Registration

We'd like to learn about you and your use of tobacco or nicotine. Your responses on this form will be kept confidential. This information will be used to help improve the program.

Personal Information

First name *

Last name *

What is your email address?

What is your date of birth? *

What is the best phone number to reach you?

Cell

Home

Work

Other

Address

What is an alternate number to reach you?

Cell

Home

Work

Other

City

State

Zip *

When is the best time to call you?

Morning: 8am-noon

Afternoon: Noon-5pm

Evening: 5pm-9pm

How did you hear about this program?

Tobacco treatment program staff

Healthcare or other service provider

Community organization or outreach event

Friend or family member

Flyer, brochure, or program website

Social media (Facebook, Instagram, etc.)

Other media (TV, radio, newspaper)

Referred from the Hawaii Tobacco Quitline

Previously enrolled in tobacco treatment program

Other

Don't know

What tobacco or nicotine products have you used in the last 30 days?

Cigarettes

Cigars, cigarillos, or little cigars

Pipes

Chewing tobacco, snuff, or dip

Vapes or e-cigarettes (this only includes products used to vape nicotine, not other substances like marijuana or THC)

Nicotine pouches (such as ZYN, On!, Velo)

Other

None

How soon after you wake up do you first use tobacco or nicotine products?

Within 5 minutes

6-30 minutes

31-60 minutes

More than 60 minutes

At what age did you start using any tobacco or nicotine products regularly?

Don't know / Not sure

How often are you around family members or friends who use tobacco or nicotine products?

All of the time

Often

Sometimes

Rarely

Never

Don't know / Not sure

Do you currently smoke cigarettes every day, some days, or not at all? Do not include vapes or e-cigarettes.

Every day

Some days

Not at all

Don't know / Not sure

How many cigarettes do you smoke in a day on the days you smoke?

Don't know / Not sure

Do you currently vape or use e-cigarettes every day, some days, or not at all?

Every day

Some days

Not at all

Don't know / Not sure

People vape or use e-cigarettes for a variety of reasons. Are you currently using them to quit tobacco products, such as cigarettes?

Yes

No

Don't know / Not sure

Not applicable, I don't vape or use e-cigarettes

Which of the following best describes your plans for tobacco use at this time? Do not include vapes or e-cigarettes.

I plan to quit in the next 30 days

I plan to cut back in the next 30 days

I do not plan to quit/cut back in the next 30 days

I have already quit or I did not use tobacco in the last 30 days

Don't know / Not sure

On a scale of 1 to 10, where 1 is not confident and 10 is very confident, how confident are you that you can quit tobacco this time? Do not include vapes or e-cigarettes.

Not Confident

Somewhat Confident

Very Confident

Which of the following best describes your plans for vaping or other nicotine products at this time?

I plan to quit in the next 30 days

I plan to cut back in the next 30 days

I do not plan to quit/cut back in the next 30 days

I have already quit or I did not use vapes or other nicotine products in the last 30 days

Don't know / Not sure

On a scale of 1 to 10, where 1 is not confident and 10 is very confident, how confident are you that you can quit vaping or other nicotine products this time?

Not Confident

Somewhat Confident

Very Confident

What is the highest level of education you have completed?

Some high school or less, no degree

GED

High school degree

Some college or some technical / trade school

Technical / Trade school degree

College or university degree

Don't know / Not sure

Are you currently...?

Employed for pay or self-employed

A stay-at-home parent

A student

Retired

Out of work

Unable to work

Don't know / Not sure

Which of the following best describes your total household income last year?

Less than $15,000

$15,000 to less than $25,000

$25,000 to less than $35,000

$35,000 to less than $50,000

$50,000 to less than $75,000

$75,000 or more

Don't know / Not sure

Including yourself, how many people are supported by this income?

Don't know / Not sure

What best describes your race?

American Indian or Alaska Native

Asian

Black or African American

Hispanic, Latino, or of Spanish origin

Native Hawaiian / Pacific Islander

White

Race not listed

Don't know / Not sure

If you identify as Asian, which specific Asian ethnicity or race do you identify with the most?

Asian Indian

Cambodian

Chinese

Filipino

Hmong

Indonesian

Japanese

Korean

Laotian

Pakistani

Taiwanese

Thai

Vietnamese

Other Asian

Don't know / Not sure

If you identify as Native Hawaiian / Pacific Islander, which specific Native Hawaiian / Pacific Islander ethnicity or race do you identify with the most?

Native Hawaiian

Chamorro / CHamoru

Chuukese

Fijian

Kosraean

Maori

Marshallese

Palauan

Pohnpeian

Samoan

Tahitian

Tongan

Yapese

Other Micronesian

Other Pacific Islander

Don't know / Not sure

Do you have any kind of health care coverage?

Yes

No

Don't know / Not sure

Which of the following best describes your health insurance?

Medicaid

Medicare

Military insurance / Tricare

Private health insurance (this includes employer, group, or individual plans)

Don't know / Not sure

Are you homeless/houseless or at-risk of homelessness? (living outside, in a public space, emergency shelter, transitional housing program, or at-risk of losing current housing)

Yes

No

Don't know / Not sure

Do you have any behavioral health conditions?

Attention Deficit Hyperactivity Disorder (ADHD)

Bi-Polar Disorder

Depression

Drug or Alcohol Use Disorder (SUD)

Generalized Anxiety Disorder

Post-Traumatic Stress Disorder (PTSD)

Schizophrenia or Schizoaffective Disorder

Other

None

Don't know / Not sure

What term best describes your sexual orientation?

Bisexual

Gay or Lesbian

Straight / Heterosexual

Questioning or unsure

Another sexual orientation not listed

What is your gender identity?

Female

Male

Transgender female (MTF)

Transgender male (FTM)

Do not identify as female, male, or transgender

Questioning or unsure

Another gender identity not listed

What sex were you assigned at birth?

Female

Male

Do any of these describe you?

I'm currently pregnant

I'm planning to get pregnant within the next 3 months

I'm currently breastfeeding

I've given birth within the last 6 months

None of the above

Don't know / Not sure

Getting feedback about this program is important to us and the people who fund our program. It lets us know what we are doing well and what we can improve. May someone contact you at a later date to ask about your satisfaction with the program and your progress towards quitting?

Yes

No

Registration

Hawai'i Island Community Health Center's E Hanu Tobacco Cessation Program

Personal Information