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Community Smoking Survey July 2014 - June 2015

Personal Information

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* 1. Name and Phone Number

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* 2. Have you filled in this survey before?

Yes

No

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* 3. Age Group

14 and under

15-17

18-25

26-35

36-45

46-55

55+

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* 4. Heritage

Aboriginal

Torres Strait

Both

Non-indigenous

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* 5. Gender

Female

Male

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* 6. What is your postcode?

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* 7. What best describes you?

Smoker

Ex-smoker

Never smoked