Cessation Program Feedback and Evaluation Form
Participant Information
Name
Email
Date
Program Experience
How would you rate your overall satisfaction with the program?
1
2
3
4
5
Which components of the program were most useful to you?
Counseling Sessions
Educational Materials
Support Group
Follow-up calls
Other
What could be improved in the program?
Program Impact
Have you reduced or quit using tobacco or nicotine products as a result of the program?
Yes
No
Reduced
What additional support would help you maintain cessation?
Additional Comments
Please share any other feedback about your experience: