- Client was asked about smoking status (current, former, or never)
- Client or baby is exposed to secondhand smoke
- Client received one or more Advise topic
- Client was assessed for their stage of change
- Client indicated they are willing to quit in 30 days
- If client identified as willing to quit, client received one or more strategy in the Assist stage
- Client set a quit date
- If client identified as willing to quit, client was scheduled with a CTTS program or other tobacco cessation program
- If client identified as willing to quit, client was referred to the quit line
- Client was scheduled with a follow-up appointment
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 SFF Client Intervention Record is designed to record the client’s progress in completing the 5 A's, and track their interest and progress through the quit process. Some of the key data being collected is listed below.
For organizations interested in implementing this data collection form, we strongly recommend it is used with every client at every visit and data is inputted and stored electronically. 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.