Lung Cancer Screening Eligibility Assessment

This survey can be used to determine whether you are eligible for lung cancer screening. To help us understand whether you may qualify for lung cancer screening, we need to ask for information about your age and smoking history. Please click "Submit" when done to determine your eligibility for lung cancer screening and avoid using the back button. We ask for your name, email, and phone number so that a team member can assist with screening information.

We will not share any of your personal information outside of our team, and will only contact you if you select "yes" at the end of the survey.

This survey was created by the American Lung Cancer Screening Initiative (ALCSI), a 501(c)(3) nonprofit dedicated to raising awareness about lung cancer and lung cancer screening. To learn more about the organization, visit www.alcsi.org.

What is your email? Your email will only be used to facilitate contact with a member of the American Lung Cancer Screening Initiative and will not be shared with other organizations or entities.

What country do you reside in?

* must provide value

What is your zip code?

Where did you take this survey (i.e., ALCSI tabling event, canvassing event, community event, ALCSI website)

You chose "Other" for your country of residence in the previous question. Please write out your country of residence.

* must provide value

You chose "United States of America" as your country of residence. What state do you live in?

* must provide value

What is your current age (enter as a whole number)?

* must provide value

Have you ever smoked? If you have smoked less than 100 cigarettes in your lifetime, you are not considered to have smoked.

* must provide value

Yes

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What is your smoking status?

* must provide value

I currently smoke

I smoked in the past

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How many packs a day do you smoke? If it is not a whole number, round to a decimal (E.g. A quarter pack of cigarettes would be 0.25 packs).

* must provide value

How many packs a day did you smoke? If it is not a whole number, round to a decimal. (E.g. A quarter pack of cigarettes would be 0.25 packs).

* must provide value

How many years have you smoked for?

* must provide value

How many years ago did you quit smoking?

* must provide value

This is your pack-year smoking history.

* must provide value

View equation

This is your pack-year smoking history.

* must provide value

View equation

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.