Salt Lake Valley Health Department

Tobacco Prevention and Control

Smoke-Free Pledge

Do not change this value:

I (your name)
pledge on (mm/dd/yyyy)
to protect myself and my family from the health risks of secondhand smoke by making my home and car 100% smoke-free.

Zip Code:

Before signing this pledge did you or anyone else (family & visitors) smoke in your home or car?
Yes No

Do you have children under the age of 18 living in your home?
Yes No

I live in a(n)
Single family home
Apartment
Condo
Duplex
Other

If you are living in an apartment, condo or duplex does your lease contain a smoke-free policy?

Yes No

Would you like a smoke-free home kit mailed to your home?
Yes No

If Yes, Please fill out the Mailing Address information below:

Street:
City:
State:
Zip: