By Stacy Hamilton,2014-07-08 10:36
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    SHIP Evaluation 2012-2013

    Follow-up Campus Tobacco-Free Policy Assessment

     INSTRUCTIONS: Complete this assessment for each campus with which you have been

     collaborating, even if there has been no change in status. Your answers should reflect as

     accurately as possible the status of the policy at the end of the SHIP funding cycle. To

     ensure you have the necessary detail for completing the form, you may need to review the

     campus policy and other official documents, visually inspect the campus grounds, and/or

     interview a campus administrator.

Name of institution: __________________________________________________________________________________

City: _____________________________________________ County: _____________________________________________

Tobacco Use Policies

1. The campus:

    ? Has a written smoke-free policy List month and year of enactment: _________________

    ? Has a written tobacco-free policy List month and year of enactment: _________________

    ? Does not have a written policy related to tobacco use (skip to question 10)

2. If the campus is smoke-free or tobacco-free, are the following areas covered by the policy?

    a. All campus grounds (i.e., there are not any designated outdoor ? ? No ? NA

    smoking areas) Yes

    b. Parking lots ? ? No ? NA


    c. Outdoor sporting venues ? ? No ? NA


    d. Indoor sporting venues ? ? No ? NA


    e. Campus vehicles ? ? No ? NA


    f. Dorms/residence halls indoors, including students’ rooms and ? ? No ? NA

    common areas Yes

    g. Dorms/residence halls outdoors, including balconies, entrances ? ? No ? NA

    and courtyards Yes

    h. Rental agreements ? ? No ? NA


     i. Other (please specify): _________________________________________

    SHIP Evaluation 2012-2013

Implementation and Enforcement

    3. Tobacco policies are communicated to students, faculty, and staff at least Yes ? No?

    three different ways:

    ? Class catalog or schedule

    ? Student policy/conduct handbook

    ? Registration materials

    ? Campus newspaper

    ? Campus website

    ? Recruitment materials

    ? Staff policy handbook

    ? Other (please specify): ______________________________________________________

    4. Posted signs reflect current tobacco use policy Yes ? No?

    5. Ash cans are placed in appropriate areas (compliant with campus policy) Yes ? No?

    6. An enforcement protocol is on file Yes ? No?

    7. The designated enforcement entity has been trained on the enforcement Yes ? No?


    8. The enforcement protocol includes procedures for responding to complaints Yes ? No?

9. How often is the enforcement protocol followed?

     ? Never

     ? Rarely

     ? Sometimes

     ? Usually

     ? Always

    SHIP Evaluation 2012-2013

Sale of Tobacco Products

10. Tobacco products and tobacco paraphernalia are sold on campus Yes ? No?

Tobacco Cessation Resources

11. Staff provide self-help materials to students, faculty or staff who want to Yes ? No?

    quit using tobacco

12. Staff provide on-campus counseling to students, faculty or staff who want

    to quit using tobacco Yes ? No?

    If yes:

    Are the staff providing the counseling Yes ? No? trained Nicotine Dependence Counselors?

13. Staff provide referrals to off-campus cessation programs for students,

    faculty and staff who want to quit using tobacco (e.g., QUITPLAN, etc.) Yes ? No?

14. Campus financially supports cessation efforts of students, faculty or staff

    (e.g., offers low-cost or free nicotine patches and cessation medicines, Yes ? No?

    provides insurance coverage for cessation services, etc.)

    Date completed _________________________________________________

    Completed by ___________________________________________________


    Phone: ___________________________________________________________

    This tool was adapted from the California Youth Advocacy Network

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