Tribal Tobacco Program Needs Assessment

3. Years you have worked in your current______Years haveworked your 3. youin position: TribalCommunity 2.Served: ______Whatyour ______current position? 1.is among thecurrentpolicy needs you provideiscriticalfor assessing information The NameOrganization’s Strongly Disagree. Strongly rate the *Please of agreement level your with of following each the statements betweenbelow 1 5; being Agree (5) and (1) Strongly and being currently )Never Do smoke? Occasionally you () Everyday ) ( 4. ( 7. 6. 5. 4. 3. 2. 1. ItemDescription of Organization’s Name Organization’s smoke andmyself family to my members. Iaboutthe effects concernedhealth secondhand am of the usesecondhand effectssmoke.tobaccoandhealth of understanding my inhavea Peoplegood about community landboundaries.tribal within restricting secondhand exposure health, smoke including protect public tribaltohas Thean government obligation environments. should employees Tribal smoke-freehave work businesses money. businesses Requiring worksites/tosmoke-freecost wouldbe businesses money. businesses Requiring worksites/tosmoke-freesave wouldbe smoke-free My a communitysupport policy would

TRIBAL LEADER POLICY READINESS ASSESSMENT ASSESSMENT READINESS POLICY LEADER TRIBAL TRIBAL LEADER POLICY READINESS ASSESSMENT ASSESSMENT READINESS POLICY LEADER TRIBAL is conducting a needs assessment of tobacco policy implementation within your community. The community. your within implementation policy tobacco of assessment needs a conducting is

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S ECTION ECTION 1: D 1: 1: D 1: 2: Y 2: 2: Y 2: EMOGRAPHIC EMOGRAPHIC OUR OUR 1 O O PINION PINION AI/AN Tribe D D ATA ATA

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1 Agre e

2 Agree

3 Neutral

4 Disagree 5 Strongly Disagree *Please rate thefor*Please frequency each below item between and (1) frequently (5) 1 5; being and being never.

2. 1. ItemDescription of community publications? community publications? tobaccosee advertisements How you your do in often messages radio community? you in or television, billboards, hear smoke-free newspapers and smoke-freesee How you ads do on often promotional returnPleaseassessment this to: you better. Thank you for completethe taking time to this assessment. willYour effortshelp us serve

S ECTION ECTION 3: S 3: 3: S 3: Phone: Fax: Fax: MOKE MOKE Fax Contact nameContact Phone Address lineAddress Two lineAddress One Organization -F -F

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2 OBACCO OBACCO Logo A A DVERTISING DVERTISING

1 Frequently

2 Sometimes

3 Neutral

4 Rarely 5 Never