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Smoking Questionnaire

Thanks for taking the time to tell us how you feel about smoke-free restaurants in your community. This information will be used by your local health department to work with restaurants on smoking issues in your community.

REMINDER: Your participation in this survey is completely voluntary. At any time you may refuse to answer questions, or you may withdraw participation. All information you supply will be confidential.

1. Please circle one:  Male   Female

2. How old are you?

3. Please circle one:  A current smoker   Former smoker   Never smoked

4. What is your zip code?  

5. What is your current employment status?: (We want to know because of our transient population.)
   Employed   Out of Work/Unable to work   Student   Retired   Homemaker  

6. How much does environmental second hand smoke in restaurants concern you?
   Not at all   Very little   Undecided/no opinion   Strongly concerned   Extremely concerned  

7. How likely would you be to visit a restaurant that is smoke-free?
   Never   Not likely   Undecided/no opinion   Very likely   Exclusively  

8. How likely are you to visit a restaurant that allows smoking?
   Never   Not likely   Undecided/no opinion   Very likely   Exclusively  

9. Is your favorite restaurant currently smoke-free?  Yes    No  

10. Do you want favorite restaurant to become smoke-free?  Yes   No  

11. When you dine out, would you prefer to eat at a smoke-free restaurant?  Yes   No  

12. How often would you estimate that you and/or your family dine out?
     Rarely if ever   Less than once a month   1-2 times a month   3-4 times a month  
     3-4 times a week   5 or more times a week   Every night  

13. Do you have children? Yes   No  

14. How many people are in your family?

15. What type eating establishments do you eat at most frequently?
      Fast Food   Sit Down Restaurant   Bar & Grill  

16. On average, how much do you spend when you or your family dines out?

17. If more restaurants in your county were smoke-free, would you dine out more often? Yes    No  


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