skip to main content

Contact Us

Public Health
Seattle & King County
401 5th Ave., Suite 1300
Seattle, WA 98104

Phone: 206-296-4600
TTY Relay: 711

Toll-free: 800-325-6165

Click here to email us

Public Records Requests

Instructions to submit a Public Records Request

Community Tobacco Cessation Partnership Screening Form

Please fill out the questions below and we will contact you about Partnership services available.

Your name:


Position:


Organization:


Street address:


Email address:


Your phone number including area code:


Please describe what your organization does:


How many clients does your organization see a year?

Please describe your clients, including: Age, gender, income, race and ethnicity, experience with disability, mental health issues, homelessness, or substance abuse.


Where do your clients typically receive health care?


Do you know the tobacco use rate of clients?


Does your organization screen clients for tobacco use? If not, how was tobacco use rate established?


How many staff work at this organization?

Have staff been trained before in cessation counseling?
Yes No Don't know
What are the organization’s goals for training in cessation?