Skip to content.
Skip to navigation
Working Toward Wellness
Sections
Search Site
Advanced Search…
Your Worksite
Brampton Assembly Plant
Chrysler Canada - Downtown Windsor
Etobicoke Casting Plant
National Parts Distribution Centre
Montreal Parts Depot
Red Deer Parts Depot
Retirees - Local 444
Retirees - Local 1285
Retirees - Local 1459
Windsor Assembly Plant
Healthy Living
Eating Well
Being Active
Dealing with Stress
Alcohol Misuse
Tobacco Issues
Injury Prevention & Safe Living
Health Resources
Tools and Surveys
Disease Prevention & Management
About Us
Program Overview
Program Staff & Wellness Committees
Program Components
Steering Committee
Terms of Use
Contact Us
You are here:
Home
→
Healthy Living
→
Tobacco Issues
→
Smoking Cessation 2011
→
Smoking Cessation Subway Gift Card Sign-up
Document Actions
Smoking Cessation Subway Gift Card Sign-up
last modified
2012-03-29
First Name
(Required)
Last Name
(Required)
Your Mailing Address:
Street Number and Name
(Required)
123 Anystreet
City or Town
(Required)
Province
(Required)
Postal Code
(Required)
Your phone number
(Required)
Your phone number will only be used if we need to contact you about your entry form. Enter your phone number like this: 519-123-4567.
Your Email Address
The Street Name of the Pharmacy You Visited
(Required)
E.g., Dougall Ave., Eglinton Ave.,
The Name of the Pharmacy You Visited
(Required)
Shoppers Drug Mart, Rexall, etc.
Please help us understand more about those who enter the Chrysler Canada Smoking Cessation Program. These questions are optional, and your information will remain confidential.
I am
Male
Female
What is your age?
Under 18
18-24
25-34
35-44
45-54
55 and older
I am a/an __ of Chrysler Canada
Employee
Family member
Retiree
At which Chrysler location do you or your family member work (or used to work if retired)?
Brampton Assembly Plant
Windsor Assembly Plant
Etobicoke Casting Plant
Automotive Research and Development Centre
Chrysler Canada Building (CCB)
Temple Drive Office Building
Mississauga Parts Distribution Centre
Montreal Parts Distribution Centre
Red Deer Parts Distribution Centre
Do any of the following people in your life smoke cigarettes? (check all that apply)
Spouse, partner, girlfriend, or boyfriend
Close friend
Parent, brother, or sister
Son or daughter
Roommate
Co-worker
If other, please specify:
At the present time do you smoke cigarettes:
Every day
Occasionally
Not at all
On the days that you smoke, how many cigarettes do you usually smoke?
How soon after waking do you have your first cigarette?
Within 5 minutes
6-30 minutes
31-60 minutes
More than 60 minutes
How many years have you smoked? (if unsure please approximate)
In the past year, how many times did you stop smoking for at least 24 hours because you were trying to quit?
No attempts
1 attempt
2-3 attempts
4 or more attempts
Have you tried to quit using the Chrysler Canada Smoking Cessation Program in the past?
Yes
No
If yes, how many times?
0
1
2-3
4 or more
Are you seriously considering quitting smoking in the next 30 days?
Yes
No
Are you seriously considering quitting smoking in the next 6 months?
Yes
No
What motivated you to participate in the Chrysler Cananda Smoking Cessation Program?
Please check all that apply
To quit smoking
To reduce the number of cigarettes you currently smoke
Prize giveaway
If other, please specify:
What is your quit date?
DD/MM/YYYY
How did you find out about the Chrysler Canada Smoking Cessation Program contest? Check all that apply.
Poster
Ad in the Health Issues Magazine
Flyer at your worksite
Working Toward Wellness website
Word of mouth
If other, please specify:
Can we contact you in the future to gather your feedback on the Chrysler Canada Smoking Cessation Program?
Yes
No
