Smoke Free Families Wave 2 Enrollment First Name * First Last Name * Last Credentials * Email Address * Practice/Organization * Practice Street Address * City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Approximate number of infants 0-12 months seen in your practice each month for a well visit. * Do you currently screen patients 0-12 months for smoke exposure in their home environment? * Yes No Please provide any information on a current screen you provide. * Phone Number Are you seeking Quality Improvement board-specific accreditation? No Yes - My accrediting board is:Yes - My accrediting board is: How did you find out about this opportunity? * (Ohio AAP Today, postcard, direct email, etc.) Who will be the main practice contact for this program? Same as above Add name Name Position Phone Email If you are human, leave this field blank.