Forms • Wichita Falls • CivicEngage

TPCC Survey

Leave This Blank:

Name: (Enter in last 2 letters of first name, last 2 letters of last name and day of the month on which you were born. ) Example Mary Smith 11/18/1990 ryth18 is the code you will enter*
1. Have you used any form of tobacco such as cigarettes, dip or snuff, or vapor or e-cigarettes in the past 30 days?
2. In the past 30 days, about how many days did you smoke cigarettes?
3. On the days you smoke, about how many cigarettes do you smoke?
4. In the past 30 days, about how many days did you dip or use snuff?
5. On the days you dip, about how many cans per day do you use?
6. Have you used any of the following in the past 30 day?
Vapor cigarettes
Tobacco other than cigarettes, dip, e-cigarettes such as cigars, pipe or other forms
Nicotine patch
Prescription medicine for smoking cessation such as Chantix.
7. If you have continued to use any tobacco products , what do you think was the main reason that you did not quit smoking?
8. Did you have someone who you identified as a friend or buddy or to help support you in your effort to quit using tobacco?
9. Was the friend or buddy . . .
10. Was the friend or buddy . . . ?

* indicates required fields.