+-----------------------------------------------------------------------+
| ![](media/image1.png){width="1.242361111111111in"                     |
| height="0.3                                                           |
| 854166666666667in"}![](media/image2.png){width="1.2902777777777779in" |
| height="1.51875in"}                                                   |
|                                                                       |
| #                                                                     |
+-----------------------------------------------------------------------+
| ######                                                                |
|                                                                       |
| ######                                                                |
|  What is the Smoke-free Home Pledge Campaign and why is it important? |
+-----------------------------------------------------------------------+
| ######                                                                |
|                                                                       |
| The *Smoke-free Home Pledge Campaign* is designed to educate parents  |
| and caregivers about health risks to children from secondhand smoke   |
| exposure and encourage them to commit to providing a smoke-free       |
| environment in their homes and cars.                                  |
|                                                                       |
| An estimated 11 percent of U.S. children 6 years of age or younger    |
| are regularly exposed to secondhand smoke in the home. Protecting     |
| children from secondhand smoke is especially important because their  |
| bodies are growing and developing. Exposure to secondhand smoke can   |
| cause children to experience more respiratory infections such as      |
| bronchitis and pneumonia, and middle-ear infections, and more         |
| frequent and severe asthma attacks. Secondhand smoke exposure has     |
| also been linked to low birth weights and Sudden Infant Death         |
| Syndrome also known as SIDS.                                          |
+-----------------------------------------------------------------------+
| ######                                                                |
|                                                                       |
| ###### Why conduct a pledge event?                                    |
+-----------------------------------------------------------------------+
| A pledge event provides a great opportunity to interact with          |
| families, caregivers, and other stakeholders. One-on-one interaction  |
| is often the most effective way to educate individuals, ensure that   |
| they understand the key messages, and encourage them to take the      |
| Smoke-free Home Pledge.                                               |
+-----------------------------------------------------------------------+
| ######                                                                |
|                                                                       |
| ###### What is included in this planning guide?                       |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| This guide provides basic tools and templates for use at any type of  |
| pledge event \-- health fairs, school or community functions,         |
| conferences, or any other event where you can make a difference.      |
| These tools offer a simple and organized way for you to encourage,    |
| document, and track pledges. (Click on the underlined text below to   |
| go directly to the tool or template.)                                 |
|                                                                       |
| -   **Event Log:** Document all of the details of your event on the   |
|     Event Log to help track your progress*.* [Event Log](#event-log)  |
|                                                                       |
| -   **Pledge Sheet:** Track all of the pledges from your event on     |
|     this simple tracking sheet. The information requested on the      |
|     tracking sheet will provide you with a complete, consistent list  |
|     of pledges, enabling you to easily send follow-up materials and   |
|     track the results of your event. If you would like to give a      |
|     Smoke-free Home Kit to individuals who have taken the pledge,     |
|     order up to 125 of them at 1-800-490-9198 (<nscep@bps-lmit.com>). |
|     [Pledge Sheet](#_Smoke-free_Home_Pledge)                          |
|                                                                       |
| -   **Pledge Card:** Provide a quick and easy way for participants to |
|     take the Smoke-free Home Pledge with the customizable Pledge      |
|     Card. As with the Pledge Sign, make it your own by adding your    |
|     logo, text, or graphic. These cards are great for securing and    |
|     tracking pledges onsite, and the individual Pledge Card allows    |
|     pledge-takers to keep their personal information private. Each    |
|     sheet contains two pledge cards. [Pledge                          |
|     Card](#take-the-smoke-free-home-pledge-2)                         |
|                                                                       |
| -   **Pledge Sign:** Grab the attention of event participants with    |
|     the Pledge Sign. Customize it to meet your needs by adding your   |
|     organization's logo, text, or graphic. The standard 8.5" x 11"    |
|     design fits most acrylic sign holders. Black and white and color  |
|     versions of the Pledge Sign are provided in this guide. [Pledge   |
|     Sign](#_Wheezing_and_coughing)                                    |
+-----------------------------------------------------------------------+
| **How do I use these tools?**                                         |
+-----------------------------------------------------------------------+
| Consider the following suggestions for your event:                    |
|                                                                       |
| -   On your display table, provide Pledge Cards and the Pledge Sheet  |
|     for participants to pledge onsite or take materials home.         |
|                                                                       |
| -   Inform participants that they can take the Smoke-free Home Pledge |
|     at any time online at                                             |
|     [www.epa.gov/smokefree](../www.epa.gov/smokefree).                |
|                                                                       |
| -   Fill out the Event Log, which can serve as a record of your       |
|     activities and achievements.                                      |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   If you have any questions or need help with the *Smoke-free Home  |
|     Pledge Campaign,* contact the Pledge Coordinator (202-343-9370)   |
|     or EPA's regional offices. See                                    |
|     [www.epa                                                          |
| .gov/iaq/whereyoulive.html](http://www.epa.gov/iaq/whereyoulive.html) |
|     for a complete listing.                                           |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **What other secondhand smoke related products are available?**       |
+-----------------------------------------------------------------------+
| Additional Smoke-free Home Pledge resources are available through the |
| National Service Center -- Environmental Publications. To order       |
| materials by **phone** (1-800-490-9198) or **e-mail**                 |
| ([nscep@bps_lmit.com](mailto:nscep@bps-lmit.com)).                    |
|                                                                       |
| Suggested resources for your Smoke-free Home Pledge event include:    |
|                                                                       |
| -   Smoke-free Home Pledge Brochure and related posters               |
|                                                                       |
| -   Smoke-free Home Kit                                               |
|                                                                       |
| -   Community Action Kit                                              |
|                                                                       |
| You can also visit                                                    |
| [www.epa.gov/smokefree](http://www.epa.gov/smokefree) for details on  |
| related videos, speaker's kits, and other publications.               |
+-----------------------------------------------------------------------+
| **Important Note:** Fonts and graphics may shift or change depending  |
| on your computer and/or software.                                     |
|                                                                       |
| **Copyright Information:** All parts of this document may be modified |
| to suit your needs.                                                   |
|                                                                       |
| **Need Help?** Contact the Pledge Coordinator at 202-343-9370.        |
+-----------------------------------------------------------------------+

