Smoking Ban Survey

All Information will be kept CONFIDENTIAL!

First Name Last Name

Address

City State Zip Code

Phone Number Cell Number E-MAIL

Please Select a job position or customer status and then select a casino.

How many days do you visit or work each month in a smoky environment?

Do yo have any perceived disability that requires you to avoid smoky environments? If yes select the one that describes you best.

Would you like to a complete ban on smoking where you work or play?YES NO

How many years have you worked or visited there?

How many times do you visit or work each month in a smoky environment?