West Virginia | Department of Health and Human Resources | Bureau for Public Health | OEHP

Survey to Determine Your Level of Interest for Clean Indoor Air Issues
First Name:    Last Name:
Do you represent an organization: Yes     No
Name of organization:
Your Title:
Address:
City:
State where you live:
Zip:
County where you live:
Home phone:
Work phone:
Fax:
Cell phone:
Your primary e-mail:
How do you prefer for us to reach you? (select only one): e-mail (what DTP prefers)    phone    fax    mail
Your occupation:
List civic, fraternal or professional groups you belong to:
Are you a member of your local tobacco prevention coalition or the state Coalition? Please list:
Your age (optional, but if you are under 18 years old you must state your age):
Do you have expertise in any area that relates to clean indoor air?
Tobacco use (check any that apply---for matching up speaking opportunities):
      I’m a current smoker.
      I’m an ex-smoker.
      I’m a current user of spit tobacco or other tobacco products.
      I’m a ex-user of spit tobacco or other tobacco products.

      I’m a lifelong nonsmoker/nonuser of any tobacco products.
Would you be willing to (check any that apply):
      testify at public hearings (county Board of Health or Legislature).
      become a member of a local Speaker’s Bureau to do public presentations.
      write letters to the editor for your local paper.
      make phone calls to your acquaintances.
      write letters to political leaders or community leaders.
      become an active member (if not already) of your local Tobacco Prevention Coalition.
      Other: you tell us what you want to do:
What areas would you like more information on:
      health effects of secondhand smoke exposure.
      statistics and research on secondhand smoke.
      legal issues.
      how to get businesses to voluntarily adopt policies.
      prohibiting secondhand smoke exposure for children.
      activism/empowerment for youth.
      enforcement and compliance.
      media and communications.
      housing issues or senior citizens issues.
      how the tobacco industry attempts to undermine local efforts.

Privacy Assurance from the WV Division of Tobacco Prevention: We are committed to protecting this list of people interested in Clean Indoor Air. We will not sell your name to other groups and we will not ask you for money. This list will be used only by the WV Division of Tobacco Prevention or its contracted agents, to promote policy change in tobacco prevention, primarily Clean Indoor Air. By providing the above information you are not obligated to engage in any of these activities, and you may request to have your name removed at any time.

To begin your advocacy, please pass along this website to 5 more people and encourage them to obtain a pass code, and complete this survey, or call the WV Division of Tobacco Prevention and it can be transmitted by fax. Thanks.

Return completed surveys to:

WV Division of Tobacco Prevention
WV Bureau for Public Health
350 Capitol Street, Room B-55
Charleston, WV 25301-3715 		garlandholley@wvdhhr.org
toll-free phone 1-866-384-5250
phone (304) 558-2939
fax (304)558-2285

   

West Virginia (WV)
Department of Health and Human Resources (DHHR)
Bureau for Public Health (BPH)
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Last updated: 3/31/03.
If you have problems navigating this page or suggestions for improvements, contact daleporter@wvdhhr.org.