Intake Data for Quitline Clients

Form Approved

CoOMB No. 0920-XXXX

Exp. Date xx/xx/XXXX

Intake Data for Quitline Clients

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: OMB 0920-XXXX

Contact Information File
Consented Y/N	(Interviewer coded after obtaining informed consent)
User ID
Mode of Cessation Service	(Quitline vs. Web-based)
Date of Registration	(dd/mm/yyyy): _ _/_ _/_ _ ___
Last Name	What is your full name?
First Name	What is your full name?
Mailing Address	What is your mailing address?
City by zip	What is your mailing address?
State by zip	(filled in by zip)
Zip	What is your zip code?
County by zip	(filled in by zip)
Primary phone	What is your main phone number?
Secondary phone	Do you have a second phone number we can use?
Cell phone	Do you have a cell phone number?
Best time to call caller back	What is the best time to call you?
Email address	Do you have an email address?

Quitline Utilization Data File
Variable	Possible Data Values
User ID
Date of Registration	(dd/mm/yyyy): _ _/_ _/_ _ ___
Mode of Cessation Service	 Quitline  Web
State
Result of first contact	(Check all that apply):  Basic information provided (no materials sent)  Literature and/or self-help materials sent  Reactive counseling (one counseling session provided during first contact)  Proactive counseling requested (more than one counseling session) (first counseling session may or may not have taken place during first contact)  Medications sent (FDA approved)  Referral to another service (for tobacco cessation or other services, including web- based services, community clinics, etc.)  Other
Mode of entry to the quitline	 Direct call to the number  Fax referral  Internet  Email solicitation/click-through  Other (specify__________)
Services RECEIVED by the caller	 Counseling using an interpreter service  Counseling (any amount, should not include time spent asking intake questions or on content that is not directly related to counseling) Web-based services (registered/logged in at least once to a cessation-focused website) Medications (medications were shipped to the caller) Materials (materials were mailed to the caller) Other (as relevant to each quitline)
Total Calls	Number of completed telephonic counseling calls
Date of each call [1, 2, …..n]	(dd/mm/yyyy): _ _/_ _/_ _ ___
Length of each call [1,2,….n]	(hh:mm:ss)

