Store It Safe QI Pilot Program – Data Collection Store It Safe - QI Pilot Data Collection Form Practice Name Olentangy Pediatrics CCHMC Fairfield Primary Care Chillicothe Pediatrics Cleveland Clinic Behavioral PriMed Physicians Other Practice Name Provider Name Jennifer Hardie, MD Irene Koesters, MD Alonzo Patterson, MD Amy Luckeydoo, MD Other Provider Name Date of Visit Age of Patient at Time of Visit Less than 2 years 2 years 3 years 4 years 5 years 6 years 7 years or older Other Age of Patient at Time of Visit Please check all items with documentation in the chart for this visit (3 of 5 required for complete documentation): Firearm safety discussion Barrier methods to prevent injuries Providing Store it Safe materials or discussing Store It Safe Recommendation of use of a locked storage device for firearms and potentially dangerous items Firearm safety in the homes of friends or relatives Was a lock box provided during this visit (if applicable)? Yes - offered and accepted No - offered but declined No - not offered N/A OtherOther Other notes related to SIS or the program for this visit: Submit If you are human, leave this field blank.
