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Cessation Support Survey

  1. (if applicable; e.g. Freedom From Smoking)

  2. Description of Services

  3. How frequently do you offer tobacco cessation services?

    Check all that apply.

  4. Which of the following services does you agency/organization offer?

    Check all that apply.

  5. In what language(s) are cessation services provided?

    Check all that apply.

  6. Which of the following self-help materials does you agency/organization offer?

    Check all that apply.

  7. Delivery of Products and Services

  8. When are services provided?

    Check all that apply.

  9. How do people register for your cessation services?

    Check all that apply.

  10. For each client, what is the average duration of an entire program?

  11. Record duration in numbers of sessions per period of time, e.g., 1 session per week for 6 weeks.

  12. What age groups do your services target?

    Check all that apply.

  13. Do you charge a fee for your cessation program?

  14. Do you offer a sliding scale?

  15. Would you like your services listed in a Jefferson County Cessation Resource List?

  16. Would you like this information forwarded to the Washington State Tobacco Quitline to be offered to callers from Jefferson County?

  17. Thank you for your help in creating a safer and healthier Jefferson County.

  18. Leave This Blank:

  19. This field is not part of the form submission.