Intake Survey Data – Minimum Dataset Items (MDS)
Variable	Survey Item	Possible Data Values
Reason for calling	How can I help you?	 WANT HELP / INFORMATION ABOUT QUITTING  WANT HELP / INFORMATION ABOUT STAYING QUIT  WANT TO REFER SOMEONE FOR HELP  WANT GENERAL INFORMATION OR MATERIALS ABOUT QUITLINE SERVICE  OTHER: ________________________________  DON’T KNOW  REFUSED
Purpose	Just to confirm, are you calling for yourself, or calling on behalf of or to help someone else?	 Calling for yourself for help with quitting  Calling for yourself but not for help with quitting  Calling on behalf of or to help someone else  DON’T KNOW  REFUSED
Referral source	How did you hear about the quitline? (CHECK ALL RESPONSES)	MEDIA  NEWSPAPER  RADIO  TELEVISION  INTERNET/WEB  OTHER: _________________________ OTHER ADVERTISING  PHONE DIRECTORY  FLYERS, BROCHURES  OTHER: _________________________ REFERRAL  HEALTH PROFESSIONAL (DOCTOR, DENTIST, ETC.)  FAMILY / FRIENDS  WORKPLACE  HEALTH INSURANCE  COMMUNITY ORGANIZATION
New user	Is this your first call to the quitline in the past 12 months?	 YES  NO  DON’T KNOW  REFUSED
Current Tobacco Use	What types of tobacco have you used in the past 30 days?	Cigarettes, B) Cigars, cigarillos, or little cigars, C) A pipe, D) Chewing tobacco, snuff, or dip E) Any other type of tobacco? Responses for each category above  YES  NO  DON’T KNOW  REFUSED
Tobacco Use Status - Cigarettes	Do you currently smoke cigarettes every day, some days, or not at all?	 EVERYDAY  SOMEDAYS  NOT AT ALL  DON’T KNOW  REFUSED
Smoking Frequency – Someday Smokers	How many days did you smoke in the last 30 days?	_____Days  DON’T KNOW  REFUSED
Intensity - Cigarettes	How many cigarettes do you smoke per day on the days that you smoke?	(cigarettes per day)___  DON’T KNOW  REFUSED
Length of abstinence - former smokers	When was the last time you smoked a cigarette, even a puff?	(dd/mm/yyy)  NEVER  DON’T KNOW  REFUSED
Tobacco Use Status - Cigars	Do you currently smoke CIGARS, CIGARILLOS, OR LITTLE CIGARS every day, some days, or not at all? (CHECK ONE)	 EVERYDAY  SOMEDAYS  NOT AT ALL  DON’T KNOW  REFUSED
Frequency – Cigars	How many days did you smoke a CIGARS, CIGARILLOS, OR LITTLE CIGARS in the last 30 days?	_____Days  DON’T KNOW  REFUSED
Intensity - Cigars	How many CIGARS, CIGARILLOS, OR LITTLE CIGARS do you smoke per week during the weeks that you smoke?	(cigars, cigarillos, or little cigars per week)_______  DON’T KNOW  REFUSED
Length of abstinence – former cigar users	When was the last time you smoked a CIGARS, CIGARILLOS, OR LITTLE CIGARS, even a puff?	(dd/mm/yyy)  NEVER  DON’T KNOW  REFUSED
Tobacco Use Status - Pipes	Do you currently smoke PIPES every day, some days, or not at all?	 EVERYDAY  SOMEDAYS  NOT AT ALL  DON’T KNOW  REFUSED
Frequency – Pipes	How many days did you smoke a PIPE in the last 30 days?	_____Days  DON’T KNOW  REFUSED
Intensity - Pipes	How many PIPES do you smoke per week during the weeks that you smoke?	(pipes per week)_______  DON’T KNOW  REFUSED
Length of abstinence – former pipe users	When was the last time you smoked a PIPE, even a puff?	(dd/mm/yyy)  NEVER  DON’T KNOW  REFUSED
Tobacco Use Status - Smokeless	Do you currently use CHEWING TOBACCO, SNUFF, OR DIP every day, some days, or not at all? (CHECK ONE)	 EVERYDAY  SOMEDAYS  NOT AT ALL  DON’T KNOW  REFUSED
Frequency – Smokeless	How many days did you use chewing tobacco, snuff or dip in the last 30 days?	_______(days)  DON’T KNOW  REFUSED
Intensity - Smokeless	How many POUCHES OR TINS do you use per week during the weeks that you use chewing tobacco or snuff?	(pouches/tins per week)_____  DON’T KNOW  REFUSED
Length of abstinence – former smokeless user	When was the last time you used chewing tobacco, snuff or dip, even a pinch?	___________ (dd/mm/yyyy)  NEVER  DON’T KNOW  REFUSED
Tobacco Use Status - OTP	Do you currently use OTHER TYPES OF TOBACCO every day, some days, or not at all? (CHECK ONE)	 EVERYDAY  SOMEDAYS  NOT AT ALL  DON’T KNOW  REFUSED
Frequency – OTP	How many days did you use other types of tobacco in the last 30 days?	_______(days)  DON’T KNOW  REFUSED
Intensity - OTP	How much [how many] [OTHER TOBACCO NAME] do you use per week during the weeks that you use other tobacco?	(other tobacco per week) ____  DON’T KNOW  REFUSED
Length of abstinence – former OTP user	When was the last time you used other types of tobacco, even a puff or pinch?	___________ (dd/mm/yyyy)  NEVER  DON’T KNOW  REFUSED
Time to first cigarette	How soon after you wake up do you smoke your first cigarette?	 WITHIN FIVE MINUTES  6 TO 30 MINUTES  31 TO 60 MINUTES  MORE THAN 60 MINUTES  DON’T KNOW  REFUSED
Intention to quit - Cigarettes	Do you intend to quit using cigarettes w/in the next 30 days?	 YES  NO  DON’T KNOW  REFUSED
Intention to quit - cigars	Do you intend to quit using cigars, cigarillos, or little cigars within the next 30 days?	 YES  NO  DON’T KNOW  REFUSED
Intention to quit - Pipe	Do you intend to quit using a pipe within the next 30 days?	 YES  NO  DON’T KNOW  REFUSED
Intention to quit - Smokeless	Do you intend to quit using chewing tobacco, snuff, or dip within the next 30 days?	 YES  NO  DON’T KNOW  REFUSED
Intention to quit - OTP	Do you intend to quit using [NAME OF OTHER TOBACCO PRODUCT] within the next 30 days?	 YES  NO  DON’T KNOW  REFUSED
Zip code	What is your zip code?	_ _ _ _ _  DON’T KNOW  REFUSED
Birthday	What year were you born?	_ _ _ _  DON’T KNOW  REFUSED
Gender	I need to verify: are you male or female?	 Male  Female  REFUSED
Education	What is the highest level of education you have completed?	 LESS THAN GRADE 9  GRADE 9 TO 11, NO DEGREE  GED  HIGH SCHOOL DEGREE  SOME COLLEGE OR UNIVERSITY(includes some technical or trade school)  COLLEGE OR UNIVERSITY DEGREE (includes AA, BA, Masters, Ph.D.)  DON’T KNOW  REFUSED
Ethnicity	Are you of Hispanic or Latino origin?	 NO (Not of Hispanic or Latino origin)  YES(of Hispanic or Latino origin)  DON’T KNOW  REFUSED
Race	What is your race? Which one or more of these groups would you say best describes you? (select one or more)	 White  Black or African American  Asian  Native Hawaiian or other Pacific Islander  American Indian or Alaska Native  SOME OTHER RACE (SPECIFY ___________)  DON’T KNOW  REFUSED