Smoking Attestation Form
The 2017 Smoke Free “1 point” award requires that employees complete and sign the certification below if you designate you are not a smoker.
*******************************************************************************
I certify that I do not smoke cigarettes and have not used tobacco products in any way in the past year.
Your signature must be witnessed by someone close to you that can attest that you have not smoked or used tobacco products in the last year.
Employee Signature: ______Date:______
Witness Signature: ______Date: ______
Relationship of Witness: ______
“Kicking the Habit” attestation form
I certify that I am a former ______user.
(nicotine, caffeine, sugared drinks or sodium)
I have quit, reduced or improved my usage and consumption and certify that I am monitoring daily my intake. I have kicked the habit and I am aware of the dangers and impacts of use of the products on my health.
Your signature must be witnessed by someone close to you that can attest that you have kicked the above habit as designated. You must submit this signed “kicking the habit attestation form” for each habit you have kicked. You may earn “1 point” for each habit you kick.
Employee Signature: ______Date:______
Witness Signature: ______Date: ______
Relationship of Witness: ______