Supporting Implementation of Smoking Cessation Programs in Public Housing Primary Care Settings LC - Registration Survey

Learning Collaborative Pre-Evaluation Questions

This survey is created to help us design the content of this activity. We will take your answers into consideration to ensure we address all of your T/TA needs and concerns.

*1.Which best describes your type of organization?(Required.)

Health Center

Non-profit organization (non-health center)

Local or state health department

Government agency

Primary Care Association

NTTAP (National Health Center Training and Technical Assistance Partner)

Other

2.Participant's contact information:

Name

Organization

E-mail

3.What percentage of your patient population are smokers?

4.Please describe the challenges you face in implementing smoking cessation programs?

5.What are the most effective strategies you use to promote smoking cessation?

6.What are the top two things you would like to get out of this Learning Collaborative?

*7.Per HRSA requirements, all participants must obtain supervisor permission prior to enrolling in an NTTAP learning collaborative. Please note your supervisor's email address, and NCHPH will obtain written permission for your participation.(Required.)

Name

Organization

Email Address

Phone Number

8.How did you hear about us?

NCHPH website or digest

BPHC digest

Health Center Clearinghouse

Social media ( i.e. Facebook, Twitter, LinkedIn)

Word of mouth

Other

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