Brief Pre-Screening Survey.
Please answer the questions below:
1. What is your current age?
2. Have you smoked at least 100 cigarettes (5 packs) in your lifetime?
3. When is the last time you smoked a cigarette, even a puff?
Within the last 30 days
More than 30 days ago
4. Have you been diagnosed with cervical dysplasia or cervical cancer in your lifetime?
5. Are you
in a smoking cessation program?
6. Do you
use nicotine gum, the nicotine patch, spray, inhaler, lozenges, Wellbutrin (Zyban) or varenicline (Chantix)?
7. What was your biological sex at birth?
8. Is another member of your household enrolled in this study?
9. Are you of Hispanic or Latino origin?
10. Which item(s) best describe your race?
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Other (please specify):
11. What is the highest level of education that you have completed? If currently enrolled, select highest degree received.
Grade school or less
Some high school, no diploma
High school diploma
GED or equivalent
Some college credit, no degree
Trade / Technical / Vocational training
College degree (Bachelor’s degree)
Some graduate education