Bartholomew County Employer Survey on Tobacco-Free Workplace Policy and Cessation Support for Employees

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* 1. Name of Employer

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* 2. Type of Employer (ie: factory, office, healthcare, education, nonprofit, etc.)

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* 3. Number of Employees

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* 4. Your Name

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* 5. Your Title/Position

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* 6. E-mail Address

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* 7. Phone Number

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* 8. Does your business have a wellness department/division for employees? If not, who do your employees seek out for wellness related activities?

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* 9. How do you think employee tobacco use impacts your business?

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* 10. How does your business engage with employees about their tobacco use?

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* 11. Does your business support a tobacco cessation program for employees?

Yes

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* 12. What types of tobacco cessation resources do you offer your employees?

Referrals to outside sources like the Indiana Tobacco Quitline (1-800-QUIT-NOW)

Sponsor employees in tobacco cessation classes

Cover the cost of tobacco cessation counseling

Provide self-help materials

Other (please specify)

None of the above

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* 13. What do you think can be done to address the barriers of quitting tobacco with your employees?

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* 14. Does your business have a 100% tobacco-free workplace grounds policy (including e-cigarettes and other electronic smoking devices)?

Yes

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* 15. If YES, would you please attach a copy of your tobacco-free workplace grounds policy?

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 16. In NO, would you be interested in learning more about the benefits of and help implementing a 100% tobacco-free workplace grounds policy?

Yes

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* 17. Do you offer your employees tobacco cessation coverage through your employer health insurance plan?

Yes

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* 18. If YES, what tobacco cessation benefits are covered (ie: counseling, medication, nicotine replacement therapy)?

Counseling/Classes

Over-the-counter medication (ie: nicotine patches, gum, lozenges, etc.)

Prescription Medication (ie: Chantix, Wellbutrin, Nicotine Inhaler/Nasal Spray)

Other (please specify)

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* 19. Are there any co-pays, pre-authorizations, or coverage limits to these tobacco cessation benefits? If so, can you describe them?

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* 20. How do you promote your tobacco cessation benefits to your employees (incentives, insurance premium surcharges, flyers, newsletters, health fairs, etc.)

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* 21. Are you familiar with the Indiana Tobacco Quitline (1-800-QUIT-NOW)?

Yes

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* 22. Would your business like to learn more about the FREE Indiana Tobacco Quitline and how you can utilize this free servce as an additional benefit for your employees?

Yes

Bartholomew County Employer Survey on Tobacco-Free Workplace Policy and Cessation Support for Employees

Question Title

* 1. Name of Employer

Question Title

* 2. Type of Employer (ie: factory, office, healthcare, education, nonprofit, etc.)

Question Title

* 3. Number of Employees

Question Title

* 4. Your Name

Question Title

* 5. Your Title/Position

Question Title

* 6. E-mail Address

Question Title

* 7. Phone Number

Question Title

* 8. Does your business have a wellness department/division for employees? If not, who do your employees seek out for wellness related activities?

Question Title

* 9. How do you think employee tobacco use impacts your business?

Question Title

* 10. How does your business engage with employees about their tobacco use?

Question Title

* 11. Does your business support a tobacco cessation program for employees?

Question Title

* 12. What types of tobacco cessation resources do you offer your employees?

Question Title

* 13. What do you think can be done to address the barriers of quitting tobacco with your employees?

Question Title

* 14. Does your business have a 100% tobacco-free workplace grounds policy (including e-cigarettes and other electronic smoking devices)?

Question Title

* 15. If YES, would you please attach a copy of your tobacco-free workplace grounds policy?

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* 16. In NO, would you be interested in learning more about the benefits of and help implementing a 100% tobacco-free workplace grounds policy?

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* 17. Do you offer your employees tobacco cessation coverage through your employer health insurance plan?

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* 18. If YES, what tobacco cessation benefits are covered (ie: counseling, medication, nicotine replacement therapy)?

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* 19. Are there any co-pays, pre-authorizations, or coverage limits to these tobacco cessation benefits? If so, can you describe them?

Question Title

* 20. How do you promote your tobacco cessation benefits to your employees (incentives, insurance premium surcharges, flyers, newsletters, health fairs, etc.)

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* 21. Are you familiar with the Indiana Tobacco Quitline (1-800-QUIT-NOW)?

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* 22. Would your business like to learn more about the FREE Indiana Tobacco Quitline and how you can utilize this free servce as an additional benefit for your employees?

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* 23. What other thoughts would you like to share related to a healthy workplace and addressing employee tobacco use?