The University of Arizona

Setting up a Tobacco Dependence Treatment Process in Your Facility

These tools, created by the Indian Health Service Tobacco Control Task Force are hosted by The University of Arizona HealthCare Partnership. Feel free to modify them to fit the needs of your facility.

  1. Assessment Survey Tool
    Assess Knowledge and Attitudes of Your Clinical Staff
  2. Patient Intake Form
    This form will help you conduct your counseling session and to document your intervention
  3. Follow-Up Form
    Follow-up, both attempted and completed, must be documented in the Resource and Patient Management System (RPMS)

For the latest news, reports and resources from Indian Health Service, click here: www.ihs.gov.

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