NCDHD Community Needs Assessment Questions
The North Central District Health Department invites you to participate in our survey to help identify gaps in tobacco prevention and cessation services within our administrative district. You have been chosen to participate as a key representative of the community. Your responses are voluntary and will remain confidential. The information you provide will be used solely to highlight areas in the community that require the most improvement. Thank you for your contribution. 
Sign in to Google to save your progress. Learn more
Which town do you live in? *
Required
What population would you consider yourself to be in? *
Required
Do you currently use tobacco products? *
If yes, which tobacco products do you use? (Check all that apply) 
Clear selection
If no, have you ever used tobacco products?
Clear selection
Have you tried to quit tobacco in the past? *
If yes, what challenges did you face in quitting? (Check all that apply)
Do you believe there are sufficient resources in your community to help people quit tobacco? *
Are you exposed to secondhand smoke or vapor in your daily life? *
How concerned are you about the impact of secondhand smoke on your health or the health of others? *
What types of support do you think would be most effective for tobacco cessation in your community? (Check all that apply) *
Required
What barriers might prevent someone from participating in a tobacco cessation program? (Check all that apply)  *
Required
What days and times are most convenient for attending a tobacco cessation program? (Check all that apply)   *
Required
Would you support a smoke-free policy in public spaces in your community? *
What additional resources would you like to see in your community to promote tobacco-free living? *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms