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2018 Gold Star Standards of Excellence Application

The Gold Star Standards of Excellence program recognizes Maine’s Behavioral Health organizations annually for creating and maintaining tobacco-free environments and supporting tobacco-free living. Behavioral Health organizations and providers seek to optimize the health of clients and employees. Tobacco-free policies are an example of this commitment that benefits clients, employees, and the entire community.


All organizations are encouraged to apply. Those meeting a minimum of 6 of the 10 standards will be recognized with an award during a celebration event on June 28th, 2018 from 11:00 am – 1:00 pm at Bangor Savings Bank (5 Senator Way, Augusta). Lunch will be provided.

6-7 Stars: Bronze Award Status
8-9 Stars: Silver Award Status
10 Stars: Gold Award Status


To apply, complete the application below answering all questions applicable, write “not applicable” for the standard(s) your organization does not meet.
Applications are due by Friday May 25, 2018.

Please note this form cannot be saved.  Best practice is to complete the word document version then copy and paste your answers into the online form.  You can also email the word version to us at BreatheEasy@mainehealth.org.

Need help?  View the 2018 Guidance Document for model answers for the application or contact us for additional assistance.



1. Tobacco-Free Policy
Standard: The behavioral health organization has a 100% tobacco-free campus policy that prohibits the smoking and use of all tobacco products including cigarettes, cigars, pipes, smokeless tobacco, snuff, chew, snus, electronic smoking devices and non-FDA approved electronic nicotine delivery systems. Smoking and tobacco use by employees, clients, visitors and contractors is prohibited at all times on the behavioral health organization property, including in parking lots, in personal vehicles parked on grounds, all organization owned or leased vehicles and at all satellite offices, buildings and any other properties owned or leased by the behavioral health organization.
Requirement: Include the written policy for the behavioral health organization.
Upload the tobacco policy (PDF or Word Doc):

2. Policy Communication
Standard: Written policies, procedures or plans detail the communication about the behavioral health organization’s policy (whether or not the policy is 100% tobacco-free) to clients, employees, visitors, contractors and at all satellite offices, buildings and any other properties owned or leased by the behavioral health organization.
Requirement: Include a copy of any policy, procedures or plans that document meeting this standard. At least three of the following strategies must be met in order to achieve this standard.
Signage can be found throughout the grounds including at all entrances to the property and buildings, in parking lots, near picnic tables and other outside seating areas, other areas where people tend to gather, etc.New client orientation/initial appointments include education on the organization policy.New employee orientation includes education on the organization policy.All employees are required to acknowledge in writing, on an annual basis, that they have read/understand the tobacco-free policy.Information about the tobacco-free policy is readily available on the behavioral health organization website and/or through the HR department.Other: (please explain)
Upload the written policies/procedure for the organization (PDF or Word Doc):

3. Policy Enforcement
Standard: Written policies, procedures or plans detail policy expectations and enforcement, including how non-compliance is addressed.
Requirement: Include a copy of any policy, procedures or plans that document meeting this standard. At least three of the following strategies must be met in order to achieve this standard.
Clients receive information on the behavioral health organization’s tobacco-free policy at their initial appointment and again as necessary that outlines policy compliance expectations.Employees are required to acknowledge in writing, on an annual basis, that they have read/understand the tobacco-free policy, including compliance expectations.The policy outlines who is responsible for enforcing the policy and how to handle non-compliance.Training on how to handle policy violations with other employees, clients, and visitors is provided for all employees.Progressive discipline for employee violations is written into the policy and made clear to all employees.Leadership walkabouts on the grounds are conducted during different times and days to approach staff, clients, visitors or contractors using tobacco to offer education and request compliance with the policy.Employee involvement in regular cleanup efforts to reduce tobacco-related waste on the behavioral health organization campus.Other: (please explain)
Upload the written policies/procedure for the organization (PDF or Word Doc):

4. Tobacco Advertising
Standard: Advertising or promotion of tobacco products is not allowed on the organization's property including all satellite offices, buildings and any other properties owned or leased by the behavioral health organization. This includes publications and magazines subscribed to by the organization for placement in waiting areas.

Requirement: Describe efforts the behavioral health organization has taken to regulate tobacco advertising. At least one strategy must be included to achieve this standard.

Organization only allows magazines without tobacco advertising.Organization removes tobacco advertising from magazines before allowing them in waiting areas.Notices (posters, flyers, tent cards, signage, etc.) are placed in magazine areas stating that the organization does not support tobacco advertising.Maine Tobacco-Free Behavioral Health Network stickers are placed on all donated or subscribed magazines that may contain tobacco advertising.Other (please describe below)

5. Tobacco Dependence & Treatment Education
Standard: Information about tobacco dependence, secondhand smoke, thirdhand smoke and local/state tobacco treatment resources are readily available to clients, employees and visitors. For example, educational brochures or posters are displayed in the lobby, waiting area and/or treatment rooms.
Requirement: Describe how the resources made available to clients, employees and visitors and what types of materials are provided.

6. Screening for Clients for Tobacco Use and Dependence
Standard: All clients are screened for tobacco use at initial appointments and annually thereafter. Tobacco use status is documented and clients are offered comprehensive, evidence-based treatment services.
Requirement: Describe the initial and annual tobacco screening process for new and existing clients.

7. Evidence-Based Tobacco Treatment Incorporated for Clients
Standard: Clients identified as being tobacco dependent are offered comprehensive, evidence-based treatment services incorporated into treatment plan. This can include tobacco cessation counseling, clinical assessment and management for nicotine withdrawal and/or offering FDA-approved tobacco treatment medications. (Reference: Tobacco Use and Dependence Guideline Panel. Treating Tobacco Use and Dependence: 2008 Update. US Department of Health and Human Services.)
Requirement: Describe how these services are referred or accessed by clients.

8. Referral to Evidence-Based Tobacco Cessation Treatment for Clients Interested in Quitting
Standard: Clients identified as being tobacco dependent and interested in quitting tobacco are referred to evidence-based tobacco cessation treatment, such as the Maine Tobacco HelpLine.
Requirement: Describe the client referral process to cessation treatment services.

9. Evidence-Based Tobacco Treatment Training for Employees
Standard: The behavioral health organization supports evidence-based tobacco treatment training for employees by offering in-services on tobacco treatment, supporting staff financially to attend trainings and/or providing access to literature and resources on-site for staff. Trained staff are available to provide treatment and counseling to tobacco-dependent clients.
Requirement: List the number of employees who have been trained on evidence-based tobacco treatment counseling and education and/or the number of tobacco treatment related activities held over the past year.

10. Tobacco Treatment Benefits for Employees
Standard: Tobacco treatment services are a covered benefit in the organization health insurance package for employees and their dependents. Benefits include coverage for counseling and medication for quitting tobacco, with minimal, or no barriers to utilization (i.e. co-pays, out of pocket costs, limits, etc.).
Requirement: Describe tobacco treatment benefits provided and how they are promoted to employees.