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Welcome to the Miami Township, OH, Action Line
Today is Thursday, March 30, 2017.
Tobacco Free Environment Survey

Purpose. Please tell us what you think about tobacco-free recreational places for our community by answering the following questions.

* Information is required.

Contact Information

First Name:
Last Name:
ZIP:

* Tobacco use should be prohibited in the following places (tobacco is defined as any type of cigarette, e-cigarette, vapor pen, cigar or other tobacco related product):

(1) = Strongly Disagree
(5) = Strongly Agree

PARKS
1
2
3
4
5
 
* (1) = Strongly Disagree
(5) = Strongly Agree

PLAYGROUNDS
1
2
3
4
5
 
* (1) = Strongly Disagree
(5) = Strongly Agree

OUTDOOR SPORTS FACILITIES
1
2
3
4
5
 
* (1) = Strongly Disagree
(5) = Strongly Agree

SKATEBOARD / BIKE PARKS
1
2
3
4
5
 
* (1) = Strongly Disagree
(5) = Strongly Agree

HIKING / BIKING TRAILS
1
2
3
4
5
 
* (1) = Strongly Disagree
(5) = Strongly Agree

PICNIC GROUNDS
1
2
3
4
5
 
* How often do you, or someone from your family, visit a Miami Township park?
At Least Once a Week
At Least Once a Month
At Least Once a Year
 
* How old are you?
Under 20
21-35
36-50
51-65
66+
 
* Are you a...(check all that apply)
Parent
Grandparent
Youth Leader / Coach
Sports Participant
Former Smoker
Smoker
Non smoker
8
 
* Are you a Miami Township resident?
Yes
No
 

* Information is required.

Notes:

If you send us a message, you will receive a Tracking Number allowing you to follow-up with your request, at your convenience.

Internal Use Only, Leave Blank:
Please leave this field blank and remove any values that have been populated for it.

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