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Quitober questionnaire for smokers:
Actual registration for Quitober will be available in August 09.
Please tell us what you think of the
Quitober 09 (see more)
& if you and your employer would be interested in participating in 09.
Privacy statement
Your Name :
Email :
Company/Employer/Uni/College :
Post Code
:
Q1: Would you participate in Quitober 09?
Yes
No
Maybe
Q2. Approx. number of smokes per day? :
Select how smokes per day
5
10
15
20
25
30
35
40
45
50
55
60
Q3. Your Age? :
Select your age
15-25
26-35
36-45
46-55
56-65
66-75
76-85
over 86
Q4. Male or female? :
Male
Female
Q1. Would you get sponsored by a Group Sponsor
(eg. employer) or an Individual Sponsor (friend)?
Single
Group
Not Interested
Q6: How many times have you tried to Quit in 2008?:
Select number of times
1 time
2 times
3 times
4 times
5 times
6 times
7 times
8 times
9 times
10 times
more than 10
Q7: Is your partner a smoker?:
Yes
No
Don't have one
Q8: Would you be willing to pay $31 to become a member of Quitober 09?
($1 per day during October- Students $15.50 ie. 50c per day)
Yes
No
Maybe
Q9: Could you get your employer friends or family to sponsor you? Your sponsor pays for your membership if you succeed quitting for the month.
Yes
No
Maybe
Don't know
Q10:
How many of your work/Uni mates smoke
?:
Select number
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
more than 100
Q11:Do you think your work/Uni mates would
participate in Quitober?:
Yes
No
Maybe
Don't know
Q12: If you were going to Quit would you use NRT ie. nicotine patches and/or gum?
Yes
No
Don't know
Any further other comments & feedback:
(further comments)
Privacy statement
What some people think of the idea
Yahoo - Answers
Flying Solo Forum
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