To receive your free Practice Quit Kit, please answer a few brief questions to help us understand how to best serve our employees. All answers are completely confidential. The survey should only take about 4 minutes. Thank you. 

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* 1. First Name

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* 2. Last Name

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* 3. City Agency Name

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* 4. Is this Practice Quit Kit for you?

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* 5. Do you want to pick up the Practice Quit Kit at 7 E. Redwood St 20th Street?

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* 6. If you want us to drop off your Practice Quit Kit, what office address should we deliver it to?

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* 7. What is the best time to pick it up or have it delivered? We will call or email you to set up the actual date and time.

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* 8. What is your best email address?

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* 9. What is the best phone number to reach you?

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* 10. How did you find out about the Practice Quit Kits?

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* 11. What is your gender?

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* 12. What is your age?

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* 13. What age did you first start using nicotine or tobacco products?

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* 14. Are you currently using nicotine or tobacco products?

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* 15. If you are currently using nicotine or tobacco products, how many times a day do you use or smoke?

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* 16. Have you made a serious quit attempt in the last 12 months?

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* 17. Do you want to make a serious quit attempt in the next 90 days or sooner?

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* 18. Have you ever tried medication, nicotine patches, gum, lozenges, quit classes, counseling, or internet programs to try to quit tobacco or nicotine?

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* 19. Have you ever sought help from a medical professional, or tobacco cessation organization to quit tobacco or nicotine?

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* 20. Is it ok if we email you or call with information about raffles, prizes, events, news and our programs? You can unsubscribe at any time.

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