JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Multi-Family Housing Tobacco Policy Survey
To learn more about smoke-free housing visit
TEAMTobaccoFree.org
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
Name
*
Your answer
Complex Name
*
Your answer
Complex Address
*
Your answer
Phone Number
*
Your answer
How many multi-unit housing buildings are on your property?
*
Your answer
How many units are in your complex?
*
Your answer
Who owns your complex?
*
Your answer
Who manages your complex?
*
Your answer
Does your complex have a tobacco policy?
*
Yes
No
If your complex has a tobacco policy, which of the following best describes it?
All of the buildings are required to be 100% smoke-free
All of the buildings are required to be 100% smoke & vape-free
Some of the buildings are required to be 100% smoke free
Some of the buildings are required to be 100% smoke & vape-free
All of the common areas (pool, picnic, playground, etc) are required to be 100% smoke-free
All of the common areas (pool, picnic, playground, et) are required to be 100% smoke & vape-free
How many buildings are covered under this policy?
Your answer
How many units are covered under this policy?
Your answer
Is your tobacco policy included in your lease agreement?
Yes
No
Clear selection
Are you in need of FREE smoke/vape-free property signage or window clings for your property?
Yes
No
Clear selection
How many metal signs and or clings would you need?
Your answer
Would you like to be added to our list of smoke/vape-free housing options in Sarpy & Cass County?
Yes
No
Clear selection
Is your complex considering implementing a tobacco policy?
Yes
No
Clear selection
Would you like to be contacted with free information on how to implement or strengthen your tobacco policy?
Yes
No
Clear selection
Would you like to subscribe to T.E.A.M.’s monthly e-newsletter?
*
Yes
No
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of CommonSpirit Health.
Report Abuse
Forms
