10-10136 Tobacco and Smoking Cessation Survey

OMB Number 2900-0770

Estimated Burden: 2 mins

EXP Date: XX/XX/2014

Tobacco and Nicotine Use Survey

OMB No. 2900-0770

Estimated burden: 2 minutes

Expiration Date xx/xx/xxxx

The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this survey will average two (2) minutes. This includes the time it will take to follow instructions, gather the necessary facts and respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this telephone/mail survey will lead to improvements in the quality of service delivery by helping to achieve services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

VA Form 10-10128

TOBACCO/NICOTINE USE SURVEY (please circle your answers)
DATE:
1. Would you be interested in answering questions regarding tobacco/nicotine use?	YES	NO
2. Do you use tobacco/nicotine products?	YES	NO	If "YES", please complete #3-8. If "NO", you are finished.
	STRONGLY DISAGREE	DISAGREE	UNSURE UNDECIDED	AGREE	STRONGLY AGREE
3. I think my use of tobacco is causing harm.	1	2	3	4	5
4. I want to change my use of tobacco/nicotine products.	1	2	3	4	5
5. I think it will be difficult to change my use of tobacco/nicotine products.	1	2	3	4	5
6. I am confident I can change my use of tobacco/nicotine products.	1	2	3	4	5
7. How much of the following products do you use?
Cigarettes (packs)		per	Day Week Month (circle one)
Cigar (small)		per	Day Week Month (circle one)
Cigar (large)		per	Day Week Month (circle one)
Pipefuls of tobacco		per	Day Week Month (circle one)
Chew (plug/wad/chews)		per	Day Week Month (circle one)
Snuff (pinch/dips/rubs)		per	Day Week Month (circle one)
E cigarette (puffs)		per	Day Week Month (circle one)
8. If you're thinking about quitting or cutting back, would you like more information?	YES	NO