####### Take the Smoke-free Home Pledge

####### Event Log

+---------------------+------------------------------------------------+
| Event name:         |                                                |
|                     |                                                |
| Sponsor:            |                                                |
+---------------------+------------------------------------------------+
| Date(s) of event:   |                                                |
+---------------------+------------------------------------------------+
| Name of your        |                                                |
| organization:       |                                                |
+---------------------+------------------------------------------------+
| Name of event       |                                                |
| coordinator:        |                                                |
+---------------------+------------------------------------------------+
| Contact information |                                                |
| for event           |                                                |
| coordinator:        |                                                |
+---------------------+------------------------------------------------+
| Number of pledges   |                                                |
| and corresponding   |                                                |
| ZIP Codes:          |                                                |
|                     |                                                |
| (Example: 20        |                                                |
| pledges for ZIP     |                                                |
| Code 12345)         |                                                |
+---------------------+------------------------------------------------+
| Number of           |                                                |
| Smoke-free Home     |                                                |
| Kits you plan to    |                                                |
| mail:               |                                                |
+---------------------+------------------------------------------------+
| Estimated total     |                                                |
| number of           |                                                |
| att                 |                                                |
| endees/participants |                                                |
| at the event:       |                                                |
+---------------------+------------------------------------------------+
| Comments:           |                                                |
+---------------------+------------------------------------------------+

