Form 4 Smoking Cessation Reactive Service Client Questions

APPENDIX 2 C

DATA COLLECTION INSTRUMENTS and

electronic contact Record Form (ECRF)

reactive smoking cessation

“Quitline” questions

SMOKING CESSATION “QUITLINE” REACTIVE DEMOGRAPHIC AND

INTAKE QUESTIONS

OMB No. 0925-0208

Expiry Date: 9/30/2012

Current Smoking Cessation Intake Questions – Background Component

Current Smoking Cessation Intake Questions – Dependency Component

D

Current Smoking Cessation Intake Questions – Motivation Component

Current Smoking Cessation Intake Questions – Intervention Component

Current Smoking Cessation Intake Questions – Callback Component

(May we contact you in the future to see how you’re doing and offer additional assistance?)

Current Smoking Cessation Intake Questions – Customer Service Component

Current Smoking Cessation Intake and Follow-up Questions – Demographics Component

11