Clean Air Childcare Recognition Survey

Exposure to second and thirdhand tobacco smoke and e-cigarette vapor can cause many negative health outcomes, especially in children. Please answer this quick survey to assess your childcare services regarding tobacco.

Question Title

* 1. Do you allow smoking, vaping (e-cigarettes, JUUL and other similar devices) or chewing tobacco

	Yes	No	N/A
Inside any portion of your home when children ARE NOT present?	Inside any portion of your home when children ARE NOT present? Yes	Inside any portion of your home when children ARE NOT present? No	Inside any portion of your home when children ARE NOT present? N/A
In garages outdoor areas or on patios when children ARE NOT present?	In garages outdoor areas or on patios when children ARE NOT present? Yes	In garages outdoor areas or on patios when children ARE NOT present? No	In garages outdoor areas or on patios when children ARE NOT present? N/A
In garages, outdoor areas or on patios, while children ARE present	In garages, outdoor areas or on patios, while children ARE present Yes	In garages, outdoor areas or on patios, while children ARE present No	In garages, outdoor areas or on patios, while children ARE present N/A
Inside any vehicle that could be used to transport children in care?	Inside any vehicle that could be used to transport children in care? Yes	Inside any vehicle that could be used to transport children in care? No	Inside any vehicle that could be used to transport children in care? N/A
During field trips, walks or other off-site activities with children?	During field trips, walks or other off-site activities with children? Yes	During field trips, walks or other off-site activities with children? No	During field trips, walks or other off-site activities with children? N/A
Do you provide a written/e-mail copy of your smoking/vaping rules to families with children in care?	Do you provide a written/e-mail copy of your smoking/vaping rules to families with children in care? Yes	Do you provide a written/e-mail copy of your smoking/vaping rules to families with children in care? No	Do you provide a written/e-mail copy of your smoking/vaping rules to families with children in care? N/A

Question Title

* 2. Do you accept DCF subsidy childcare payments?

Yes

Question Title

* 3. Are you interested in making changes to qualify for the Clean Air Childcare Recognition program? We are here to help! Please list your name and email address and you will be contacted to receive FREE technical assistance.

Thank you for doing all you can to provide a safe, caring and healthy environment for children in your care. Email: shelleyrich@med-soc.org or call: (316) 285-9355 for questions, assistance, or education on the dangers of secondhand and thirdhand smoke.