HII: Freedom from Smoking - Registration and Pre-Survey (2025)

Freedom From Smoking Cessation Program - Registration and Pre-Survey
This registration form and pre-survey will be reviewed by a wellness coach, who will reach out with you to determine a plan to work through Freedom From Smoking together. This is not a group program.
Work Location*
Job Type*
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Email*
example@example.com
How long have you been using tobacco/nicotine?

Less than 1 year1-7 years8-15 years16-22 yearsOver 22 years
How many times per day do you use tobacco/nicotine?

A few times per week1-3 times per day4-10 times per day11-20 times per dayOver 20 times per day
What tobacco/nicotine products are you currently using?

CigarettesChewing TobaccoPouchesCigarsE-CigarettesOther
How many times have you tried to quit?

None - this is my first attempt1-34-67-10More than 10 times

On a scale of 1-5, how ready are you to stop using tobacco/nicotine? (1 being "Not ready at all" to 5 being "Very ready to quit right now"

	1	2	3	4	5

1 is Not ready at all, 5 is Very ready to quit right now

Which statement best describes your current tobacco/nicotine use?

I'm not thinking about quittingI'm thinking about quitting someday, but not right nowI want to quit within the next month or twoI'm ready to quit nowI have quit using tobacco and I want to know more about maintaining that

On a scale of 1 to 10, how confident are you that you can quit using tobacco/nicotine? (1 being "not confident" to 10 being "extremely confident"

	1	2	3	4	5	6	7	8	9	10

1 is Not Confident, 10 is Extremely Confident

On a scale of 1 to 10, how important is it to you to quit? 1 being "not important" and 10 being "extremely important"

	1	2	3	4	5	6	7	8	9	10

1 is Not Important, 10 is Extremely Important

To what extend to you "agree" or "disagree" with the follwing statements?*

	Strongly Disgree	Disagree	Neutral	Agree	Strongly Agree
I am confident I can resist the urge to smoke even if family and friends continue to smoke
I am confident that I can resist the urge to smoke even if I feel tense or stressed
I am confident that I can resist the urge to smoke even if I am having a strong craving
I have a detailed plan of how to arrange my daily routines to manage my triggers

How did you hear about this program? Select all that apply.*

BeWell Bulletin monthly newsletterDepartment meetingDigital monitorsEmailEventmy.HII.com/HIIbenefits.comMy leadermyquadmed.com/bewellMobile app (Ingalls Connect, HII TechKnow, NNS to Go)Nutrition Bytes monthly newsletterPostal mailPosterQuadMed provider/coachWellness OnlineWord of mouthOther
BeWell for Life wellness services are available to all HII employees, regardless of medical coverage. Some services may be limited to the HII Family Health Center or online.
Should be Empty:

Freedom From Smoking Cessation Program - Registration and Pre-Survey