Name of Community (required) (required)

Street Address (required) (required)

Address Line 2

City (required) (required)

State (required) (required)

Zip (required) (required)

Name (required) (required)

Email (required) (required)

Phone (required) (required)

Website Address (required) (required)

Public Housing (required)
(required)

YesNo

Please select Yes or No.

Affordable Housing(required)
(required)

YesNo

Please select Yes or No.

Market Rate(required)
(required)

YesNo

Please select Yes or No.

Single Family Home(required)
(required)

YesNo

Please select Yes or No.

Other

Number of Smoke free Units

Number of Smoke free Buildings (required) (required)

Restrictions on smoking on premises(required)
(required)

YesNo

Please select Yes or No.

Details of the smoking policy (e.g., no smoking within distance from building; includes vaping/e-cigarettes; etc.)

Policy effective date (required) (required)