Sample Needed Assesment FOR PART C

Smoking and Pregnancy Survey
 
Directions: Please take this brief survey about what you know about smoking and pregnancy.  This information will help me plan a teaching session for you on this topic.  Please do not write your name on this survey. Thank you and I look forward to our session together on March 9^th.
Please answer the following questions by circling your answer.
 

1. Do you think second-hand smoke is harmful to the child or mother during pregnancy?

Yes                                         No

2. Can you name three effects of smoking in the unborn child?

Yes                                         No

3. Do you know where to find help if you are trying to quit smoking?

 
Yes                                         No
 

4. What would you like to know about the topic?

 
 

5. How do you learn best?

 

1. By listening to someone talk

 

1. By trying a new skill on my own

 

1. By watching a video on the topic

 
 
 
 
 
Thank you for your time!
 
Kristina G.
Purdue University Northwest
Baccalaureate Nursing Student