Evaluation Form Evaluation Form Juul Evaluation Form First Name * Last Name * Email * Phone * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Who used JUUL or other E-Cigarette products? * Self Son Daughter Spouse Other At what age was the JUUL or other E-Cigarette product first used? * 17 or younger 18 or older Has the JUUL or E-Cigarette user experienced any of the following symptoms? * Nicotine Addiction Lung Problems Advanced Asthma Seizures Shortness of Breath OtherOther Check all that apply. reCAPTCHA Submit By Travis|2019-10-15T19:41:38-05:00October 15th, 2019|Comments Off on Evaluation Form Share This Story, Choose Your Platform! FacebookTwitterRedditLinkedInWhatsAppTumblrPinterestVkEmail
