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
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
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?
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