1. Name:     
2. Street:   
3. City:     
4. State:    
5. Zip:      
6. Phone:    
7. Email:    
8. Are you Female or Male?
   
Female
  Male
  
9. Which category best represents your age?
   
  No Response
  Under 19
  20-25
  26-32
  33-39
  40-49
  50+
   
10. Which category best represents your household income?
     
  No Response  
  Under $30,000  
  $31-45,000  
  $46-60,000  
  $61-75,000  
  $76-90,000  
  $91-99,000  
  $100,000  
   
11. Are you married or single?
   
  Married
  Single
   
12. How many children do you have?  
13. What are the ages of your children?  
14. How long have you had Internet access?
   
   Less than 1 year  
   1-2 years  
   2-3 years  
   3+ years  
   

15. Where do you most often access the Internet?
   
   Home  
   Office  
   Library  
   School  
   Other  
   

16. Why do you typically go on-line?
   
   Information/Research  
   Purchase Products  
   Write/Send e-mail  
   Talk in chat rooms  
   Read magazines/newspapers
   Other
   

17. How many times have you accessed this site?
   
   First timer  
   2-4 Times  
   5-7 Times  
   Once per week
   Twice per week
   Three times per week
   

18. On a scale of 1 to 5, with 1 being "poor" and 5 being "excellent",
    how would you rate this site on the following?
  Quality of Content:      1  2  3  4  5

  Organization of Content: 1  2  3  4  5

  Speed of Delivery:       1  2  3  4  5

  FAQ Sections:            1  2  3  4  5

19. Please fill in the following with any additional comments including
    particular likes/dislikes, was your search successful, comments, etc...


20. Are you a smoker?
   
   Yes
   No
   

21. If so, would you be interested in an internet based quit smoking program?
   
   Yes
   No
   

Thank you for taking the time to fill out this survey and Good Luck!