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Hollandale PTSA Simmons High
Community-Based Needs Assessment
Tobacco Prevention Campaign
Sponsored by The Campaign for Tobacco-Free Kids
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Basic Demographic Questions- Age
25 - or less
26 - 39
40- 54
55 - 64
65 or over
I prefer not to answer
Option 7
Option 8
Clear selection
Sex
Male
Female
Other (please specify)
I prefer not to answer
Clear selection
What best describes your racial/ethnic background? Choose all that apply).
African-American/Black
Asian
Hispanic/Latino
Caucasian/White
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
I prefer not to answer
Community Tobacco Use and Behavior Assessment
How often do you currently use tobacco, e-cigarettes or other tobacco-related products?
Every day
Some days
Not at all
Clear selection
Have you ever observed students within our school community using tobacco, e-cigarettes or other tobacco-related products?
Yes
No
I don't know
Clear selection
How do you suspect students are accessing tobacco product?
Purchase from store
Stole from others
Bought from others
I don't know
Received from an adult
Peer provided
On the internet
Other
Clear selection
Have you ever observed parents or caregivers within our school community using tobacco, e-cigarettes or other tobacco-related products?
Yes
No
I don't know
Clear selection
Have you ever observed any of our school officials using tobacco, e-cigarettes or other tobacco-related products?
Yes
No
I don't know
Clear selection
What kind of tobacco is being used most frequently in our school community?
Pipe, hookah/narghile(Water pipe)
Chewed tobacco
Snuff
Cigar/cigarillo
Electronic cigarettes(eCigs)
Vape pipes
Cigarettes
Other (specify)
I don't know
Clear selection
How much do you think people harm themselves when they use tobacco products?
No harm
Little harm
Some harm
A lot of harm
Clear selection
How strongly do you agree with the statement "All tobacco products are dangerous"?
Strongly agree
Agree
Disagree
Strongly disagree
Clear selection
If you currently use tobacco, do you want to quit?
Yes
No
I don't use tobacco
Clear selection
What do you perceive as the most common barrier to tobacco cessation within our school community?
Stress management
Lack of support
Acceptability of smoking
I don't know
Clear selection
Based on your opinion, do students within our school district receive adequate education on tobacco prevention?
Yes
No
I don't know
Clear selection
Can you name at least one tobacco prevention within your school community?
Yes
No
I don't know
Clear selection
Have you ever helped promote tobacco prevention within your school community?
Yes
No
I don't know
Clear selection
Does your school district have a tobacco-free or smoke-free policy?
Yes
No
I don't know
Clear selection
What type of tobacco prevention programs would you like to see implemented within your school community?
Your answer
In your opinion what is the best way to provide tobacco prevention education to our community?
Social media platforms newsletter
In person/virtual education sessions
Activities within the classroom
Monthly "tobacco prevention"
Tobacco prevention handout
Other (please specify):
Clear selection
Would you be interested in joining your school's PTSA or becoming involved in programs that help prevent tobacco use?
Yes
No
I don't know
Clear selection
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