
Sample smoke-free employee surveys
The following surveys can be used to assess how adopting a smoke-free workplace policy might effect your business. They can also be downloaded in MS Word format (77kb) so that you can edit them for your own use.
| Secondhand Smoke: Business Report Card | |
| Customer Survey | |
| Employee Opinion Survey |
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Secondhand Smoke: Business
Report Card
Curious about your policy on smoking in the workplace? Take a quick test and see
how you score!
Category |
Grade Determinants |
Possible Scores |
Your Score |
|
Policy |
Smoke free on entire business campus, in business owned vehicles and at business sponsored events. |
40 |
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Smoke free inside business but smokers are allowed to smoke outside, away from windows and entrances. |
35 |
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Smoke free in most of the building with separately ventilated rooms for smokers. |
30 |
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Smoke free in most of the building; smoking sections in lounges and lobbies. |
20 |
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Smokers are allowed to smoke anywhere in building. |
0 |
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Partners in the Policy |
Everyone, including employees, managers, owners, customers and guests, are prohibited from smoking. |
10 |
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Employees are prohibited from smoking but guests are allowed to smoke in prohibited areas. |
5 |
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Employees and guests allowed to smoke anywhere. |
0 |
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Enforcement |
Policy is strictly enforced by both employees and managers who respect the policy. |
20 |
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Policy is reluctantly enforced by managers, leaving the work to employees who feel strongly about the policy. |
10 |
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The policy is not enforced by employee or managers. |
0 |
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Cessation Resources |
Any employee who expresses an interest in quitting is provided with cessation resources, positive incentives to quit and breaks on the costs of quitting. |
20 |
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Employees who are smokers and who want to quit have access to cessation pamphlets and are compensated by their insurance for cessation aides. |
15 |
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Employees who are smokers are encouraged to quit through education as well as by peers. |
10 |
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Employees who want to quit are encouraged to look for cessation resources when they’re not at work. |
5 |
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There are no cessation resources offered. |
0 |
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Community Involvement |
Business sponsors community events that educate people about secondhand smoke and smoking, and offers advice to businesses which are changing their smoking policy. |
10 |
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Sponsors some community events as long as they are tax deductible and promote the business’ logo. |
5 |
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Does not sponsor community events and is not willing to talk to other businesses about smoking policies |
0 |
Tally your score for a final grade _______
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85 to 100 points | ||
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71 to 84 points | ||
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56 to 70 points | ||
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41 to 55 points | ||
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40 or less |
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Customer Survey
Here is a set of easy questions about secondhand smoke you can ask customers
and visitors as they leave your business. You can then tally these results to
determine whether your customers would support a smoke-free policy.
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Assessing Secondhand Smoke: Customer Survey |
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Question |
Very True |
Somewhat True |
Not Very True |
False |
Don’t Know |
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Knowledge of secondhand smoke |
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Exposure to secondhand smoke is dangerous for children. |
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Secondhand smoke causes lung cancer. |
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Secondhand smoke causes heart disease. |
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Secondhand smoke causes asthma and bronchitis. |
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Secondhand smoke irritates asthma and bronchitis |
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Preference |
A smoke-free environment is the only way to protect yourself from secondhand smoke. |
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It is ok to be exposed to some secondhand smoke. |
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Affect on Patronage |
I would be more likely to eat/shop at a smoke-free restaurant/store. |
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I would tell my friends if a restaurant/store was smoke-free. |
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The following worksite survey is a two-part survey to determine whether employees would appreciate and benefit from a smoke-free policy in the workplace.
Worksite Survey
| Frequently bothered | |
| Occasionally bothered | |
| Seldom bothered | |
| Never bothered |
| Eye, nose and throat irritation | |
| Concern for your long-term health | |
| Interference with work performances | |
| Headaches | |
| Pregnancy related concerns | |
| Other, please specify_________________________________________ |
| Company grounds should be entirely smoke-free | |
| The building should be entirely smoke-free | |
| Smoking should be allowed in rooms with separate ventilation, dedicated
only to smoking. Please specify the location_______________________ |
| Currently smoke cigarettes | |
| Currently smoke pipe/ cigar | |
| Used to smoke | |
| Never smoked |
For current smokers only:
| Yes | |
| No | |
| Maybe |
| It would not affect it | |
| I would smoke less | |
| I would smoke more at home | |
| I would try to quit. |
Thank you for your cooperation!
Worksite Follow-Up Survey
| Currently smoke cigarettes | |
| Currently smoke pipe/ cigar | |
| Former smoker (stopped before the smoking policy was adopted) | |
| Former smoker (stopped after the smoking policy was adopted) | |
| Never smoked |
| Not strict enough | |
| Reasonable | |
| Too strict |
| Definitely harmful | |
| Probably harmful | |
| Not harmful | |
| Not sure |
For those who smoked at the time the smoking policy was implemented:
| Yes, I have enrolled. | |
| No, I have not enrolled. |
| I smoke less overall. | |
| I smoke less at work. | |
| I smoke more overall. | |
| I smoke more at work. | |
| I smoke more at home. | |
| It has not affected me. | |
| I quit smoking. | |
| I am trying to quit. | |
| I smoke less at home. | |
| I only smoke outdoors. |
This page was last updated on May 28, 2003. Copyright © 2003 Tobacco Prevention and Control Branch, NC Department of Health and Human Services. All rights reserved. Click here for disclaimer.