Public Health Unit

Tobacco Cessation Program Survey

2012
Completed by: ___________________________
Date: ______________________________________
Name/ Contact: __________________________

Please complete the following partner survey to help us improve our program. This information will
also be used as part of our program evaluation. All identifiers will be removed. Please return the
completed survey to phutobacco@ccac.on.ca

1. Was the program (MT2Q) easy to refer clients/patients to?
a) Yes, why?____________________
b) No, why not?____________________
c) Do you have any suggestions as to how we can improve the referral process?

2. What do you like about the referral process?


3. What has allowed you to refer clients/patients to the program?


4. What has inhibited you from referring more clients/patients?

5. Do you believe that the program was well explained when it was presented to you?
a. Yes, comments_______________________________
b. No, comments________________________________

6. Do you believe that the NRT voucher ($15 voucher for 10 weeks of NRT treatment) is an
appropriate incentive that encourages clients/patients to attend a quit smoking program?
a. Yes
b. No

7. What do you perceive (if any) to be the main barriers to participate in this program? (from the
professional and client perspective).

8. Do you have any suggestions regarding strategies to increase client participation in the MT2Q
program?

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9. How has the reimbursement process been for the vouchers?

10. Does your pharmacist offer any counseling upon a client's redemption of the vouchers?
Yes
No

11. Does your pharmacist answer any questions upon a client's redemption of vouchers?
Yes
No