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Butt In Reporting Form
Thank you for being a participant in the Butt In: Cigarette Litter Prevention Program. This form is part of the Business Responsibilities agreement to help the Northcoast Environmental Center with cigarette litter data collection.
Please fill out this form each time your cigarette receptacle is emptied and tell us approximately how full it was so we can track how many cigarette butts were kept off our streets and out of our waterways.
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* Indicates required question
Business Name
*
Your answer
Contact Name
Your answer
Date your cigarette receptacle was emptied
*
MM
/
DD
/
YYYY
Approximately how full was the cigarette receptacle when it was emptied?
*
25% (~200 cigarettes)
50% (~400 cigarettes)
75% (~650 cigarettes)
100% (~850 cigarettes)
Other:
Do you have any questions, comments, concerns, or feedback about the Butt In program and/or your cigarette receptacle?
Your answer
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