Are all indoor work areas smoke free?	Yes No
Are the grounds smoke free?	Yes No
Would you like your facility and grounds to become smoke free?	Yes No
Is there a union?	Yes No
Is cessation assistance offered by the employer?	Yes No
Is cessation assistance as a health benefit?	Yes No
If YES to either, what type of cessation assistance is offered?
Cessation counseling coverage
Medication coverage
Other (please specify)

Business Name:
City/Town:
HR Contact name:
Email:
No. of employees:
Type of industry:
(ie: construction, medical, manufacturing, etc.)