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The purpose of this assessment is to help communities determine their level of readiness to engage in a smoke-free community campaign or to propose or enact a smoke-free ordinance. The information collected will be used to tailor the technical assistance provided to the individual community by the Kentucky Center for Smoke-Free Policy (KCSP).

All information collected will be kept confidential and used only by the KCSP staff.
Community Readiness Assessment
Your Name:
Your organization/coalition/community name:
Your position in the organization/coalition:
Your contact information:
Work Phone:
Other Phone:
Fax:
Cell Phone:
Other Address:
Work Address:
Month
Day
Year
/
/
City:
State:
Zip:
City:
State:
Zip:
1. How many members does your organization or coalition have (fill in all that apply):
a. # of volunteers
c. # of email advocates (i.e. individuals on a listserv or Action Alert list)
d. # of Board of Directors
e. # of Partner organizations
b. # of paid staff
Please fill in all that apply:
f. # of other individuals (please describe)
2. In the past year, has your organization (fill in all that apply):
Please explain below:
3. How many people in your organization are employees with 100% of their time dedicated to tobacco control?
4. How many people in your organization are employees with at least 25% of their time dedicated to tobacco control?
5. How many people in your organization are volunteers who spend at least 5 hours per month dedicated to tobacco control?
Local Board of Health
Health voluntaries (Heart, Lung, and Cancer)
Newspaper editor(s)
Faith-based organizations
Minority organizations (African-American, Hispanic, etc.)
Gay/lesbian organizations
Medical community: doctors, hospitals, clinics, etc.
Groups that advocate for low-income populations
Schools
District Board of Health
Other (please list)
6. Have you talked with the following organizations in your community about being partners in a campaign for a smoke-free ordinance or regulation (if yes, what is their level of support?):
1 = very supportive (actively involved)
2 = moderately supportive (involved when called upon)
3 = not supportive (uninvolved)
4 = opposed to smoke-free efforts
Local Health Department
7. What is the position of your local leaders on enacting a smoke-free law:
Mayor
County Judge Executive
County Attorney
City Manager/City Administrator
# For
# Uncommitted
# Against
# Don't know
Chamber of Commerce
Industrial Board Members
Council members
# For
# Uncommitted
# Against
# Don't know
County commissioners/magistrates
# For
# Uncommitted
# Against
# Don't know
Board of Health
# For
# Uncommitted
# Against
# Don't know
Business/civic leaders: (Please describe their level of support or opposition)
Other: (Please explain)
8. What voluntary smoke-free policies are currently in place in your community? (i.e. courthouse, malls, businesses, etc.) Please describe:
9. How do your local media portray tobacco issues (Please rate on a 1-5 scale; 1 = unfavorable toward tobacco control, 5 = very favorable toward tobacco control):
TV
Newspaper
Radio
Comments:
11. Please describe any issues or potential concerns within your own organization or partner organizations that exist related to smoke-free laws? (i.e. youth only focus vs. worker health; or restaurant only vs. all public places)
10. What groups are likely to oppose a smoke-free law in your community? (Fill in all that apply)
12. Some organizations can lobby policymakers. Others can only provide education. Who in your own organization or partner organizations can lobby policymakers for a smoke-free law in your community? (Please list all that apply):
13. What mechanisms does your organization have for communicating with members, partners, and interested citizens (fill in all that apply):
14. What financial resources are currently dedicated to a smoke-free campaign in your community?
(Actual $)
(In-kind)
15. In general, how much experience do members of your organization have with:
( 1 = Little or None, 5 = Extensive)
Organizing grassroots supporters
Educating political leaders
Disseminating research-based information on SHS
Conducting media campaigns
16. Within the next year, what policy outcome does your organization want most to achieve?
17. How do you rate your community's readiness to propose or enact a smoke-free ordinance or regulation or to initiate a smoke-free community campaign?
18. Who provides the leadership for tobacco control efforts in your community?
Name:
Affiliation:
19. In your opinion, how effective is this person (see question # 18) in providing leadership in moving your community toward enacting a smoke-free law or ordinance?
20. What help do you need most in moving your community toward enacting a smoke-free law or ordinance? Please rank from 1 (most help) to 6 (least help):
a. Data and interpretation of the latest and most important scientific evidence , including:
secondhand smoke
economic effects of smoke-free laws
ventilation standards
tobacco industry tactics

b.
Basic legal information concerning :
Benefits of municipal ordinance versus health board regulation
Model smoke-free laws
Examples of exemptions to avoid

c.
Assistance in conducting, analyzing and disseminating public opinion polls , conducting policymaker assessments, and other community-based studies

d.
Media advocacy consultation including:
How to meet with editorial boards
Writing letters to the editor and opinion editorials
Advocating through talk radio programs
Planning low-cost, paid media campaigns

e.
Technical assistance
One-on-one consultations tailored to specific communities
Threaded online discussion available to all participants
Samples of materials from successful smoke-free campaigns

f.
Strategies for leveraging additional funds
Identifying funding sources
Fundraising consultation
Identifying in-kind support

g. OTHER (Please describe):

21. What else would you like us to know about your community's readiness to propose or enact a smoke-free ordinance or regulation or to initiate a smoke-free campaign?
Thank you for participating in this readiness assessment. If you have questions or comments, please contact us at kcsp00@lsv.uky.edu or (859) 323-1730.
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