Live Tobacco Free Online Program Participant Survey

Please note that a response is not automatically generated, please allow 48 hours for an access code to be emailed to you.

Contact Information

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* 1. Contact Information

How did you hear about the Live Tobacco Free Program?

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* 2. How did you hear about the Live Tobacco Free Program?

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

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

What is your gender?

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* 4. What is your gender?

What is your date of birth?

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* 5. What is your date of birth?

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

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

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

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

Have received any of the following adult immunizations within the past 12 months? (check all that apply)

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* 8. Have received any of the following adult immunizations within the past 12 months? (check all that apply)

Which of the following best describes your current income?

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* 9. Which of the following best describes your current income?

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

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

About how much do you currently use per day?

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

Would you say in general your health is:

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* 12. Would you say in general your health is:

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