Date:

Name:
School (if any):
Address:
*Phone number: Cell Phone:
E-mail:

1. How old are you?

2. Where did you attend the quit group?

3. Before attending the SPORT cessation group, what type/s of tobacco did you use? (Please check all that apply)

Cigarettes
Chewing Tobacco/Snuff
Cigars
Tobacco Pipe
Clove Cigarettes
Flavored Cigarettes
Bidis
None
Other - What kind of product?

4. What was your reason(s) for attending the SPORT Cessation group?
(Please check all that apply)

To quit smoking
To quit chewing
To cut down on my smoking
To cut down on my chewing
I already quit but I wanted to learn how to stay tobacco free
To learn how to help my friends quit using tobacco
To learn how to help my family quit using tobacco
Other reason -

5. Before attending the SPORT Cessation group, how much tobacco did you use each day? (Enter the amount next to each type of tobacco you used - number of cigarettes each day or number of pinches of chew each day)

Cigarettes
Chewing Tobacco/Snuff
Cigars
Tobacco Pipe
Clove Cigarettes
Flavored Cigarettes
Bidis
Other - What product?

6. Upon completion of the SPORT Cessation Group, did you accomplish the goal you set for yourself (the reason you attended the group)?

Yes
No
Partly - What didn't you meet?

7. Have you been able to maintain your goal?
Yes
No
Partly

8. Currently, how much tobacco do you use each day? (Enter the amount next to each type of tobacco you used - number of cigarettes each day or number of pinches of chew each day)

Cigarettes
Chewing Tobacco/Snuff
Cigars
Tobacco Pipe
Clove Cigarettes
Flavored Cigarettes
Bidis
Other - What product?

9. Are you interested in attending the program again?
Yes
No

10. Did you help others to quit using tobacco products while or after attending the SPORT Cessation Group?
Yes - Who?
No

11. After the SPORT Cessation Group, are you now able to deal with stress better?
Yes
No

12. After the SPORT Cessation Group, do you have more confidence in yourself?
Yes
No

13. After the SPORT Cessation Group, do you feel that you have more support?
Yes
No

What helped you the most in group?