1. Which of the following best describes your organization?
Tribal Health Organization Health Care Provider's Office Urban Health Care Center/Hospital Rural Health Care Center/Hospital Dental Health Office Community-based Organization Other (please specify below):
2. What type of technical assistance is your organization most interested in receiving?
Provide tobacco cessation education/reference materials Consultation on your organization's current tobacco cessation protocols/policies Consultation on implementing new or expanded tobacco cessation protocols/policies at your organization Training for providers and staff on implementing tobacco cessation best practices at your organization Presentation on implementing tobacco cessation best practices at a conference or other training Presentation on the Alaska Tobacco Quit Line and its services at a conference or other training Other (please specify below)
3. What type of information is your organization most interested in receiving?
General Tobacco education for patients General Tobacco education for health care providers and staff Alaska Tobacco Quit Line services for patients Alaska Tobacco Quit Line services for providers Alaska Tobacco Quit Line Fax Referral Program Tobacco Brief Intervention/5A's for providers and staff Implementing a comprehensive tobacco cessation program at your organization Other (please specify below)
4. What is your timeline for technical assistance?
