Application for Office Champions Tobacco Cessation National Dissemination Project

Practice Name

Practice Address

Practice City/State/Zip

Practice Phone Number

Number of physicians in practice Number of FTE non-physician staff

Number of active patients

Practice setting:

Urban

Suburban

Rural

Are you a family medicine residency program? Yes No

Do you use electronic health records in your practice (not required for participation)? Yes No

Do you have an institutional review board in your practice/organization? Yes No

What is your current system for identification and treatment of patients who use tobacco? (Limit response to 50 words, please)

Why are you interested in this project? (Limit response to 50 words, please)

This project is supported by Pfizer Inc.

How did you hear about the Office Champions Project?

AAFP email blast AAFP News Now

Chapter meeting Tobacco control listserv

Other (please specify) ______National Research Network member

Office Champion

The Office Champion is responsible for recommending and implementing office system changes to integrate tobacco cessation activities into the practice’s daily office routines.

Name

Title

Direct phone number Email address

Name and title of person who will assume Office Champion role in the event the designated Office Champion is unable to fulfill duties

Physician Champion

The Physician Champion is responsible for ensuring that the practice’s physicians and staff support the AAFP Office Champions project and that the Office Champion is allocated adequate time, resources and support to fulfill the responsibility of the Champion role.

Name

AAFP ID # Email address

By signing this document, I agree to the following:

·  Our Office Champion will complete the Office Champions training program, including an online course, Collaborative Institutional Training Initiative (CITI) course, a teleconference, and review of a practice manual.

·  Our Office Champion or Physician Champion will present an overview of the Office Champions Project to our practice’s physicians and staff at a staff meeting in June 2012.

This project is supported by Pfizer Inc.

·  Our Office Champion will complete a pre- and post-project review of 20 random patient charts, following parameters distributed during the course of the project.

·  Our office will identify and implement system changes to better integrate tobacco cessation activities into the practice’s daily office routines and to create a culture that encourages tobacco cessation.

·  Our Office Champion will be allocated adequate time, resources and support to fulfill the responsibilities of the Champion role.

·  Our practice will participate in all phases of program evaluation including chart reviews and surveys.

I understand that my practice will receive $2,000 to cover administrative costs associated with the project, based on the following milestones:

·  $1,000 to be awarded following completion of the online training program, CITI course, teleconference, pre-project chart review, staff meeting, and submission of implementation plan, approximately July 2012.

·  $1,000 to be awarded following completion of all phases of program evaluation including post-project chart review and evaluation survey, approximately December 2012.

Office Champion Date

Physician Champion Date

If you have any questions, please contact Sandy Sheehy, Office Champions Project Manager, at or 800-274-2237, extension, 3141.

Return this form by email, fax, or mail no later than May 8, 2012 to:

Sandy Sheehy

Health of the Public and Science

American Academy of Family Physicians

11400 Tomahawk Creek Parkway

Leawood, KS 66211

913-906-6000, extension 3141

800-274-2237

Fax: 913-906-6099

This project is supported by Pfizer Inc.