Safe Smoking Assessment Form

New Jersey Veterans Memorial Homes

Resident’s Name: __________________________________ Resident #__________ Room #_______

Date: ________________________ Diagnoses:____________________________________________

(Please circle Y or N, and add comments as applicable below )

Does the resident know the location(s) of the designated areas for smoking?

Can the resident get to these areas independently?

When observed, can the resident independently light smoking materials safely?

(If no, explain)______________________________________________________________________________

Does the resident shake / have tremors while smoking?

Does the resident fall asleep while smoking?

Can the resident extinguish smoking materials completely in an appropriate receptacle?

(If no, explain)______________________________________________________________________________

Can the resident dispose of ashes or other tobacco-related residue appropriately?

(If no, explain)______________________________________________________________________________

Has the resident had any past accidents / incidents with smoking materials?

(If yes, explain)______________________________________________________________________________

Are there any visible burn marks on the resident’s clothing / coat?

Interdisciplinary Care Plan (IDCP) Team recommendations: ______________________________________

___________________________________________________________________________________________

This resident is safe to smoke unsupervised, at this time:

This resident requires 1:1 supervision while smoking:

This resident requires a fire-resistant smoking apron while smoking:

All smoking materials will be kept at the nurses’ station (circle which ones↓):

Cigarettes / Pipe / Cigars / Electronic Smoking Device / Smokeless Tobacco / Matches / Lighter / Other

Resident notified of restrictions: Y

N Comments: ____________________________________________

Family or POA notified of restrictions: Y

N Comments: ______________________________________

Staff notified of restrictions: Y

N Comments: _______________________________________________

A “Smoking Care Plan” is in place: Y

N Comments: _________________________________________

IDCP Team Signatures: ___________________________________

________________________________

___________________________________

_________________________________

09-02-005A

May 2013

Safe Smoking Assessment Form - 2013