Qualtrics Survey | Qualtrics Experience Management

Organization/School Name:

School District Name (if applicable):

Organization's Website:

Point of Contact (First and Last Name):

Title:

Email:

Phone:

City:

State:

Zip Code:

County:

Has your school or organization participated in any programs previously (select all that apply):

ASPIRE
EndTobacco: Eliminate Tobacco Use, Project TEACH, TCCEP, CTTTP, Policy Coalitions
Too Cool to Smoke
None

Age of students your organization serves (select all that apply):

Please provide an estimated number of students who will receive materials for Ex Program:

What types of materials would you need to share? (select all that apply)

What type of audience will you share the above materials with?

Would you like to request a presentation on the harms of tobacco and vaping products? (Only available to schools in Houston MSA)