“Cha-may weeya
Medicine Talk
Siletz
Community
Health
Clinic
Tobacco Prevention and Education
Program Survey
Please complete the enclosed survey. Any comments, suggestions, or ideas
are greatly appreciated. This tool will help me complete the objectives of the
Tobacco Prevention and Education Program. Mail the survey to or drop it off at:
Siletz Community Health Clinic
Tobacco Prevention Program
Attn: Shannon Chrisman
107 SE Swan Ave.
P.O. Box 320
Siletz, OR 97380
Information (optional)
Name Age
Shannon Chrisman
Address Phone (
Chrisman Leads Tobacco Prevention
Hello. I am Shannon Chrisman and I’m pleased to be the new Tobacco
Prevention & Education coordinator.
I was bom and raised in Alaska and I am a member of the Siletz Tribe. In
1993, I graduated from Southern Oregon University in Ashland, Ore., with a
degree in psychology. I have worked primarily in the social service fields and
have held positions with Head Start in Washington as a family advocate and as a
women’s and single-parents’ counselor for the Alaska Job Corps Center in Palmer.
In September, my family relocated from Portland to the Newport area. My
husband, Steve Chrisman, is a regional sales executive for Chinook Winds Casino.
We have a 2-year-old daughter named Cheney.
I am excited to be on board here and am interested in ways I can better serve
the community in tobacco prevention. My duties center on fulfilling the objectives
of the Tobacco Prevention Grant from the Oregon Health Division. These include
assisting tribal and community members in the 11-county service area with support
and guidance to quit tobacco products as well as promoting healthy, smoke-free
environments for children and families.
My office is located at the Siletz Community Health Clinic and I can be
reached at 1-800-648-0449, ext. 661, or 541-444-1030, ext. 661.1 look forward
to working with the community and getting to know you.
If you are a current smoker, our program would benefit greatly from your
input. Please take a few minutes to complete the following survey and mail it or
drop it off at the Siletz Clinic. Filling in your name is optional, but if you let us
know who you are, we’ll enter you into a drawing for a $25 Fred Meyer gift card.
Thank you for your support.
Kick Butts Day!
April 4, 2001, is Kick Butts Day, a national (becoming global) event
encouraging activism and leadership among young people in elementary, middle,
and high schools. It’s billed as a day for the kids of America to stand up to
tobacco and for us adults to stand up for kids.
Kids across the country are coming up with exciting and creative activities
to fight youth tobacco use in their own communities. You can, too. Use your
voice today.
Forexciting and interesting information, log on to www.tobaccofreekids.org
and find out what’s being done in our schools and communities.
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Siletz News
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April 2001
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Questionnaire
At what age did you begin to smoke?
How many years total would you guess you’ve been smoking?
Have you ever tried to quit?
How many times have you tried to stop smoking?
What methods have you tried when quitting (cessation classes, hypnotism, cold
turkey, weaning slowly, using medications - Zyban, patches, or nicotine gum,
etc.) ?_________________________________________________________________
When was the most recent time you attempted to quit, if at all?
This most recent time, how long did you stay quit?
What happened that got you off track?____________________________________
How many cigarettes do you smoke per day now?
Are you ready to try to stop smoking now?
In general, what do you think we could do differently to get community members
interested in quitting?__________________________________________ _______
Do you have ideas on how the Tobacco Prevention Program could provide better
support and assistance to people trying to quit?
Thankyou!
All information on this questionnaire will be kept confidential.