* 1. How long have you lived in this unit?

* 2. How harmful do you think it is to breathe secondhand smoke (smoke from someone else’s cigarette, pipe or cigar?)

* 3. Would the smell of someone else’s tobacco smoke within your building bother you?

* 4. Have you ever complained to the management about tobacco smoke drifting into your unit?

* 5. In your building or complex, where do people smoke?

* 6. Do you have children, teens, or older people living in your apartment?

  Yes No
Children 0-12 Years old?
Youth 13-19 Years old?
Eldery over 65?

* 7. Do you or does someone who lives with you live with a chronic disease such as heart disease, diabetes, arthritis, asthma or cancer?

* 8. Does anyone who lives in your home currently smoke cigarettes or use tobacco products?

* 9. Do you allow smoking in your apartment unit?

* 10. Would you support any of the following measures to limit smoking in your building?

  Yes No Not Sure
a. Making common areas such as hallways, rec. rooms, laundry room, and elevators non-smoking?
b. Making outside areas like balconies, patios, playgrounds, or a swimming pool non-smoking?
c. Creating smoking and non-smoking apartment sections of the building?
d. Making the entire building non-smoking?