Quit Now Indiana Employer Survey Question Title * 1. Business/Organization Name Question Title * 2. Type of business Question Title * 3. Contact Name Question Title * 4. Position/Title Question Title * 5. Email Question Title * 6. Phone number Question Title * 7. Street Address Question Title * 8. City Question Title * 9. Zipcode Question Title * 10. County Question Title * 11. Does your organization have a wellness program? Yes No I'm not sure Other (please specify) Question Title * 12. If you answered yes, does the program include any or all of the following? Physical Behavioral Social Question Title * 13. Does your company/organization have a comprehensive tobacco cessation program/services Yes No I'm not sure Done