Name of Community (required)

Address (required)

City, State and Zip Code (required)

Contact Name (required)

Your Email (required)

Phone (required)

Website Address (required)

Public Housing (required)
YesNo

Affordable Housing (required)
YesNo

Market Rate (required)
YesNo

Single Family Home (required)
YesNo

Other

Number of Smoke free Units (required)

Number of Smoke free Buildings (required)

Restrictions on smoking on premises (required)
YesNo

Details of the smoking policy no smoking within distance from building, does the policy including vaping and electronic cigarettes?, etc

Policy effective date (required)