# ![](media/image1.jpeg){width="0.8701388888888889in" height="0.39861111111111114in"}

# HHS/FOH SMOKING CESSATION ELIGIBILITY FORM

## 

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| Are you a federal employee? Yes No                                    |
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|   --------------- --------------------------------------------------  |
|   Name                                                                |
|                                                                       |
|   Agency                                                              |
|                                                                       |
|   Address                                                             |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
|   Phone (office)                                                      |
|                                                                       |
|   Email                                                               |
|                                                                       |
|                                                                       |
|   --------------- --------------------------------------------------  |
+-----------------------------------------------------------------------+
| Are you ready to set a quit date within the next two weeks? Yes No    |
+-----------------------------------------------------------------------+
| Does your health insurance provide a smoking cessation benefit? Yes   |
| No Don't Know                                                         |
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| If yes, have you used this benefit in the past? Yes No Don't Remember |
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| Is there a FOH Occupational Health Center near your office? Yes No    |
| Don't Know                                                            |
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|   ---------------------------- -------------------------------------  |
|   If yes, where is it located?                                        |
|   Address:                                                            |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
|   ---------------------------- -------------------------------------  |
|                                                                       |
| Don't Know                                                            |
+-----------------------------------------------------------------------+
| How do you prefer that we contact you?                                |
|                                                                       |
| Email                                                                 |
|                                                                       |
| Phone                                                                 |
|                                                                       |
| Fax number:                                                           |
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**After you have completed this form, please email to
<aengelstad@psc.gov> or fax to (206) 615-2446.**

You will be contacted to schedule an interview to record your smoking
history, determine which over-the-counter nicotine replacement therapy
medication will work best for you, and help you create a quit-smoking
plan that best fits you. If you are not contacted within two weeks of
faxing this document; please contact Arlene Engelstad at (206) 615-2511
or <aengelstad@psc.gov>.