Project ACCESS
Brief Pre-Screening Survey.
Please answer the questions below:
FullName
*
1. What is your current age?
2. Have you smoked at least 100 cigarettes (5 packs) in your lifetime?
Yes
No
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?
Yes
No
5. Are you
currently
in a smoking cessation program?
Yes
No
6. Do you
currently
use nicotine gum, the nicotine patch, spray, inhaler, lozenges, Wellbutrin (Zyban) or varenicline (Chantix)?
Yes
No
7. What was your biological sex at birth?
Male
Female
Intersex
8. Is another member of your household enrolled in this study?
Yes
No
9. Are you of Hispanic or Latino origin?
Yes
No
10. Which item(s) best describe your race?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
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
Associate degree
College degree (Bachelor’s degree)
Some graduate education
Graduate degree