######### 

![](media/image3.png){width="1.29375in" height="1.51875in"}

+---+-----+-----------+------+--------------+------------+------------+
| # |     |           |      | **OPTIONAL:  |            |            |
| # |     |           |      | USE ONLY IF  |            |            |
| # |     |           |      | YOU PLAN TO  |            |            |
| # |     |           |      | MAIL A       |            |            |
| # |     |           |      | PLEDGE KIT** |            |            |
| # |     |           |      |              |            |            |
| # |     |           |      |              |            |            |
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| D |     |           |      |              |            |            |
| G |     |           |      |              |            |            |
| E |     |           |      |              |            |            |
+---+-----+-----------+------+--------------+------------+------------+
| * | **  | **NAME    | #    | **STREET     | **CITY,    | **S        |
| * | Has | (please   | #### | ADDRESS**    | STATE**    | IGNATURE** |
| \ | s   | print)**  | ###  |              |            |            |
| # | mok |           | ZIP  |              |            |            |
| o | ing |           | CODE |              |            |            |
| f | b   |           |      |              |            |            |
| k | een |           |      |              |            |            |
| i | a   |           |      |              |            |            |
| d | llo |           |      |              |            |            |
| s | wed |           |      |              |            |            |
| a | in  |           |      |              |            |            |
| t | ho  |           |      |              |            |            |
| h | me? |           |      |              |            |            |
| o | (   |           |      |              |            |            |
| m | cir |           |      |              |            |            |
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| 6 |     |           |      |              |            |            |
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| * |     |           |      |              |            |            |
+---+-----+-----------+------+--------------+------------+------------+
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|   | /   |           |      |              |            |            |
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+---+-----+-----------+------+--------------+------------+------------+
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+---+-----+-----------+------+--------------+------------+------------+
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|   | /   |           |      |              |            |            |
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|   | o** |           |      |              |            |            |
+---+-----+-----------+------+--------------+------------+------------+
|   | **  |           |      |              |            |            |
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+---+-----+-----------+------+--------------+------------+------------+
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+---+-----+-----------+------+--------------+------------+------------+
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|   | o** |           |      |              |            |            |
+---+-----+-----------+------+--------------+------------+------------+
|   | **  |           |      |              |            |            |
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|   | /   |           |      |              |            |            |
|   | N   |           |      |              |            |            |
|   | o** |           |      |              |            |            |
+---+-----+-----------+------+--------------+------------+------------+
|   | **  |           |      |              |            |            |
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|   | /   |           |      |              |            |            |
|   | N   |           |      |              |            |            |
|   | o** |           |      |              |            |            |
+---+-----+-----------+------+--------------+------------+------------+
|   | **  |           |      |              |            |            |
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|   | /   |           |      |              |            |            |
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|   | o** |           |      |              |            |            |
+---+-----+-----------+------+--------------+------------+------------+
|   | **  |           |      |              |            |            |
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|   | o** |           |      |              |            |            |
+---+-----+-----------+------+--------------+------------+------------+

#### ***Take the Smoke-free Home Pledge***

Number of young children (birth-6 yrs. old) in the home:\_\_\_\_\_\_\_\_

#### Has smoking been allowed in the home or car (by family or visitors):  Yes  No

### I, \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, on \_\_\_\_\_\_\_\_\_\_\_\_,\_\_\_\_\_\_\_\_\_\_,

(Your name here) (Date) (ZIP Code)

pledge to protect children from the health risks of secondhand smoke by
keeping my home and car smoke-free.

Would you like a *Smoke-free Home Kit* mailed to you?  Yes  No

Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_State:\_\_\_\_\_ZIP
Code:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_![](media/image3.png){width="0.8597222222222223in"
height="1.0229166666666667in"}

***Congratulations on making your***

***home and car smoke-free!***

#### ***Take the Smoke-free Home Pledge***

Number of young children (birth-6 yrs. old) in the home:\_\_\_\_\_\_\_\_

Has smoking been allowed in the home or car (by family or visitors): 
Yes  No

### I, \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, on \_\_\_\_\_\_\_\_\_\_\_,\_\_\_\_\_\_\_\_\_\_\_,

(Your name here) (Date) (ZIP Code)

pledge to protect children from the health risks of secondhand smoke by
keeping my home and car smoke-free.

Would you like a *Smoke-free Home Kit* mailed to you?  Yes  No

Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_State:\_\_\_\_\_ZIP
Code:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_![](media/image3.png){width="0.8597222222222223in"
height="1.0229166666666667in"}

***Congratulations on making your***

***home and car smoke-free! !***