Business Survey
RequiredRequired Question(s)
Required 1.
Please tell us a little about your business.

First Name:
Last Name:
Job Title:
Company Name:
Work Phone:
Email Address:
emailaddress@xyz.com
Address 1:
City:
Postal Code:

Required 2.
How many employees are on your campus?
 

50 characters left.
Required 3.

Does your workplace have a policy for smoking/tobacco use outdoors?

 

If yes, please write the implementation date in the comment box below and continue to #4.

 

If no, skip to question #8.

No
Yes
  • Comment:

  • 500 characters left.
4.
What is your workplace's policy on smoking/tobacco use outdoors?
100% smoke free
Smoking is allowed in designated areas only
E-cigarettes are allowed in all outside areas
5.

What does your policy include?

 Please check all that apply.

Employees
Entrances
Parking lot
Non-cigarette tobacco (smokeless tobacco, pipes)
Other nicotine products (electronic nicotine deilvery systems aka e-cigarette type devices)
Vehicles
Visitors & guests
Other  
6.

How are employees & visitors informed of the smoke/tobacco free policy?

 Please check all that apply.

Employee handbook
Employee orientation
Signs
Other  
7.

Would you like to be added to our free publicized list of Cass & Sarpy smoke/tobacco free businesses?

No
Yes
Required 8.

Which of the following has your business done in the last 12 months?

 Check all that apply.

 

Offered incentives to employees to quit tobacco.
Offered employees who use tobacco products, a quit tobacco program or any other help to quit tobacco.
Offered free nicotine replacement therapy to employees who use tobacco products to help quit.
None of the above.
Required 9.
Is your workplace considering implementing or expanding a smoke/tobacco free policy?
No
Yes
Required 10.

Would you like to be added to T.E.A.M.'s email list for quarterly updates?

Yes
No
11.

Please feel free to add any additional comments.

 

350 characters left.