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# SMOKING CESSATION SIGN-UP FORM

Welcome to the Smoking Cessation Program brought to you by the National
Institutes of Health (NIH) in partnership with Federal Occupational
Health (FOH). To get started on the quitting process, please complete
this form and fax it to Arlene Engelstad at (206) 615-2446 or email to
<Aengelstad@psc.gov>.

Here's how the program works:

1\. INTERVIEW

> Once you have completed the Smoking Cessation Sign-Up Form, an FOH
> representative will contact you for an initial interview, which will
> take about 30 minutes and will focus on the details of your smoking
> history. The FOH representative will assist you in deciding the
> nicotine replacement product (NRT) that is best for you. If an
> interviewer does not call you within 2 weeks of submitting your form,
> please call Arlene Engelstad at (206) 615‑2511.
>
> Please have the following information available for the interview: a.
> Please verify if any pre-existing Smoking Cessation support programs
> are available through a work related healthcare provider. b. During
> the interview NIH Federal Employees are required to provide the 10
> digit employee ID and sub-division of NIH they are associated with.

2\. QUIT PLAN

> The main purpose of the initial interview is to help you formulate a
> quit plan. To assist you with this plan, the FOH representative will
> provide you with an "NIH/FOH Smoking Cessation Quit Plan Form," which
> you will be asked to complete during your interview. Expect to make
> changes to your plan during your quit effort. For example, you may
> identify difficult situations that were not covered adequately when
> you first wrote the plan. Nicotine patches, gum or lozenges help
> control withdrawal symptoms, having a written plan will help your quit
> effort.

3\. NRT PRODUCTS

> Once your interview has been completed, FOH will mail the NRT to you
> or to a nearby FOH Health Center. You will receive one of the
> following NRT products: nicotine skin patches, nicotine gum or
> lozenges depending on the product selected with your quit plan. In
> addition, you will be sent a handbook covering specific topics such as
> how to break habits and routines, what to do if there is another
> smoker in your household, etc.

4\. YOUR RESPONSIBILITIES RELATED TO NRT

> NIH provides an initial eight-week supply of NRT. NRT will be sent in
> 2 separate 4 week shipments, at 3 weeks a follow up will determine
> continuation with same product. Once you start your quit effort, you
> will no longer be purchasing cigarettes. We encourage you to save your
> cigarette money during the period that your employer is paying for
> your NRT so that you can purchase the additional NRT that you will
> need. Follow the directions that come with the product and use it for
> the full 8 weeks.

5\. FOLLOW UP

> Six months after your quit date, FOH will follow up to see how you are
> doing with your smoking cessations efforts.

6\. CONTACT US

> FOH, a division of the U.S. Public Health Service, is working in
> partnership with NIH to provide this valuable service. If you have any
> questions, please contact Arlene Engelstad at (206) 615-2511 or
> <Aengelstad@psc.gov>.

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  Last Name                       First Name                   M.I.        

  NIH 10                                                              
  digit ID \#                                                         

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                                  You at Home                         
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