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Second Hand Smoke Survey
Do you want bars, restuarant and clubs in NYC to be smoke free. Yes No Don't Care Undecided  
Are You a Smoker ? Yes No Sometimes    
Have you ever smoked ? Yes No      
Age? 13-16 17-25 26-35 36-49 50 and older
Your Sex? Male Female      
Are you aware why nonsmokers are concerned about clean air indoors? Yes No Kind of Don't Care No Opinion

Very Important for Data

Name:

State:
City:

Country:

Your present occupation? If Other Explain

 

Any additional comments about Second hand Smoke?