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Please tell us when you were born.*
Please tell us how we can best assist you.*
You want help - information about quittingYou want help - information about staying quitYou want general information or materials about the NDQuits program
Please tell us how you found NDQuits.*
Billboard / bus benchDentistDoctor / Nurse / Other healthcare providerFlyer/brochureInsurance Internet / WebsiteNewspaperMedicaidPharmacistPostcard / Direct MailingRadioRelative / Family / FriendsTelevisionWomen’s Way programOtherUnknown
Please tell us where you are at in the quit process.
No immediate interest in quittingWant to quit in the next 30 daysAbout to quit in the next weekQuit in the last monthQuit in the last 6 monthsQuit over 1+ year ago
What types of tobacco have you used in the past 30 days?*
NoneCigarettesSmokeless tobacco, chew tobacco, snuff, or dipCigars, Cigarillos, or Small CigarsPipesOther tobacco productsMultiplee-Cigarettes
After you participate in this program, someone may contact you by email or phone to ask you a few questions about our services. We use this information to improve our program. Your participation in the evaluation is voluntary.
On a scale of 1 to 10, with 1 being not at all confident and 10 being highly confident, how confident are you that you can quit using tobacco?*
Several communities have been targeted by the tobacco industry or have higher smoking rates. We have some specific materials for people in these communities. So we'd like to ask you some demographic questions. Please remember that your answers are completely confidential.
What is the highest level of education that you have completed?
Less than grade 9Grades 9 to 11, no diplomaGEDHigh school diplomaSome college or university (includes technical or trade school) College or university degree (includes AA, BA, Masters, PhD)No CollegeDon't know
Are you Hispanic or Latino/Latina?*
Yes NoDon't KnowRefused
Which of these groups would you say best describes you?*
WhiteBlack or African AmericanAsianNative Hawaiian or Pacific IslanderAmerican Indian or Alaska NativeOther
What is your marital status?*
MarriedDivorcedWidowedSingleDo not wish to answer
Do you consider yourself to be:
Heterosexual Gay or LesbianBisexualTransgenderOtherRefused
Would you say that in general your health is excellent, very good, good, fair, or poor?
ExcellentVery GoodGoodFairPoorDon't know/unsure
Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?
Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
NDQuits offers a free text messaging program to supplement your coaching calls. Through this program, you will receive motivational messages, appointment reminders, and other messages while enrolled in the coaching program. Standard text messaging rates will apply. Are you interested in signing up for the text messaging program?
Please tell us which program you are interested in.*
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