Tobacco Documents Online

C C - DDF~ Q BUSINESS SMOKING SURVEY 1 2 3 4 Please take a few minutes to answer the following questions about your corporation's smoking policies and programs. Information collected as a result of this survey will be used, in part, to assist member agencies of the National Interagency Council on Smoking and Health to plan smoking education and cessation programs for American businesses. All corporations completing this survey will receive a complete report of our findings. The report will not identify any corporation responding to this survey unless prior approval is obtained. Thank you in advance for your coop- eration in this effort. I. POLICY (e) A. Which of the following best describes your company's policy restricting or prohibiting smoking for some areas of. 5 company facilities? (check one answer) B. If your company currently has (or previously had) a policy prohibiting or restricting smoking in company facilities, what year was it implemented? 19 (78~ (9) C. Who was responsible for initiating the policy? (check the one best answer) Q Medical/Health Director 1 O 2 0 Q Company currently has a corporation-wide smoking policy 1 Q Smoking policy is set on an individual facility/plant/office basis 2 p Company had a smoking policy but policy no longer exists (PLEASE ANSWER QUESTIONS B-F REGARDING 3 COMPANY'S FORMER PROGRAM) p Company has never had a policy (SKIP TO SECTION 1, QUESTION G -TOP OF NEXT PAGE) 4 p Don't know (SKIP TO SECTION 1, QUESTION G -TOP OF NEXT PAGE) Personnel Director Other Management p Unions 4 Q Employees 5 Q Don't know 6 p Other (please specify) 7 D. If your company previously had a policy which no longer exists, what year was it discontinued? 19 Why was it discontinued? E. What is (was) the policy of your company with regard to smoking in the following areas: No Restrictions Designated Smoking on Smoking Non-Smoking Areas Completely Prohibited Dining areas Blue collar work areas White collar work areas Conference rooms Bathrooms Medical facilities All company property Other 0 C] El 1 2 3 11 El C1 1 2 3 C n n , 2 3 a a o 1 2 3 Cl L Cl 1 2 3 (specify) K

A ~ .. , F. Are (were) there penalties for violating the policy? L Yes p No p Don't know (22) G. (23) 1 2 3 Have the financial costs incurred by your company as a result of employees' smoking ever been calculated (i.e., increased absenteeism, health care utilization, housekeeping costs, early retirement)? = Yes ~; No G Don't know 1 2 3 1 2 3 H. Have any employees claimed that exposure to the cigarette smoke from other employees caused them to develop an illness or physical problem? [ Yes ` No C Don't know II. PROGRAMS (24) A. Does your company have (or did it ever have) an incentive program for encouraging smokers to quit (e.g. time" off, money, prizes, etc.)? (check one answer) 0 [ Yes, currently have an incentive program ~ L., Previously had an incentive program but no longer exists 2 C No, never had an incentive program (SKIP TO QUESTION B) 3 i"I Don't know (SKIP TO QUESTION B) 4 If your company currently has (or had) an incentive program please describe the program briefly. In your opinion, how successiul was the program? (25) B. Does your company currently have (or did it have) health education or promotion programs on any of the follow- ing topics for employees? (check all that apply) Q Weight control/diet (26) O High blood pressure • (27) Q Smoking (2s) p Breast self-examination (29) p Exercise (30) Q Stress management/control (31) Q Other, please specify (32) Q No, never had such programs (SKIP TO SECTION 111) (33) [ Don't know (SKIP TO SECTION III) C. How are your employees made aware of these program(s)? (check all that apply) (34) Q Payroll stuffers - (3S) O Posters (36) Q Announcements in company newsletter O (37) Q Through their union CJ (38) Q Shop foremen ~ C.: (39) Q Medical department ~ (40) C Word-of-mouth cJ (41) F-1 Don't know O (42) C Other (specify) D. If your company has (had) an education program devoted to helping smokers quit, please answer the following questions. (IF IT DOES NOT, SKIP TO SECTION III) What form(s) does your company's smoking program take? (check all that apply) (43) Q Physician counseling of smokers (44) Q Other health professional counseling (45) Q Distribution of how-to-quit smoking materials 0

1 i> (46)' (47) (48) (49) ~ c Q Single session smoking presentation/films p Multi-session group clinics Q Other (specify) Q Don't know (SKIP TO QUESTION G) E. Of the program(s) provided, which are (were) conducted primarily by or both: Company Outside Staff Organization(s) Both (52) (53) (54) (55) (56) Physician counseling Other health professional counseling Distribution of how-to-quit smoking materials Single session smoking presentation Multi-session group cessation clinics Other _ 3 G G 7 2 3 O C ~ ~: . 7 2 3 O C u 1 2 3 a a C 1 2 3 a Cl o 1 2 3 If outside service(s) or organization(s) are involved, please specify name(s) F.• Of the services provided, which are (were) administered on company time, before or after On Company Before or Time After Working Hours (59) (62) (63) (64) (65) Physician counseling Other health professional counseling Distribution of how-to-quit smoking materials Single session smoking presentation/films Multi-session group cessation clinics Other company staff, outside organization(s) 0 2 G. Has your company allocated any funds to support smoking programs? (check one answer) Q No 1 Q $100 or less, annually 2 Q $100 - $500, annually 3 Q $500 - $1,000, annually 4 p $1,000 - $5,000, annually 5 Q Over $5,000, annually 6 Q Funds allocated one time (specify amount) ~ p Don't know 6 H. Has your company conducted any evaluation Q Yes p No p Don't know 1 2 3 of its smoking education program(s)? (check one May we request a copy of your evaluation results? III. PROGRAM DEVELOPMENT [ Yes L No , 2 N (66) A. Would your company be interested in developing/expanding a program on smoking and health for employees? (check one answer) Q Yes C No C Don't know (67) 1 2 3 B. If yes, would you like essistance with the program? (check one answer) p Yes Q No 1 2 answer) O W ~ W ~ U f 0

IV. DEMOGRAPHICS 1 2 3 4 Name Position Company Name Company Address City State Zip Type of Business (e-7) Number of health care personnel on staff: MD. ~ R.N. _, Health Educator , Other (specify) (8-9) (10-11) (12-13) Number of employees in corporation (16-21) (14-15) What percentage of your work force is: (22-24) white collar % (ss-27) blue collar % (2") unionized % If unionized, which union(s) represents these employees? (31-32) How many offices/facilities/plants does your company have? (please indicate number) (33-36) NOTE: PLEASE DESCRIBE ANY SAMPLE LITERATURE DEVOTED TO SMOKING WHICH YOUR COMPANY HAS USED. IF YOUR COMPANY HAS PRO- DUCED ANY ORIGINAL MATERIALS, PLEASE ATTACH COPIES. O W ~ W Please return questionnaire by June 15th to: ~ C National Interagency Council on Smoking and Health ~j 291 Broadway Room 1005 , New York, New York 10007 0