Quit Solutions :: Collaborator's Form

Collaborator Name:
Collaborator Email:
# of patients screened for tobacco use (Ask)
# of patients in sample
# of patients identified as tobacco users
# of tobacco users receiving brief interventions (Advise, Assess, Assist, Arrange)
# of tobacco users in sample
Method of obtaining tobacco user information (Select one)	Chart Review Electronic Medical Records Other Electronic Records Patient Survey Encounter Forms NYC Cessation Registry Discharge Plans