City of Baltimore's DHR's B'Nicotine Free Program - Cessation Class Registration Survey

Congratulations for taking this step towards your nicotine free journey! To register for one of or classes, please share your experience with nicotine and tobacco use. This survey should only take about 4 minutes. We are providing FREE WELLNESS T-SHIRTS or JACKETS on the first day of class to show our appreciation for your candid responses.

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* 1. First Name

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* 2. Last Name

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* 3. Agency or Department of Employment

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* 4. Which class are you most interested in? All classes are to be held around lunch time. You will receive more info and exact times after you register.

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* 5. Best Email

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* 6. Alternative Email

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* 7. Best phone number to reach you.

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* 8. Alternative Phone Number

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* 9. T-Shirt Size?

2XL

3XL

4XL

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* 10. How did you find out about our classes?

Direct contact with DHR Quit Coach

Email Blast

Flyer

Co-worker

Supervisor

At Wellness Table or Event

On DHR Website

Other (please specify)

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* 11. Which social media networks do you use?

Facebook

Twitter

Instagram

Snapchat

Tumblr

Other (please specify)

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* 12. What is your gender?

Male

Female

Other (please specify)

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* 13. What is your age?

18-24

25-34

35-44

45-54

55-64

65+

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

12 or younger

13-17

18-24

25-34

35-44

45-54

55-64

65+

I have never used nicotine or tobacco products.

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* 15. What is the highest level of school you have completed or the highest degree you have received?

Less than high school degree

High school degree or equivalent (e.g., GED)

Some college but no degree

Associate degree

Bachelor degree

Graduate degree

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* 16. Have you ever served in any branch of the United States military?

Yes, I have

No, I have not

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

Yes, every day.

Yes, on most days

Yes, on some days

Yes, but only every now and then.

No, not at all.

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

Yes

Does not apply. I am not a tobacco or nicotine user.

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* 19. Do you want to make a serious quit attempt in the next 30 days or sooner?

Yes

No, I just want to reduce or control my use.

Unsure

Does not apply. I am not a tobacco or nicotine user.

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

Yes

Does not apply. I am not a tobacco or nicotine user.

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

Yes

Does not apply. I am not a tobacco or nicotine user.

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* 22. Do you live with people who use any nicotine or tobacco products?

Yes

Unsure

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* 23. Do you have friends or family members who use any nicotine or tobacco products?

Yes

Unsure

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* 24. Will you be able to stay for the full class and attend each session?

Yes

Unsure

Other (please specify)

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* 25. 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.

Yes