Smoke Free Families Wave 2 Enrollment

First Name *

First

Last Name *

Last

Credentials *

Email Address *

Practice/Organization *

Practice Street Address *

City *

State *

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

Please provide any information on a current screen you provide. *

Phone Number

Are you seeking Quality Improvement board-specific accreditation?

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