Information Survey

SECTION A -- You

Please answer the following:

1. What is your name?
   
   
   
   
2. What is your e-mail address?
3. What is your age group? 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50 and over No response
4. What is your occupation? Professional Student Homemaker No Response
   

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SECTION B -- Opinion of smoking

Please answer the following:

1. Do you smoke?
   
   Yes No
   
2. Is there a smoker in your family or household?
   
   Yes No
   
   
3. What do you think of smoking?
   
   Disgusting
   Unacceptable
   No opinion
   Acceptable
   Fine
   
4. Have you ever seen an underage teen buy cigarettes?
   
   Yes No
   
5. If yes to the last question, did you confront the person that sold the cigarettes to the teen?
   
   Yes No
   
6. Do you believe the Tobacco Companies when they say that nicotine is not addictive? No Yes
7. Please enter any other comments you have about smoking here:

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SECTION C -- About our page

Please answer the following:

1. How would you rate the appearance of this page?
   
   Bad Poor Fair Good Excellent  

2. How would you rate the content of this page?
   
   Interesting Fairly Interesting Sorta Interesting No Opinion Disinteresting Not Interesting
3. How would you overall rate this page (one being the best and six being the worst) - 1 2 3 4 5 6
4. Would you consider bringing someone that smokes here to inform them of the dangers and methods to quit? Definitely YES Sorry, I dont think so I'll think about it
5. Please enter any additional comments regarding our page:
   
   

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FORM SUBMISSION

Thank you for filling out this survey. Press Submit form to send it our way, and press clear form to redo the survey.

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