The QuitPath program is designed to help those who want to quit smoking. Information gathered in this survey may be shared with researchers to unsure the quality of programs offered in the Yukon are meeting the needs of Yukoners. Your personal contact information is kept confidential and is required for participation in the QuitPath program; all other questions are optional.

Question Title

* Personal information:

Question Title

* You are:

Question Title

* Contact information:

Question Title

* Are you 18 or over?

Question Title

* As a participant of the Quitpath program you will be contacted at the 3 and 6 month mark. Participation in a short 5 minute survey is required during these calls. We would like to find out how you are doing and if there is anything else we can do to support you in your efforts in becoming smoke free. During this time we would also appreciate feedback on our program and the resources and support we provide.   

I will participate in 2 follow up calls?

Question Title

* When is the best time to reach you for the follow up calls?

Question Title

* Would you like to receive information via email on upcoming workshops and updates on the QuitPath program?

Question Title

* How did you learn about the QuitPath program? (please check all that apply).

Question Title

* How old were you when you started smoking on a regular basis?

Question Title

* What year were you born? (please indicate with numbers ie 1940)

Question Title

* 1. Are you currently?

Question Title

* 2. Which of the following best describes you?

Question Title

* 3. Typically, how soon after waking up do you smoke your first cigarette (in minutes)?

Question Title

* 4. How many cigarettes per day do you typically smoke?

Question Title

* 6. Have you made a serious attempt to quit smoking before?

Question Title

* 7. How many times have you tried to quit smoking before?

Question Title

* 8. When was the last time you tried to quit smoking?

Question Title

* 10. What helped or is helping you stay smoke free?

Question Title

* 11. If you have tried to quit before what are the main reasons you started smoking again?

Question Title

* 12. What do you think will be the hardest thing about quitting for you now?

Question Title

* 13. Is there someone in your life who supports you on your journey to becoming smoke-free? (please check all that apply)

Question Title

* 14. Have you spoken with a health professional for help or information on becoming smoke-free? (please check all that apply)

Question Title

* 15. Are you currently using, or have you used in the past, any of the following medications to help you quit smoking?

  No Currently using In the past
Champix
Nicotine Gum
Nicotine Inhaler
Nicotine Lozenge
Nicotine Patch
Zyban
About you:
The Health Promotion Unit is committed to providing the best service possible to the residents of the Yukon. The following questions help us know who our programs are reaching. Assist us in identifying barriers to participation while allowing us to continually develop and alter our programs to serve you better.

Please remember that all questions are optional and choosing not to answer any, or all, of the following questions will in no way affect your ability to participate in programs offered by the Health Promotion unit.

Question Title

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

Question Title

* 17. Do you identify as an aboriginal person (e.g. First Nation, Metis, Inuit)

Question Title

* 18. Are you a member of a visual minority population other then aboriginal?

Question Title

* 19. Are you single married or common law?

Question Title

* 20. Do you have any dependents living with you?

How can we help?
The Health Promotion Unit offers a number of services to help smokers to quit smoking; how can we help you?

Question Title

* 21. Are you interested in any of the following smoking cessation options or resources?

  Yes Maybe No
Information on how to quit smoking
A group based Getting Started Session
One-on-one coaching in-person or over the phone
Free patches
A free quit smoking 'Quitpack'
Thank you for taking the time to share this information, now let's talk about next steps!

T