Survey - FFS Clinic - Post Clinic Survey - American Lung Association

Question - Required - eventID:

Question - Required - Facilitator's Name:

Question - Required - Facilitator's Email Address:

Question - Required - Clinic Location (State):

Question - Required - Clinic Location (City):

Question - Required - Clinic Start Date:

Month

Day

Year

Question - Required - Clinic End Date:

Month

Day

Year

Question - Required - Number of total clinic participants:

Question - Required - Number of participants who completed the clinic:

Question - Required - Number of participants who did not complete the clinic:

For the next two questions, enter "Don't Know" if the number is unknown.

Question - Required - Number of participants that 100% quit smoking or using any form of tobacco at the end of clinic:

Question - Required - Number of participants that still used tobacco, but reduced tobacco use after end of clinic:

Participant Demographics - Gender

PLEASE NOTE: We recognize that these numbers may not equal the total number of participants. Please report as you are able.

Question - Not Required - Gender - Male (number of participants):

Question - Not Required - Gender - Female (number of participants):

Question - Not Required - Other Gender Identification (number of participants):

PLEASE NOTE: We recognize that these numbers may not equal the total number of participants. Please report as you are able.

Question - Not Required - White:

Question - Not Required - Hispanic or Latino:

Question - Not Required - Black or African American

Question - Not Required - Native American

Question - Not Required - Asian or Pacific Islander

PLEASE NOTE: We recognize that these numbers may not equal the total number of participants. Please report as you are able.

Question - Not Required - 18 - 24 years:

Question - Not Required - 25 - 34 years:

Question - Not Required - 35 - 44 years:

Question - Not Required - 45 - 54 years:

Question - Not Required - 55 - 64 years:

Question - Not Required - 65 - 74 years:

Question - Not Required - 75 years or older:

Question - Not Required - Please give us your post-clinic feedback: