Smoking cessation Standard Reporting template (SCSRT)

Smoking cessation
Standard Reporting template (SCSRT)

Standard Report Template

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<<ADD Organisation name, programme name>>

Provider Number: ________________

Contract Number: _______________

Contract Term: ______________________

Contract Deputy Manager: ______________________________

Report number: 04/05 - 1 (Financial year ‘04/’05, first half of year)

Reporting Period
Start Date	End Date	Due Date
1 Jan 2005	30 June 2005	July 20^th2005

Please ensure you complete and forward this SCSRT by the July 20^th 2005. This completed SCSRT should be forwarded to:

<<ADD MoH address>>

CEO/Manager’s Confirmation of the accuracy of this report:

Signature: ___________________

Position: _________________

Date: ____________________

Smoking Cessation (cessation team) contact person:

Name: ____________________

Phone: ____________________

Smoking Cessation (database) contact person:

Name: ____________________

Phone: ____________________

Programme name: ____________________________

*A. Client numbers – those worked with in general*	Clients referred 1 Jan. ‘05 to 30 June. ‘05
*A. Client numbers – those worked with in general*	Write Number
1. Total number referred
Client numbers – Intervention other than cessation	Write Number
2. Number of clients single session intervention only (Assessment of readiness to quit/assessment of intention to treat, and/or Smokefree information provided)
3. Number of clients supported on ongoing basis only (for reduction, Smokefree, working towards motivation to quit, preparation to quit i.e. Relapse Prevention Planning (RPP)) – may be multiple events
4. Number of clients provided with maintenance support only (already quit when referred/at first contact¹)
Client numbers - On cessation programme(s)	Clients enrolled on programme² 1 Jan. ‘05 to 30 June. ‘05
Client numbers - On cessation programme(s)	Write Number
5. Number of clients enrolled ³ on “cessation programme” without NRT (Refers to clients using other cessation therapies and other NRT products)
6. Number of clients enrolled on “cessation programme” with NRT (Refers to clients using MoH approved NRT eg; Patches & Gum only)
7. Total number of clients worked with (add up above categories 2 to 6 – Number of clients that received single session intervention (2), ongoing support (3), maintenance support (4) , cessation (5 & 6)

*B. Profile clients when enrolled on “cessation* *programme”*		Clients enrolled on programme 1 Jan. ‘05 to 30 June ‘05
		With NRT	Without NRT	Combined Total
		Write Number
8. Age	a. Under 15 years.............. b. 15 to 17 years................ c. 18 or 19 years............... d. 20 to 24 years …........... e. 25 to 29 years................ f. 30 to 34 years................. g. 35 to 39 years................ h. 40 to 49 years................ i. 50 to 59 years................. j. 60 to 69 years................. k. 70 to 79 years................ l. 80+ years........................ m. Declined to answer......












	n. Total (on programme)...........
9. Gender	a. Male............................... b. Female.......................... c. Declined to answer.......


	d. Total (on programme)...........
10. Ethnicity - Record all that apply, can be more than one ethnic group Which ethnic group do you belong to? No “Total” data as can be more than one ethnic group	a. New Zealand European. b. Mäori.............................. c. Samoan......................... d. Cook Island Mäori.......... e. Tongan.......................... f. Niuean............................ g. Chinese......................... h. Indian............................. i. Other ⁴............................ j. Declined to answer.........









11. Pregnancy status when enrolled on programme	a. Pregnant........................ b. Not pregnant.................. c. Declined to answer.......


	d. Total (females on programme)

*B. Profile clients continued*		With NRT	Without NRT	Combined Total
*B. Profile clients continued*		Write Number
12. Smoking level - tailor made cigarettes when enrolled on programme How average, how many tailor made cigarettes do you smoke per day?	a. 1 to 10 cig. /day............. b. 11 to 20 cig. /day........... c. 21 to 30 cig. /day........... d. 31 or more cig. /day...... e. Don’t smoke these........ f. Declined to answer........





	g. Total (on programme)..........
13. Smoking level – loose tobacco/rollies when enrolled on programme On average, how many grams of tobacco do you smoke in a week?	a. Up to 30 grams/week.... b. 31 to 50 grams/week..... c. 50+ grams week........... d. Don’t smoke these........ e. Declined to answer.......




	f. Total (on programme)...........
14. Smoking at home when enrolled on programme At your home, is smoking allowed anywhere inside your home?	a. Allowed inside home..... b. Not allowed inside......... c. Declined to answer.......


	d. Total (on programme)..........
15. Smoking in car when enrolled on programme Is smoking allowed in your car?	a. Allowed in car................ b. Not allowed.................... c. No car............................ d. Declined to answer.......



	d. Total (on programme)..........
16. Household size ⁵ Include babies and borders etc How many persons, including yourself, babies, children, and boarders, live in your household?	a. One person (client only) b. Two people.................... c. Three people................. d. Four people................... e. Five people.................... f. Six people....................... g. More than six people..... h. Declined to answer.......







	i. Total (on programme)
17. Household smokers Including yourself, how many people living in your household are daily smokers?	a. One person (client only) b. Two people.................... c. Three people................. d. Four people................... e. Five people.................... f. Six people....................... g. More than six people..... h. None currently smoke... i. Don’t know...................... j. Declined to answer.........









	k. Total (on programme)

*C. Client numbers – Completed intensive phase of programme*		Clients enrolled on programme 1 July ‘04 to 31 Dec. ‘04
		With NRT		Without NRT		Combined Total
		Write Number
18. Number completed “intensive phase” as per service specification-intensive phase = NRT & weekly/fortnightly contact etc. First 6 – 12 weeks.	a. Complete...................... b. Not complete................. c. Total (on programme).............


*D. 6 month follow-up*		Clients enrolled on programme 1 July ‘04 to 31 Dec. ‘04
		With NRT		Without NRT			Combined Total
		Write Number
19. Number of clients spoken to at follow up* ⁶
20. Number of clients lost to followed up
21. Number of clients quit/not smoking at follow up
22. Number of clients smoking at follow up
23. Number of relapsed clients that have repeated the intervention activities ⁷ since the intensive phase
24. Number of clients totally Smokefree house
25. Number of clients totally Smokefree car
26. Number of clients provided less than 7 days NRT
27. Number of clients provided 1 week to 7 weeks NRT
28. Number of clients provided 8 weeks NRT
*E. Client numbers – Completed the programme*		Clients enrolled on programme 1 Jan. ‘04 to 30 June ‘04
		With NRT		Without NRT				Combined Total
		Write Number
29. Number “completed the programme” as per service specification-support, maintenance planning, milestone celebrations etc. 6 months to 12 months after start of programme	a. Complete...................... b. Not complete................. c. Total (on programme).............


*F. 12 month follow-up*			Clients enrolled on programme 1 Jan. ‘04 to 30 June ‘04
			With NRT		Without NRT			Combined Total
			Write Number
30. Number of clients spoken to at follow up⁶
31. Number of clients lost to followed up
32. Number of clients not smoking/quit at follow up
33. Number of clients smoking at follow up
34. Number of relapsed clients that have repeated the intervention activities ⁸ since six month follow-up
35. Number of clients totally Smokefree house
36. Number of clients totally Smokefree car

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¹For example as can occur in a hospital based programme for cardiac services patients (this does not refer to clients that relapse after a quit attempt that occurred while on the programme).

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²This refers to the point in time that the client was assessed and the decision was made that the client was ready to quit/was motivated to quit/had set a quit day and they were enrolled on to the cessation programme, or that you had an ‘intention to treat’ with intended outcomes that included a quit attempt, and they were enrolled on to the relevant programme.

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³‘Enrolled’ see previous footnote. These clients may have also received a single session intervention, or been supported on an ongoing basis etc, however record them only once in row #2 to row #6.

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⁴Write number saying ‘other’, do not write what the ‘other’ ethnic groups were

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⁵For household size data write the number of clients on “the programme” that “live on their own” or who “live in house of more than 6” (i.e. this is NOT the number of people in the house)

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⁶For 6-month data - #19 & #20 should be the total number due for follow-up (i.e. the number enrolled on the programme from 12 to 6 months ago). For 12-month data - #30 & #31 should be the total number due for follow-up (i.e. the number enrolled on the programme from 18 to 12 months ago).

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⁷Number that commenced the Relapse Prevention Planning (RPP) & cessation activities, from end of intensive until six months after starting

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⁸Number that commenced the RPP & cessation activities, from six months until 12 months after starting