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Outdoor Recreational Survey
Tobacco Education & Advocacy of the Midlands (T.E.A.M.) would like to thank you in advance for taking the time to fill out our Outdoor Recreational Survey. If you have any questions or would like some free signs for your facility email us at
info@teamtobaccofree.org
.
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* Indicates required question
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
Your Name
*
Your answer
Phone Number
*
Your answer
Location of your outdoor recreational facility (playground/park)
*
Your answer
Does your facility (playground/park) have a tobacco-free policy?
*
yes
no
Required
Which of the following best describes your tobacco policy?
Ban on all tobacco use (including smokeless tobacco)
Ban on smoking
Smoking is restricted to certain areas
Clear selection
Are electronic nicotine delivery systems (eg. e-cigarette/vaping type devices) included in your policy?
yes
no
How is your policy visibly communicated? Please check all that apply.
Entrance sign
Fence mounted sign
Stand-alone sign
Other:
Clear selection
Would you like to be contacted with free information on how to implement or strengthen a tobacco-free playground & park policy?
*
yes
no
Required
Would you like to be added to T.E.A.M.’s email list for quarterly updates?
*
yes
no
Required
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