I Choose to Say No: Smoking Cessation Questionnaire

Demographics

Please fill out all sections of the form before moving forward.

Question Title

* 1. Address

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. What is your date of birth?

Date / Time

Date

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* 3. What is your age?

18 to 25

26 to 34

35 to 44

45 to 54

55 to 64

65 or older

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* 4. What is your ethnicity? (Please select all that apply.)

American Indian or Alaskan Native

Asian or Pacific Islander

Black or African American

Hispanic or Latino

White / Caucasian

Other (please specify)

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* 5. What is your gender?

Female

Male

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* 6. Which of the following best describes your current relationship status?

Married

Widowed

Divorced

Separated

In a domestic partnership or civil union

Single, but cohabiting with a significant other

Single, never married

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* 7. What is the highest level of education you have completed?

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* 8. Your total household income is between:

Less than to $10,000

$10,001 to $25,000

$25,001 to $50,000

$50,001 to $100,000

$100,001 to $200,000

$200,001 or over

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* 9. Do you participate in SNAP?

Yes

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* 10. Are you on Medicaid?

Yes

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20% of survey complete.