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Information
Survey It also asks a few questions about your equipment, so that we can know how to better design our web site for faster, more entertaining, and easier browsing in the future. If you do not know this information, just ignore it. You need not fill in all (or any) of the information asked, as there are no required entries. But the more you offer, the better we may understand and help those of you who want and need to quit smoking.
This survey is divided into the following sections:
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Section A: Your history with tobacco
Section B: For cigarette smokers only
Section C: About your system
Section D: About the Survey
Form Submission
Please fill out the information in each section as requested. Then, at the end of the form, please supply your name and contact information, and submit the form. You will receive a confirmation message from us shortly and, if you have chosen so, be subscribed to the "Quit Smoking Now" newsletter. All information offered here is kept confidential, and will not be sold, given, nor transferred to any other company or agency without your expressed written permission. |
SECTION A -- Your History With Tobacco
Please fill in the answers to these questions as accurately as you can.
| Are you male or female? | Male Female |
| What form of tobacco did you start with? | |
| At what age did you start using tobacco? | |
| What is your current age category? | Under 18 18-25 26-50 51 + |
| What form of tobacco do you use now? (If you've quit, what was the last form?) | |
| How much do you (or did you) use per day? | |
| Were you breast-fed at infancy? | Yes No Don't know |
| Have you any tobacco related health problems? | Yes No Don't know |
| If so, what problem(s)? |
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Form Submission
SECTION B -- For cigarette smokers only
The questions in this section deal only with cigarettes.
If you do not now or never have smoked cigarettes, please click here for next section.
| What brand did you start with? | |
| What brand do you smoke now? (If you've quit, what was your last brand?) | |
| If you've successfully quit, how did you do it? | |
| Who was the biggest influence to start you smoking? | |
| Have you tried to quit? | If so, how many times? |
| If so, what is the longest you've gone without smoking? | |
| What got you to start back? | |
| How long have you smoked all together? | years |
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Form Submission
SECTION C -- About your System
These questions are asked so that, as we see the average capability of
the systems that are viewing our site grow, we may upgrade the "bells and
whistles" (i.e., Java, Shockwave, etc.) without putting anything on the site that the
average browser/system may not be able to see, or that loads too slowly, due to speed or
browser version of the average viewer. Of course, if you do not know the answer to a
question, simply ignore it.
| What type of system do you use? | Mac IBM |
| What brand? | |
| What version? | 486 Pentium Pentium II Pentium III |
| What mghtz? | 66-100120-166 200-500More |
| What OS? | Win 3.1 Win 95 Win98
Win2K OS2Other |
| How much RAM? (Choose closest) | 8 megs. or less 16 megs. 32 megs.64 or more |
| Modem speed? | 28,8 33,656KCablemodem ISDN T1 |
| Hard disk capacity? | 99 megs. or less 100-500501-1 gigMore |
| Browser & version you normally use? | |
| Size of monitor? | WebTV 14" 15" 20" other |
| Normal viewing resolution setting? | 640 X 480 800 X 600 1024 X 768 |
| Do you normally browse with your graphics display set to On or Off? | On Off Depends |
SECTION D -- About this Survey
| How would you rate this survey? | Excellent Good Fair Poor Terrible |
| Did you find this survey easy to take? | |
| Why or why not? |
Name Email (will not be shared with any 3rd party!) Do you have a web site? (URL )