Parent Survey/Fax Referral Form (click here to find your office)
A brief survey for all parents/guardians of young children (0-5) to fill out at their child’s six-month well-child visit. This form serves as 1) A survey to screen for/identify individual and household smoking status, 2) A fax referral form to the California Smokers’ Helpline for parents/guardians who identify themselves as smokers and want help to quit, 3) A guide to be placed in each patient’s medical chart to assist the clinician in giving appropriate advice about tobacco use/exposure, and 4) A guide for the office to determine which education materials to give to each family.
Patient Education Materials
Pediatric Flyer: English | Spanish
A one-page flyer designed to be given to ALL parents/guardians of young children. This flyer reminds people of the harmful effects of secondhand smoke exposure on children and the importance of letting their child grow up in a smoke-free environment. Information about free smoking cessation counseling is also included.
(ETS) Environmental Tobacco Smoke Handouts (series of 3): English | Spanish
A series of 3 handouts designed to inform parents of young children of the harmful effects of secondhand smoke on their child(ren)’s health. Each handout focuses on a specific health complication and the increased risk that infants and children of smokers have of suffering from these negative health outcomes compared to infants and children of non-smokers.
- Sudden Infant Death (SIDS): English | Spanish
- Secondhand Smoke and Childhood Illness: English | Spanish
- Asthma and Smoking: English | Spanish
Program Implementation Materials
Pediatric Office Implementation Procedures
Detailed step-by-step procedures designed to help participating offices become familiar with the program, program materials, and program implementation. All aspects of the program are outlined here to assist and guide participating offices with program implementation.
Steps to Follow: Pediatric Provider Offices
A 2-page organization tool designed to help offices successfully implement the PSF program. All the steps from screening parents/guardians, faxing referrals, and providing education materials to placing completed surveys in the patients’ medical chart and following-up at subsequent visits are outlined here. Suggestions for when each step should be performed as well as who is in charge of performing which steps are also offered to help offices build the program into their routine and ensure that all aspects of the program are carried out.
Advice for Parental Smokers Flowchart
A flow chart designed to help providers talk to smokers about quitting based on their willingness to quit. These parental quit smoking assistance and follow-up techniques are based on best practice research shown to increase the likelihood of helping patients successfully quit smoking.
Rx: English | Spanish
A prescription-style handout for providers to give to all identified smokers to encourage them to call the California Smokers’ Helpline for smoking cessation services. This should be done in addition to faxing the survey/fax referral form to reinforce the message. (Prints four per sheet: cut after printing).
Peds Chart Stickers
A sheet of sticker labels for office members to use to check off the smoking status of the parent/guardian and stick on the child’s chart. Sticker labels serve to remind providers to ask, advise, assist, and follow-up with smokers, recent quitters and members of a smoking household, and to confirm that the parent/guardian has completed the Parent Survey and been screened for personal and household smoking status. (Print on label sheets; prints 30 per sheet)
Print Ads for Health Care Providers
The California Smokers’ Helpline has developed five different print ads to help remind health care providers to Ask patients about their smoking status, Advise them to quit, and Assist patients in quitting by referring them to the Helpline. Click on the links below to access a PDF version of the 8.5” x 11” print ad to display in your office.