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This form is used to verify the tobacco usage status of an employee or retiree and includes a disclaimer about the consequences of providing false information.

How to fill out tobacco use affidavit form

How to fill out TOBACCO USE AFFIDAVIT FORM

1. Obtain the TOBACCO USE AFFIDAVIT FORM from the relevant authority or website.
2. Read the instructions provided on the form carefully.
3. Fill in your personal information, including your name, address, and contact details.
4. Indicate your current tobacco use status by selecting the appropriate option (e.g., 'smoker', 'non-smoker', etc.).
5. If applicable, provide details about your tobacco use history, including dates and frequency.
6. Sign and date the affidavit to certify that the information you provided is accurate.
7. Submit the completed form by the specified deadline to the required authority or organization.

Who needs TOBACCO USE AFFIDAVIT FORM?

1. Individuals applying for jobs or insurance where tobacco use is a factor.
2. Patients undergoing medical procedures where tobacco use could affect treatment.
3. Participants in health programs or studies that require disclosure of tobacco use.

People Also Ask about

What are the four ways tobacco is used?

The predominant use of tobacco is by smoke inhalation of cigarettes, pipes, and cigars. Smokeless tobacco refers to a variety of tobacco products that are either sniffed, , or chewed.

What form is tobacco in?

Cigarette smoking is the most common form of tobacco use worldwide. Other tobacco products include waterpipe tobacco, cigars, cigarillos, heated tobacco, roll-your-own tobacco, pipe tobacco, bidis and kreteks, and smokeless tobacco products.

What is a tobacco use affidavit?

This form is used to determine your premium rate. You are only eligible for the lower non-tobacco user rate after you can attest that you use tobacco products, on average, less than four (4) times per week for six (6) months or longer.

What is tobacco use in any form?

There is no safe form of tobacco use. All forms contain nicotine and can cause addiction and health problems.

Do you use tobacco in any form?

Cigarette smoking is the most common form of tobacco use worldwide. Other tobacco products include waterpipe tobacco, cigars, cigarillos, heated tobacco, roll-your-own tobacco, pipe tobacco, bidis and kreteks, and smokeless tobacco products.

What qualifies as tobacco use for insurance?

ing to the federal Department of Health and Human Services, insurance companies consider folks tobacco users if they use tobacco products – including cigarettes, cigars, pipe tobacco, and chewing tobacco – on average four or more times a week during the past six months.

In what forms is tobacco used?

Tobacco products encompass multiple varieties of products, including cigarettes, cigarette tobacco, roll-your-own tobacco, smokeless tobacco, electronic cigarettes, cigars, hookahs, pipe tobacco, nicotine gels, and dissolvables.

Is tobacco used for anything besides smoking?

Tobacco leaves are applied to cuts as an antiseptic and to stop bleeding. Ground tobacco leaves were also used as “” (inhaled through the nose) for medicinal and ritualistic purposes. Tobacco smoked is sometimes blown into the ear to treat earaches.

For pdfFiller’s FAQs

What is TOBACCO USE AFFIDAVIT FORM?

The Tobacco Use Affidavit Form is a legal document used to certify an individual's use of tobacco products, often required in various transactions or applications, such as those involving health insurance or workplace health programs.

Who is required to file TOBACCO USE AFFIDAVIT FORM?

Individuals who are applying for health insurance, participating in wellness programs, or individuals involved in any situation where their tobacco use may impact coverage or employment may be required to file the Tobacco Use Affidavit Form.

How to fill out TOBACCO USE AFFIDAVIT FORM?

To fill out the Tobacco Use Affidavit Form, individuals must provide personal information such as their name, date of birth, and contact information, along with a declaration of their tobacco use status, including details on frequency and types of tobacco products used.

What is the purpose of TOBACCO USE AFFIDAVIT FORM?

The purpose of the Tobacco Use Affidavit Form is to obtain an accurate declaration of an individual's tobacco use to help determine health risks, insurance premiums, and eligibility for certain health programs.

What information must be reported on TOBACCO USE AFFIDAVIT FORM?

The report must include individual identification details, a statement confirming whether or not the individual uses tobacco, the type of tobacco used, and the frequency of use, along with any other relevant health information as required by the specific context of the form.