Today's date:
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Today M-D-Y
First name:
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Last name:
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Phone number:*If you have ever registered for this program in the past with this phone number, our system won't let you register a second time. Submit your name and phone number here , and we will happily help you get connected with the help you need!
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Special information regarding my phone number and best way to contact me. Include details on if you won't have access to your phone or if a certain time of day is best to reach you.
Please select which you are interested in participating in below.
Select all that apply.
Our tobacco cessation currently meets at 12pm on Mondays, either in person at North Kansas City Hospital, or on Zoom. If you are able to attend on Mondays, please select Monday from below. If you are unable to attend on Mondays and would prefer to attend class on a different day, please check I want to attend some other time.
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If a participant wants to be added to a storyline after initial registration, or wants to change storylines later, this must be done in MOSIO. Do not make changes to a participants texting enrollment or storyline in REDCap.
To update a participants storyline in MOSIO, view the participants Group Storylines and select Add to storyline near the bottom of the page.
Currently, classes are held Mondays at 12pm and Tuesdays at 5:30pm. Which class is your preference?
Mondays at 12:00pm
Tuesdays at 5:30pm
I do not have a preference at this time.
Interested in classes during initial registration prior to 7.12.2023
What language do you prefer for your texts?
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English
Spanish
Which texting program would you like to enroll in at this time? You will have an opportunity to change to a different texting program weekly throughout your program.
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I know I should quit or people tell me I should quit, but I'm just not ready. Send me texts to help me get motivated and get started on the path toward using less or no tobacco.
I'm ready to quit! Please send me texts to help me make a plan to quit
I have quit recently. Please send me texts to help me stay quit.
How frequently would you like to receive texts to help you get motivated to quit?
* must provide value
Once per day
Twice per week
What time of day would you like to receive your texts to help you get motivated to quit?
* must provide value
9:00am
5:00pm
How frequently would you like to receive texts to help you come up with a plan to quit?
* must provide value
Once per day
Twice per week
What time of day would you like to receive your texts to come up with a plan to quit?
* must provide value
9:00am
5:00pm
How frequently would you like to receive texts to help you stay quit?
* must provide value
Once per day
Twice per week
What time of day would you like to receive your texts to help you stay quit?
* must provide value
9:00am
5:00pm
County:
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Cass (MO) Clay (MO) Jackson (MO) Johnson Saline Wyandotte Adair (MO) Andrew (MO) Atchison (MO) Audrain (MO) Barry (MO) Barton (MO) Bates (MO) Benton (MO) Bollinger (MO) Boone (MO) Buchanan (MO) Butler (MO) Caldwell (MO) Callaway (MO) Camden (MO) Cape Girardeau (MO) Carroll (MO) Carter (MO) Cedar (MO) Chariton (MO) Christian (MO) Clark (MO) Clinton (MO) Cole (MO) Cooper (MO) Crawford (MO) Dade (MO) Dallas (MO) Daviess (MO) DeKalb (MO) Dent (MO) Douglas (MO) Dunklin (MO) Franklin (MO) Gasconade (MO) Gentry (MO) Greene (MO) Grundy (MO) Harrison (MO) Henry (MO) Hickory (MO) Holt (MO) Howard (MO) Howell (MO) Iron (MO) Jasper (MO) Jefferson (MO) Johnson (MO) Knox (MO) Laclede Lafayette (MO) Lawrence (MO) Lewis (MO) Lincoln (MO) Linn (MO) Livingston (MO) McDonald (MO) Macon (MO) Madison (MO) Maries (MO) Marion (MO) Mercer (MO) Miller (MO) Mississippi (MO) Moniteau (MO) Monroe (MO) Montgomery (MO) Morgan (MO) New Madrid (MO) Newton (MO) Nodaway (MO) Oregon (MO) Osage (MO) Ozark (MO) Pemiscot (MO) Perry (MO) Pettis (MO) Phelps (MO) Pike (MO) Platte (MO) Polk (MO) Pulaski (MO) Putnam (MO) Ralls (MO) Randolph (MO) Ray (MO) Reynolds (MO) Ripley (MO) St. Charles (MO) St. Clair (MO) Ste. Genevieve (MO) St. Francois (MO) St. Louis (MO) St. Louis City (MO) Saline (MO) Schuyler (MO) Scotland (MO) Scott (MO) Shannon (MO) Shelby (MO) Stoddard (MO) Stone (MO) Sullivan (MO) Taney (MO) Texas (MO) Vernon (MO) Warren (MO) Washington (MO) Wayne (MO) Webster (MO) Worth (MO) Wright (MO) Allen Anderson Atchison Barber Barton Bourbon Brown Butler Chase Chautauqua Cherokee Cheyenne Clark Clay Cloud Coffey Comanche Cowley Crawford Decatur Dickinson Doniphan Douglas Edwards Elk Ellis Ellsworth Finney Ford Franklin Geary Gove Graham Grant Gray Greeley Greenwood Hamilton Harper Harvey Haskell Hodgeman Jackson Jefferson Jewell Kearny Kingman Kiowa Labette Lane Leavenworth Lincoln Linn Logan Lyon Marion Marshall McPherson Meade Miami Mitchell Montgomery Morris Morton Nemaha Neosho Ness Norton Osage Osborne Ottawa Pawnee Phillips Pottawatomie Pratt Rawlins Reno Republic Rice Riley Rooks Rush Russell Scott Sedgwick Seward Shawnee Sheridan Sherman Smith Stafford Stanton Stevens Sumner Thomas Trego Wabaunsee Wallace Washington Wichita Wilson Woodson Other
Emergency contact name/relationship:
Emergency contact relationship:
How did you hear about us?
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Flyer/QR code Friend/Family Google/internet search Kansas Tobacco Quit Line Social Media Referred by health care or cancer center Primary Care Provider UKanQuit counselor (when I was in the hospital at KU) Your Health magazine/North Kansas City Hospital Screening Event Business Card Community Bulletin Board Other
What cancer center or health center referred you?
Ascension Via Christi, Pittsburg Ascension Via Christi, Wichita Children's Mercy Kansas City Citizens Health Coffeyville Regional Medical Center HaysMed Kansas State University Johnson Cancer Research Center LMH Health Masonic Cancer Alliance (MCA) North Kansas City Hospital Olathe Health Salina Regional Health Center Stowers Institute for Medical Research University Health (previously known as Truman Medical Center) The University of Kansas The University of Kansas Health System The University of Kansas Health System St. Francis Campus University of Kansas Medical Center Other
List other way(s) you heard about MCA's Tobacco Cessation Program here:
Name of provider or staff member who referred you (if applicable):
Daniel Craig, MS Vicky Portwood, MSN Stephanie Sherode, LMSW Susan Miller, LCSW Tina Shropshire, OPN-CG Michelle Gates PhD Jeni Wakefield, BSN, RN Paola Alor Alor, LMSW Laura McCulloch Vidya Anantharaman Magdalena Kosinska, BSN Other
Other provider or staff member:
Our staff will call you for a 20-minute visit to discuss our programs. Please choose your preferred times and days of the week for us to call.
Please check the days of the week you would be available for a call. (Check all that apply.)
How would you like to be contacted to schedule?
Email Phone call Text
Please let us know in the area below what days or times you would prefer a call:
We know that quitting tobacco products is hard. We will be following up with a brief survey via text message in 3 and 6 months to see how things are going, If you would prefer to be contacted another way, please indicate below.
I prefer to be texted in 3 and 6 months
I prefer to be emailed in 3 and 6 months
I prefer to be called in 3 and 6 months.
Female Male Choose not to disclose
Female Male Transgender Woman/Transgender Female Transgender Man/Transgender Male Other gender identity (e.g., non-binary, genderqueer, gender-diverse, or gender fluid) Choose not to disclose
Patient's pronouns (e.g. he/him, she/her, they/them):
OLD FIELD We know that quitting tobacco products is hard. We would like to follow up with you in 3 and 6 months to see how things are going, Please indicate how you would like us to contact you.
Please contact me by email in 3 months and 6 months.
Please call me at the number I listed above.
Please send me the survey in the mail.
Please text me the survey.
Please do not contact me in 3 and 6 months.
