The National Survey on Tobacco Prevention at Homeless Service Agencies

1. The National Survey on Tobacco Prevention at Homeless Service Providers

The National Coalition for the Homeless supports the work of the National Network on Tobacco Prevention and Poverty (NNTPP), a program of the Health Education Council, which focuses on preventing and reducing tobacco use in low-income communities.

Please take a moment to complete the following survey if you work in an organization such as a shelter or soup kitchen that offers assistance to those experiencing homelessness. Your answers will help guide the National Network on Tobacco Prevention and Poverty, and the National Coalition for the Homeless on their next activity phase.

This survey is being administered jointly by the Association of Gospel Rescue Missions (AGRM), the National Coalition for the Homeless (NCH), and the National Network on Tobacco Prevention and Poverty (NNTPP).

Thanks for your time! Your responses will help guide further research and funding to this issue.

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* 1. Your name, title, organization, address, and phone number:

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* 2. What are the primary populations that your agency serves?

Homeless Individuals and Families

Individuals with Mental Illness

Individuals in Substance Abuse Treatment

All of the Above

Other (please specify)

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* 3. Do you feel that tobacco is an important issue to address with the participants or residents you serve? Please choose one:

Yes

Don’t Know

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* 4. Does your organization have a written tobacco use policy in place? Please choose one:

Yes

Don’t Know

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* 5. How would you describe your tobacco use policy? Please choose all that apply:

Tobacco is prohibited within my organization’s main facility AND on the grounds.

Tobacco use is prohibited within my organization's facility only.

Tobacco use is allowed only in designated areas inside my organization's main facility.

Tobacco use is allowed only in designated areas outside my organization's main facility.

Other (please specify)

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* 6. Do the majority of your clients and staff comply with your tobacco use policy?

Yes

Comments:

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* 7. If your organization does NOT have a written tobacco use policy in place, please choose all that apply:

We have no need of adopting a policy at this time

We would like assistance with policy adoption

We have discussed adopting a policy, but currently have nothing in place

We have drafted policy language, and are moving towards adoption

We have tried to adopt a policy in the past without success

Other (please specify)

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* 8. Does your organization currently offer programs to help people stop smoking or using tobacco? Please choose one:

Yes

Don’t know

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* 9. Would your agency be interested in training for staff so they can help their clients stop using tobacco?

Yes

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* 10. Is your agency able to provide nicotine replacement therapies (gum, patches, etc.) for clients who are trying to quit tobacco?

Yes

Don’t Know