Please take a few minutes to complete this survey. Your feedback is greatly appreciated! 

Sincerely, 
Will County Health Department Tobacco Control & Prevention Program

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* 1. What city do you live in?

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* 2. What type of housing do you live in?

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* 3. Including yourself, how many people live in your home?

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* 4. Of the people in your unit, how many smoke?

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* 5. Do you allow smoking inside your home?

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* 6. In the past year, how often has tobacco smoke entered your home from somewhere else in or around your home or building?

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* 7. If tobacco smoke has entered your home, did it bother you?

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* 8. If tobacco smoke were to enter your home in the future, would it bother you?

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* 9. Are you concerned about the effects of secondhand or thirdhand smoke on your health or the health of those you live with?

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* 10. Would you prefer to live in a home or building that is completely smoke-free, including units, balconies/patios, and 25 feet around the building?

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* 11. Additional Comments:

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* 12. Building Name and Address:

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* 13. Your Name (optional):

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* 14. Contact Information (optional):

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