Smoke-Free Establishment Survey

The purpose of this survey is to gather information about tobacco use in businesses of Pottawattamie County. The survey should take no more than a couple of minutes.

Establishment Name:

Address:

Phone Number:

Manager or Owner Name:

Date:

1. How Would you describe your establishment?
Restaurant

Bar

Bar & Grill

Other


Please circle the answer that best matches your response:

2. What is the size of your establishment?
0 - 49 seats

50 - 99 seats

100 seats or more


3. How many employees do you have?

4. Which areas (if any) of your establishment are smoke-free? Check all that apply
Indoor restaurant seating

Indoor bar seating

Outdoor restaurant seating

Outdoor bar seating

Employees - only areas

Smoking is allowed everywhere


If smoking is allowed indoors move to Question 9

5. How long has your establishment been smoke-free?

6. What is the main reason the establishment went smoke-free? (mark only one)
Customers requested it

Employees requested it

Concern over losing business

Personal values/Right thing to do

Public health

Corporate decision

Don't know

Other


7. Have you noticed a financial impact after going smoke-free?
Revenue is more now

Revenue is about the same

Revenue is less now

Don't know

Not applicable (establishment opened smoke-free)

Other


8. Can we include your establishment in our smok-free dining guide?
Yes

No


If smoking is allowed indoors:

9. Are you considering a smoke-free policy?
Yes

No


10. What is the reason that smoking is still allowed?
There are no other restaurants/bars in the area that are smoke-free.

Many of my customers smoke.

Company policy states that the establishment cannot go smok-free.

Don't have a lot of demand for seating in non-smoking area.

Remodeling costs would be high.

Not required by local ordinance or state law.

Don't have enough information about the benefits of becoming smoke-free.

Establishment to small.

Other


Thank you for taking the time to complete this survey.

The Pottawattamie County Tobacco Prevention Coalition


© Copyright 2008 Pottawattamie County Tobacco Prevention Coalition, All rights reserved.