We are conducting a survey to gather data on 2nd hand smoke exposure and diabetes in the American Indian community. Please help us by taking a few minutes to answer the following questions. Thank you.

Fields marked with * are required.

Name*

Street Address*

City*

State*

Zip Code*

County

Are you American Indian from a tribe located in the United States or Canada?*

Yes No

What tribe are you enrolled with?

If you are not an enrolled member of a tribe, please give a brief description of why?

Number of people in Household?*

Chldren under the age of 18?*

Seniors over the age of 60?*

Is Your Home*

Single Family Residence? Duplex? Multi-Family?

Do you or anyone in your household smoke?

If yes, please check all that apply

Cigarettes Cigars Hookah Other

Are you Diabetic?

Is anyone else in your home Diabetic?

If you answered yes to either question, please provide the age(s) of the individual(s) with Diabetes.

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