Smoke-free Homes Promise form – Smoke Free Highland

1. How many children/young people live at your address or stay overnight on a regular basis?

2. How many people who smoke live at your address?

3. How many people who live at your address have recently stopped smoking?

(Quit smoking in the last two months)

4. Now that you have had the chance to look at this leaflet, is there a promise that you would like to take?

If you have chosen 'none' why would this be the case?

5. Before hearing about this project where did smoking occur in your home?

6. Before hearing about this project did you or anyone smoke in your car?

Yes
No
We don’t have a car

7. Where did you find out about this challenge?

If you found out about the challenge via a 'special event' or 'other', please specify:

8. Would you like us to send you a free Smoke-Free Homes Guide?

Yes
No
No, I’ve already been given one

9. Would you like a Stop Smoking Adviser to contact you?

Yes
No
No, I already have one

10. Would you like the Fire & Rescue Service to contact you to see if you require a free home fire safety visit?

Yes
No
No, I’ve already had one

By ticking ‘Yes’ you are agreeing to us passing on your details to the Fire & Rescue Service.

Name *

First

Last

Address

Postcode *

Telephone Number

NHS Highland has a policy not to pass on your details to anyone else. We may contact you in the future for evaluation purposes to find out how useful this project has been. I consent to NHS Highland contacting me for this purpose. *

Yes
No

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.