SELF AUDIT 0 = No / not implemented STANDARD 5: Tobacco-free environment 1 = Less than half implemented The healthcare organisation has strategies in place to achieve a tobacco-free campus. 2 = More than half implemented 3 = Yes / Fully implemented REFLECTION & ACTION PLAN ACTION PLAN Summary of current situation Summary of plans for next 12 months IMPLEMENTATION CRITERIA 0 1 2 3 (Please describe the current situation for each implementation criteria. This will provide a context for your planned actions for the next 12 months) The healthcare organisation has All buildings within the completely tobacco-free organisation are completely buildings (including associated tobacco-free (including devices/e-cigarettes). associated The healthcare organisation has The grounds and transports completely tobacco-free grounds systems of the organisation and transport systems (including are completely tobacco-free associated devices/e-cigarettes). (including associated devices/e-cigarettes). The healthcare organisation has Signage identifies prohibited clear and unambiguous signage products and the that defines the products campus boundaries for prohibited and identifies buildings and grounds. boundaries for buildings and grounds of the tobacco-free campus. The healthcare organisation Tobacco and associated prohibits the sale, distribution devices/e-cigarettes are not and advertisement of tobacco sold, distributed or advertised products and associated devices/ within the organisation. e–cigarettes, anywhere within the organisation. The healthcare organisation has There is a procedure to a procedure in place to ensure record and prevent that all service users, staff and secondhand visitors are never exposed to vapour exposure. secondhand smoke/e-cigarette vapour within the boundaries of the tobacco-free campus.
STANDARD 5: Tobacco-free environment The healthcare organisation has strategies in place to achieve a tobacco-free campus. SELF AUDIT 0 = No / not implemented 1 = Less than half implemented 2 = More than half implemented 3 = Yes / Fully implemented IMPLEMENTATION CRITERIA REFLECTION & ACTION PLAN Summary of current situation (Please describe the current situation for each implementation criteria. This will provide a context for your planned actions for the next 12 months) 0 1 2 3 ACTION PLAN Summary of plans for next 12 months The healthcare organisation has completely tobacco-free buildings (including associated devices/e-cigarettes). All buildings within the organisation are completely tobacco-free (including associated The healthcare organisation has completely tobacco-free grounds and transport systems (including associated devices/e-cigarettes). The grounds and transports systems of the organisation are completely tobacco-free (including associated devices/e-cigarettes). The healthcare organisation has clear and unambiguous signage that defines the products prohibited and identifies boundaries for buildings and grounds of the tobacco-free campus. Signage identifies prohibited products and the campus boundaries for buildings and grounds. The healthcare organisation prohibits the sale, distribution and advertisement of tobacco products and associated devices/ e–cigarettes, anywhere within the organisation. Tobacco and associated devices/e-cigarettes are not sold, distributed or advertised within the organisation. The healthcare organisation has a procedure in place to ensure that all service users, staff and visitors are never exposed to secondhand smoke/e-cigarette vapour within the boundaries of the tobacco-free campus. There is a procedure to record and prevent secondhand vapour exposure.
global-network-standards-self-audit-template-english-020118-wfiqleqxxfgz.docx