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To receive your free (one-time only), 8-week supply of nicotine patch or gum, you must:
- complete a brief survey now;
- meet the basic health eligibility requirements;
- provide a ground address and an email address
As soon as you provide the required information, Leave The Pack Behind will initiate shipment of the nicotine product to your ground address. You’ll receive about 8 motivational emails over the next several weeks. In 6 months’ time, Leave The Pack Behind will email you a final, optional survey about your quitting and smoking experiences. You might also receive emails from Leave The Pack Behind about other stop-smoking aids and related survey opportunities.
All information collected from you will be kept confidential as required by applicable privacy laws. Details are provided below. Your consent for this collection of information is required.
Read the information below about the surveys, then click the AGREE button if you agree to take part. The order form, the eligibility questions, and the survey will automatically appear.
Reasons and Methods for Information Collection
Why is information collected from me?
Leave The Pack Behind collects information to better understand and serve the young adults who use its services. To receive your free nicotine patch or gum, you must complete the initial health screening and smoking history surveys. Six months from now, you can complete the final, optional survey that is emailed to you.
How is my information stored and maintained?
When you submit the initial surveys, a personal identification number (PIN) appears on your screen. This number, along with your answers, but not your name, is downloaded into “Database 1.” (There is no personally-identifiable information in Database 1). This database is used by Leave The Pack Behind to evaluate its services. It is retained for up to 15 years.
Completely separate from Database 1, your PIN, name, and contact information are downloaded into “Database 2.” This database is used by Leave The Pack Behind to send you emails. Database 2 is retained for up to 15 years. Your information remains in this database if you agree to receive emails from Leave The Pack Behind about other quit-smoking aids and/or surveys. If you decline this opportunity, your information is deleted from this database one year after the last use of your contact information.
How is my privacy protected?
All data are encrypted and protected with numerous security features during data collection and transmission to the databases. Both databases are securely maintained under strict password protection, and both are kept confidential as required by applicable privacy laws.
Brock University (where Leave The Pack Behind is housed) protects your privacy and your personal information. The personal information requested in this survey is collected under the authority of The Brock University Act, 1964, and in accordance with the Freedom of Information and Protection of Privacy Act (FIPPA). The information collected is used to improve service provision, and to understand young adults’ smoking and quitting experiences. Reports include aggregate data; no personally-identifying information is included.
Reports may be shared with community stakeholders at meetings, conferences and on the web.
How can I withdraw my information from the databases?
You can withdraw your information at any time, for any reason with no penalty. To withdraw now, click DECLINE. To withdraw your information any time after submitting the initial surveys, send an email to email@example.com stating your PIN and your desire to withdraw. (The Administrative Assistant who receives your email will delete your name and contact information from Database 2, then forward your PIN (not your name) to staff who maintain Database 1 so they can delete your answers. The Administrative Assistant will permanently erase your email request. It may take up to 10 business days to process your request to stop receiving emails.)
What else should I know?
This service is funded by the Ontario Ministry of Health and Long Term Care. Obtaining the patch or gum through Leave The Pack Behind should in no way be taken as a form of or substitute for medical consultation.
IMPORTANT. Carefully read the package insert for specific and important information about whether and how to use the nicotine product, and any possible side effects you might experience. If you are not sure the product is right for you, or if you experience any negative side effects or a change in your health/medical condition (e.g., become pregnant, start using new medications, etc.), please stop using the gum/patch and see your health provider.
If you have general questions about this service or how your information is collected, stored and used, please contact Leave The Pack Behind:
T 905-688-5550 x4992
I have read and understood all the information presented here. Based on this information:I AGREE to provide information and receive emails from Leave The Pack Behind about other quit-smoking aides and/or surveys.
I AGREE to provide information. I DECLINE to receive emails from Leave The Pack Behind about other quit-smoking aides and/or surveys.
I DECLINE to provide information. This means I cannot receive free nicotine patch or gum.