Storefront SurveyBusiness Name (optional):

The Creating Healthy Communities Program would like your opinion on a smoke-free storefront initiative in Bluffton. This could help lead to a smoke-free Main Street, or business district, where residents, customers and visitors could experience a smoke-free environment while shopping and attending events on Main Street. We would appreciate your thoughts and ideas on this.

Please take a moment to complete this survey to provide feedback to us on your thoughts and opinions about a smoke-free storefront project in Bluffton. Taking part in this survey is voluntary. All information you provide on this form is confidential and will be kept anonymous.

Thank you for taking time to complete this survey.

  1. Do you have employeesthat use tobacco products? Yes No
  2. If they smoke tobacco, where do they smoke during thework day?(which includes E-cigarettes)

Outside the front of the building

Outside the back of the building

In their car (in the parking lot)

In their car (off property)

They do not smoke during thework day

Other: ______

  1. Have you noticed people smoking (including E-cigarettes) outside your storefront or other storefronts along Main Street?

Yes No

  1. Do you believe that exposure to secondhand smoke is harmful to others?

Yes No

  1. In the past six months, how often has tobacco smoke entered your business from someone smoking outside your building?

Frequently (every day)

Often (one or more times a week)

Sometimes (one to three times a month)

Rarely/Never

  1. If tobacco smoke entered your business, did it bother you? Yes No N/A
  2. Would you like to have a smoke-free storefront?

Yes No I don’t care

  1. If you would like to have a smoke-free storefront, why? (Check all that apply)

I don’t like the smell

Smoke bothers me/affects my health

I worry that smoke affects the health of my customers/clients

I worry that smoke deters customers/clients from my business

Other: ______

  1. Would you support a smoke-free Main Street? Yes No Maybe No opinion

Allen County Creating Healthy Communities Program. This work is funded either in whole or in part by a grant awarded by the Ohio Department of

Health, Bureau of Healthy Ohio, Creating Healthy Communities and as a sub-award of a grant issued by Ohio Department of Health under the

Preventive Health and Health Services Block Grant, and CFDA number 93.991.