Data Collection

  • Caregiver is asked about their own smoking/ vaping status (current, former, or never); and
  • If baby is exposed to secondhand smoke from others living in the household
  • Caregiver received brief education on harm of smoking and secondhand smoke
  • Caregiver receives handouts and materials about smoking cessation
  • If caregiver is identified as willing to quit, caregiver is referred to Ohio Quit line or other tobacco cessation program

A data collection form can be used by organizations to guide health care professionals or programmatic staff through the implementation of the 5 A’s counseling intervention. Results can be entered into a database and used to track progress on the implementation of the 5 A’s over time. The collection form is designed to screen caregiver and other family member's smoking/vaping behavior and track how the 5A's intervention is implemented. Some of the key data being collected is listed below.


Click here to download the collection form

Smoke Free for Me Screening Tool

For organizations interested in implementing this data collection form, we strongly recommend it is used with every caregiver bringing the infant to the well child visit. The form does not collect Personal Health Information (PHI) but can be revised to fit the needs of the implementing organization. Please refer to the Contact Us section if you have questions on the form.