Live Tobacco Free Online Participant Intake Form

Live Tobacco Free Online Program Participant Survey

Please note that a response is not automatically generated, please allow 48 hours for a response.

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* 1. Contact Information

First and Last Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Cell Phone Number

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* 2. How did you hear about Tarrant County Public Health's Tobacco Cessation Program?

Doctor/nurse or other healthcare professional

Friend or family member

Community center of faith-based organization

Nextdoor App

Online advertisement

Online search (ie. Google, Yahoo, etc)

Social media (ie. Facebook, Twitter, etc.)

Event attended

Work

Other (please specify)

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* 3. Why did you chose to participate in this program? (check all that apply)

Better manage my current health condition (ie. COPD, heart disease, etc.)

Prevent a chronic health condition

Save money by quitting

Save on health insurance premiums

Doctor/health care provider referred me

Friend/Family member wants me to participate

Employer referred me

Other (please specify)

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* 4. What is your gender?

Male

Female

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* 5. What is your date of birth?

Date

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* 6. How would you describe yourself? (check all that apply)

American Indian or Alaska Native

Asian or Asian-American

Black or African-American

Hawaiian Native or Pacific Islander

Hispanic or Latino

White or Caucasian

Other (please specify)

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* 7. What is your insurance coverage? (check all that apply)

None or Uninsured

Medicaid

Medicare

Private Insurance

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* 8. Which form of nicotine do you currently use? (Check all that apply)

Cigarettes

Cigars

Electronic nicotine delivery systems (ENDS, also known as vape or e-cigs)

Smokeless tobacco

Other (please specify)

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* 9. About how much do you currently use per day?

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* 10. Based on what you know or believe, does tobacco use cause chronic illness/disease?

Yes

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* 11. On a scale of 1 to 5, with 1 being not at all confident and 5 being extremely confident, how confident are you that you can quit tobacco now?

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* 12. How often do you allow smoking inside your home?

Daily

Weekly

Monthly

Less than monthly

Never

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* 13. How many people currently live in your home?

8 or more

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* 14. What is your current annual household income?

Less than $10,000

$10,000 - $19,999

$20,000 - $29,999

$30,000 - $39,999

$40,000 - $49,999

$50,000 - $59,999

$60,000 - $69,999

$70,000 - $79,999

$80,000 - $89,999

$90,000 - $99,999

$100,000 - $149,999

Over $150,000