I can be best reached during the following days/times of day:
Additional UKanQuit Information:
DAYS SMOKED THIS MONTH: In the past 30 days, how many days did you smoke or use tobacco?
CIGARETTES PER DAY: In the last 7 days, if you smoke cigarettes or little cigars, on average how many cigarettes did you smoke per day?
OTHER TOBACCO: In the last 7 days, did you use any other tobacco products other than cigarettes? (check all that apply)
No, I did not use any tobacco products other than cigarettes
Smokeless (dip, loose chew, snus, snuff)
Cigar (full-sized), Cigarillo (Black & Mild, Swisher Sweets or other medium-sized cigar), Little cigar (cigarette sized, brown cigar paper)
Cigarillo (Black & Mild, Swisher Sweets or other medium-sized cigar)
Little cigar (cigarette sized, brown cigar paper)
Roll your own
Flavored imported (clove /bidi/kritek)
E-cigarette, Juul, Vape, etc.
Water pipe/hookah
Other
Quantity: How much: ______
How often did you use ______ , and how much did you use when you used it?
How many years have you smoked/used tobacco?
Have you tried to quit in the past?
Yes
No
What have you tried before to help you quit? (check all that apply)
What other methods have you used to quit in the past?
Past medication use: Have you ever used a medication in the past to help you quit tobacco? If yes, answer all that apply:
Current medication use: Are you currently using any medications to help you quit tobacco? If yes, answer all that apply:
Please note if you had any side effects or problems with medication to quit tobacco, and what they were.
What was the longest period you have been able to quit in the past and what helped you do this?
What do you hope to get out of group? (answer all that apply)
What else do you hope to get from the group?
What led you to decide to register for this class? (check all that apply)
What other reasons did you decide to register for this class?
Has your home been tested for radon in the last 12 months?
We ask because we know that people who have high levels of radon in their houses are at increased risk of developing lung cancer, just like smokers. Being sure that you don't have high levels of radon when you're quitting smoking helps you decrease your risk of developing cancer. You can contact your local county extension office to get a free or low cost home radon testing kit.
Yes
No
I don't know
Other
What are your top three reasons for quitting tobacco? If you aren't sure, it's OK to say that. Not everyone is ready to quit when they come to group, and that is OK.
Communication from Karin to participant:
Ready to quit - 9am - 2x week
View equation Ready to quit - 9am - 1x day
View equation Ready to quit - 5pm - 2x week
View equation Ready to quit - 5pm - 1x day
View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation Interested in tobacco cessation classes
View equation OLD FIELD Where were you referred from?
Ascension Via Christi, Pittsburg Ascension Via Christi, Wichita Children's Mercy Kansas City Citizens Health Coffeyville Regional Medical Center HaysMed Kansas State University Johnson Cancer Research Center LMH Health Masonic Cancer Alliance (MCA) North Kansas City Hospital Olathe Health Salina Regional Health Center Stowers Institute for Medical Research University Health (previously known as Truman Medical Center) The University of Kansas The University of Kansas Health System The University of Kansas Health System St. Francis Campus University of Kansas Medical Center UKanQuit Screening Event Your Health Other
OLD FIELD Which texting program would you like to enroll in at this time? You will have an opportunity to change to a different texting program weekly throughout your program.
I know I should quit or people tell me I should quit, but I'm just not ready. Send me texts to help me get motivated and get started on the path toward using less or no tobacco.
I'm ready to quit! Please send me texts to help me make a plan to quit
I have quit recently. Please send me texts to help me stay quit.
OLD FIELD How frequently would you like to receive texts to help you come up with a plan to quit?
Once per day
Twice per week
OLD FIELD What time of day would you like to receive your texts to come up with a plan to quit?
9:00am
5:00pm
OLD FIELD How frequently would you like to receive texts to help you stay quit?
Once per day
Twice per week
OLD FIELD What time of day would you like to receive your texts to help you stay quit?
9:00am
5:00pm
Three month follow up - Calculate to show 90 days from day of enrollment
Today M-D-Y
Six month follow up - Calculate to show 180 days from day of enrollment
Today M-D-Y
90 days after enrollment - send 3 month follow up
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180 days after enrollment - send 6 month follow up
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