Employee Status
Full-time
Part-time
Temporary
Casual Appointment
Employment Classification
Administration
Faculty
Staff
Age
18-25
26-30
31-35
36-40
41-45
46-50
51 or older
Gender
Female
Male
Transgender
I prefer not to respond
Ethnicity
Hispanic/Latino
Non-Hispanic/Latino
I prefer not to respond
Racial/Ethnic Background
American Indian or Alaskan Native
Asian
Hawaiian or Pacific Islander
White
Black or African American
Bi-racial or Multi-racial
I prefer not to respond
Campus
Main Campus
Satellite Campus
If you are employed by a satellite, Please specify
Relationship Status
Single
Married/Have partner
Long-term relationship
Divorced or Separated
Widowed
Which of the following tobacco products have you used in the past year?
Do not use Tobacco products
Cigarettes
Cigars
Smokeless Tobacco (chewing, spit, dip)
Tobacco pipes
Hookah
E-cigarettes
Other
If other, Please specify
How often do you smoke hookah?
A few times a year
1-3 times a month
1-2 times a week
3-6 times a week
Everyday
Not Applicable
In which settings/occasions do you smoke hookah?
Where I live
At a hookah bar
At a friend's house
At a party
Other
Not Applicable
If other, Please specify
How often do you use e-cigarettes?
A few times a year
1-3 times a month
1-2 times a week
3-6 times a week
Everyday
Not Applicable
How often do you use smokeless tobacco?
A few times a year
1-3 times a month
1-2 times a week
3-6 times a week
Everyday
Not Applicable
In which settings/occasions do you use smokeless tobacco?
Where I live
When I am bored
In class
Playing Sports
After Meals
At a party
Whenever I can't smoke a cigarette
Not Applicable
How often do you smoke cigarettes?
A few times a year
1-3 times a month
1-2 times a week
3-6 times a week
Everyday
Not Applicable
Did you smoke before you were employed by Lincoln University?
Yes
No
Have you attempted to quit smoking?
Yes
No
Not Applicable
Do you want to quit smoking?
Yes
No
Not Applicable
Did you know that smoking cessation tools (gum, patches, etc) are available to you free of charge? Visit http://www.lincolnu.edu/web/thompkins-health-center/tobacco-free-lu for more information.
Yes
No
Do you know that Lincoln University has a Tobacco Free Policy that will go into effect on January 1, 2013?
Yes
No
Additional Comments
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