PRACTICE ID
Participant ID
Q1A Project influence (1-5): Identify/screen pts for tobacco use
Q1B Project influence (1-5): Advise tobacco users to quit
Q1C Project influence (1-5): During office visit, provide education materials
Q1DA Project influence (1-5): Refer to QUITLINE
Q1DB Project influence (1-5): Refer to other cessation websites
Q1DC Project influence (1-5): Refer to other providers (for cessation)
Q1DD Project influence (1-5): Refer to tobacco programs in area
Q1E Project influence (1-5): Help tobacco users set a quit date
Q1F Project influence (1-5): Recommend nicotine replacement therapy
Q1G Project influence (1-5): Prescribe medicines to help a tobacco user quit
Q1H Project influence (1-5): Document patient tobacco use in the record/chart
Q2A: Not time to help a patient quit smoking
Q2B: Not adequate training cessation counseling
Q2C: Do not counseling b/c must focus other health issues
Q2D: Do not have resources needed
Q2I: Prescribing nicotine replacement Rx for patients ready quit IS high priority
Q2E: Do not counseling b/c others outside of clinic do
Q2F: Do not counseling because have few patients who smoke
Q2G: Believe smoking cessation counseling has limited effect
Q2H: Cannot get reimbursed for smoking cessation counseling
Q4: Overall satisfaction with Project (1-5 satisfied-dissatisfied)
Q5: Overall recommendation (1-strongly rec, 2-recom, 3-not rec)
Q6_a: How helpful was training call
Q6_b: How helpful were booster calls or emails
Q6_c: How helpful was Help desk/ technical support
Q6_d: How helpful were information Prescription
Q6_e: How helpful were posters for your practice
Q6_f: How helpful were incentives to participation
Q9A Number of patients are seen per week
Q9B Percent of the patients ASKED about using tobacco
Q9C Percent of the tobacco users ADVISED TO QUIT to quit
Survey was complete: 2=yes
Q3_1: Increased staff training for adherence to tobacco control guidelines
Q3_2: Changed office protocols/policies to increase screening/advising
Q3_3: Increased systematic screening for tobacco use
Q3_4: Increased systematic advice to tobacco users to quit using
Q3_5: Increased use of patient education materials related to tobacco use/quitting