1. What is the code number for your quit kit (look in the CD jewel case to find this). We cannot process the evaluation without this code number.

2. How did you hear about the Maryland TRASH Quit Kit?

3. Did you request the Quit Kit or was it given to you?
Self request
Given to me

4. What is your age?
13
14
15
16
17
18
Other (Please specify)

5. How long have you been using tobacco?
-Please Select One- 1 - 6 months 7 - 11 months 1 year 2 years 3 years 4 years 5 or more years

6. What made you decide to quit?

7. Have you tried to quit before?
Yes (if yes, go to next question)
No (if no, skip to question 10)

8. If you have ever tried to quit before, how many times have you attempted to quit in the past?
-Please Select One- 1 2 3 4 5 or more

9. How did you attempt to quit before?
Cold turkey
Patch or gum
Group classes
Cessation websites
Other (Please specify)

10. Overall, how helpful was the kit to you?
-Please Select One- Very helpful Somewhat helpful Helpful Not really helpful Not helpful at all

11. How helpful was the information in the booklet? Please rate each section.
Level 1: Pre-Quit
-Please Select One- Very helpful Somewhat helpful Helpful Not really helpful Not helpful at all

Level 2: Building UR Support Base
-Please Select One- Very helpful Somewhat helpful Helpful Not really helpful Not helpful at all

Level 3: Testing the Waters
-Please Select One- Very helpful Somewhat helpful Helpful Not really helpful Not helpful at all

Level 4: Week 1
-Please Select One- Very helpful Somewhat helpful Helpful Not really helpful Not helpful at all

Level 5: 2 weeks
-Please Select One- Very helpful Somewhat helpful Helpful Not really helpful Not helpful at all

Additional comments/suggestions for the booklet

12. Please rate the content found on the CD (1 – 5, with 1 being your favorite)
Meet Matt (video)
-Please Select One- 1 2 3 4 5

Music
-Please Select One- 1 2 3 4 5

Cessation Tips (Beat the Cravings and Dealing with Withdrawal)
-Please Select One- 1 2 3 4 5

Extra journal pages/calendar
-Please Select One- 1 2 3 4 5

Website links
-Please Select One- 1 2 3 4 5

Additional comments/suggestions for the CD content

13. Please rate the items included in the kit (1 – 5, with 1 being your favorite)
Stress toy
-Please Select One- 1 2 3 4 5

Bendy stick
-Please Select One- 1 2 3 4 5

Gum
-Please Select One- 1 2 3 4 5

Lollipops
-Please Select One- 1 2 3 4 5

Coin holders
-Please Select One- 1 2 3 4 5

Pen
-Please Select One- 1 2 3 4 5

Additional comments/suggestions for kit items

14. Would you recommend the Quit Kit to your friends?
Yes
No

Additional comments

That’s it! It wasn’t so bad, right? Easy for you, invaluable for us.
In order to send you your free gift as our thanks for filling out the evaluation, please provide your name and address here. If you’re ok with us contacting you via e-mail, please provide that too.*

First Name

Last Name

Street Address 1

Street Address 2

City

Maryland County*
Quit Kit is for Maryland teens only
- Select Your County - Allegany Anne Arundel Baltimore County Baltimore City Calvert Caroline Carroll Cecil Charles Dorchester Frederick Garrett Harford Howard Kent Montgomery Prince George's Queen Anne's Somerset St. Mary's Talbot Washington Wicomico Worchester

Zip Code

E-mail

* Please note, by filling out your name, address and email address, you are consenting that it is ok to contact you. We will not sell your information or give it out to anyone outside of Maryland TRASH.