JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Business Survey
We would like to thank you for completing this survey to help T.E.A.M. gather and update our data from local businesses on their tobacco policies. If you have any questions or would like some free signs or window clings for your business please contact us at
info@teamtobaccofree.org
.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
Your Name / Job Title
*
Your answer
Company Name
*
Your answer
Phone Number
*
Your answer
Company Address
*
Your answer
How many employees are on your campus?
*
Your answer
Does your workplace have a policy for smoking/tobacco use outdoors?
*
Yes
No
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
Clear selection
What does your policy include?
Emplyees
Entrances
Parking lot
Vehicles
Visitors & Guests
Non-cigarette tobacco (smokeless tobacco, pipes)
Other nicotine products (electronic nicotine delivery systems eg. e-cigarette type devices)
Other:
Clear selection
How are employees & visitors informed of the smoke/tobacco free policy?
Employee Handbook
Signs
Employee Orientation
Other:
Clear selection
Which of the following has your business done in the last 12 months?
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
Other:
Clear selection
Is your business considering implementing or expanding a smoke/tobacco free policy?
*
Yes
No
Are you in need of FREE smoke-free/tobacco-free signage for your business?
*
Yes
No
How many metal signs/window clings would you need?
Your answer
Would you like to be added to our list of smoke/tobacco free businesses in Sarpy & Cass County?
*
Yes
No
Would you like to be contacted with free information on how to implement a smoke/tobacco free policy?
*
Yes
No
Would you like to be added to T.E.A.M.’s email list?
*
Yes
No
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of CommonSpirit Health.
Report Abuse
Forms
