless tobacco that is placed under the lip and against the gum)?

If you answered YES to question 4 or 5, please continue with question 9, and complete survey.

If you answered NO to questions 4 and 5, please SKIP to question 32.

* 9. On average, how many cigarettes do you smoke each day?

* 10. On average, how much do you pay for a pack of cigarettes?

* 11. In the PAST 12 MONTHS, how many times have you tried to quit smoking for at least one day (24 hours)? (fill in ONLY one)

* 12. Are you planning on quitting smoking over the next 6 months?

* 13. How much do you want to quit smoking? (fill in ONLY one) (1 = Don't want to quit; 10 = Very much want to quit)

* 14. Have you and your physician discussed quitting smoking in the past 12 months?

* 15. Have you and your physician discussed treatment options for quitting smoking in the past 12 months?

* 16. On average, how many minutes do you spend smoking at work each day?

Fagerstrom Test for Tobacco Use (1)

* 17. How soon after you wake up do you smoke your first cigarette?

* 18. Do you find it difficult to refrain from smoking in places where it is forbidden e.g. in church, at the library, in cinema, etc.?

* 19. Which cigarette would you hate most to give up?

* 20. How many cigarettes/day do you smoke?

* 21. Do you smoke more frequently during the first hours after waking than during the rest of the day?

* 22. Do you smoke if you are so ill that you are in bed most of the day?

Readiness Questionnaire (2)
For questions 23 to 30, choose the response that best describes how important each numbered statement is to you. If a statement does not apply to you, please choose "Not at all important to me".

* 23. Quitting might make me irritable.

* 24. I might be stressed if I quit.

* 25. Quitting might make it hard to be around other smokers.

* 26. I would have to deal with cravings if I quit.

* 27. If I quit, I would reduce my chances of developing chronic diseases such as cancer and heart disease.

* 28. I would set a good example for others if I quit.

* 29. My clothes, car and home would smell better if I quit.

* 30. I won't be exposing other people to secondhand smoke.

* 31. Quitting would save money.

* 32. Does your employer offer smoking cessation as part of your insurance benefit?

* 33. Does your employer or workplace have a smoking policy?

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