Second-hand Smoke Survey

1. Which category below includes your age?

2. What is your gender?

3. What town do you live in?

4. Do you currently smoke tobacco some days or every day?

5. During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?

6. Check all that apply: I support the following areas of public parks being smoke free:

7. Check all that apply: I support the following public events being smoke-free:

8. Check all that apply: I support the following town-owned properties being smoke-free:

9. Check all that apply: I support my workplace to:

10. Thank you for your time and input. Please share any comments you have.