Smithville Smoke-Free Workplaces Survey

Clay County Public Health Center and Clean Air Smithville have developed this brief survey to better understand the community's opinions about smoke-free workplaces, including bars and restaurants in the Smithville area. Be sure to fill out your name, address and phone number at the end of this survey to be entered into a drawing for a $25 gas card from Clean Air Smithville. No responses will be tracked back to the individual. Thank you for your time and participation!

Question Title

* 1. Do you think smoking should be allowed in:

	Yes	No
indoor dining areas of restaurants?	indoor dining areas of restaurants? Yes	indoor dining areas of restaurants? No
bars?	bars? Yes	bars? No
public buildings?	public buildings? Yes	public buildings? No
outdoor parks?	outdoor parks? Yes	outdoor parks? No

Other (please specify)

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* 2. Some cities and towns are considering laws that would make workplaces smoke-free by prohibiting smoking in ALL indoor workplaces, including restaurants and bars. Would you support such a law in Smithville?

Yes

Comments

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* 3. In the past year, did you NOT go to a restaurant because you knew that smoking WAS permitted?

Yes

Comments:

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* 4. Over the past year, did you avoid a restaurant because smoking was NOT allowed.

Yes

Comments:

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* 5. Which type of establishment are you MORE likely to visit ?

Other

A restaurant/bar where smoking IS NOT allowed inside.

A restaurant/bar where smoking IS permitted inside (either in a section or throughout the restaurant).

It does not matter to me if smoking is or is not allowed in a restaurant. .

Comments:

Question Title

* 6. Do you think breathing smoke from another person's cigarette is:

Very harmful to one's health?

Somewhat harmful to one's health?

Not very harmful to one's health?

Not harmful at all to one's health?

Please tell us about yourself so we can compare your responses with others we receive

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* 7. What is your age?

Younger than 18

18-24

25-34

34-44

45-54

55-64

65 and over

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* 8. Do you live within the city limits of Smithville?

Yes

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* 9. How often do you visit Smithville businesses (stores, restaurants, services, etc.)?

Daily

Weekly

Monthly

Every once in a while

Hardly Ever

Never

Other (please specify)

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* 10. Do you use tobacco products?

I don't use tobacco products

Cigarettes

Chewing tobacco/dip

Other tobacco products

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* 11. Please leave any additional comments or feedback

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* 12. Please leave your phone number and/or email address if you would like to receive future updates or information from Clean Air Smithville:

Email Address:

Phone Number:

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* 13. To be entered into the drawing for the $25 gas card, please leave the following information. All answers obtained from this questionnaire will be kept confidential and responses will not be tracked back to the individual.

Name:

City/Town:

Email Address:

Phone Number: