Nebraska Tobacco Quitline Order Form

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​Tobacco Free Nebraska offers free materials to help promote quitting resources. Request materials in the form below or download materials to use today. Requests are only filled for Nebraska residents, healthcare providers, businesses and organizations. All materials while supplies last. Please allow 7-10 business days for delivery. Questions? Email DHHS.TFN@Nebraska.gov.

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Requestor Details:

Please correct the errors in filling the form.

Name of Organization *

Name of Requestor *

What best describes your role? * Healthcare Provider/Facility Oral Healthcare Provider/Office Mental Health Provider/Facility Substance Use Treatment Provider/Facility Community Organization Local Health Department Middle School/High School Community College/University Other

Address *

City *

Zip *

County * Adams Antelope Arthur Banner Blaine Boone Box Butte Boyd Brown Buffalo Burt Butler Cass Cedar Chase Cherry Cheyenne Clay Colfax Cuming Custer Dakota Dawes Dawson Deuel Dixon Dodge Douglas Dundy Fillmore Franklin Frontier Furnas Gage Garden Garfield Gosper Grant Greeley Hall Hamilton Harlan Hayes Hitchcock Holt Hooker Howard Jefferson Johnson Kearney Keith Keya Paha Kimball Knox Lancaster Lincoln Logan Loup Madison McPherson Merrick Morrill Nance Nemaha Nuckolls Otoe Pawnee Perkins Phelps Pierce Platte Polk Red Willow Richardson Rock Saline Sarpy Saunders Scotts Bluff Seward Sheridan Sherman Sioux Stanton Thayer Thomas Thurston Valley Washington Wayne Webster Wheeler York

Telephone *

Email *

How will you use the materials? * Patient Education Quitline Referrals Health Fair Community Event Policy Implementation Other

If other please specify

How did you hear about these resources? *

Resources:

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​Maximum request amount is 50 unless specified		​Quantity in English	​Quantity in Spanish
​Behavioral Health Quitline Brochure	English Preview Spanish Preview
Diabetes and Tobacco Brochure	English Preview Spanish Preview
Foldable Quitline Referral Card (Limit 25)	English Preview Spanish Preview
Maternal Health Quitline Brochure	English Preview Spanish Preview
Maternal Health Quitline Healthcare Provider Flyer (English Only)	English Preview
Maternal Health Quitline Poster (Limit 25)	English Preview Spanish Preview
​Nebraska Tobacco Quitline Logo Magnet (Limit 25)	English Preview Spanish Preview
​​New Parents Quitline Brochure	English Preview Spanish Preview
No Smoking Including Electronic Cigarettes Window Cling (Limit 25)	English Preview Spanish Preview
Quitline Business Card (Limit 25)	English Preview Spanish Preview
Quitline Cessation Resource List	English Preview Spanish Preview
​Quitline Pens (Limit 25)	English Preview Spanish Preview
Quitline Quitting Checklist	English Preview Spanish Preview
Quitline Wrist Bands (Limit 25, English Only)	English Preview
Quitting Chew Brochure	English Preview Spanish Preview
Quitting Chew Checklist	English Preview Spanish Preview
​​Smoke-Free Car Window Cling (Limit 25)	English Preview Spanish Preview
​Smoke-Free Home Window Cling (Limit 25)	English Preview Spanish Preview
​​Talking to Patients About Smoking and Chronic Disease (Limit 25)	English Preview Spanish Preview
What to Expect Quitline Brochure	English Preview Spanish Preview
​What’s Your Why – Quitline Magnet (Limit 25)	English Preview Spanish Preview
Youth Vaping Quitline Brochure	English Preview Spanish Preview

Thank you for your submission. Please allow 7-10 business days for delivery.

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