G1 NQDW Services Survey

Form Approved
OMB No. 0920-0856
Exp. Date 07/31/2012

National Quitline Data Warehouse
Quitline Services Questionnaire

Public reporting burden of this collection of information is estimated to average 7 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/ATSDR Reports Clearance Officer; 1600
Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0856)

Please respond to the following questions about the services your quitline offered.
1. Please provide your contact information
Name __________
Job Title _____________
Employer/Organization ___________
State____________
Email ___________
Phone ___________
Second phone __________
2. Please provide state and name of your quitline:
State _________
Name of quitline __________
3. Did your quitline ask the following question on the NQDW Intake Survey during Quarter (X)
{Q1, Q2, or Q3}?

Yes

No
In the past three months, did you hear about 1-800-QUIT-NOW from any advertisements
with smokers telling personal stories and tips about living with health problems?

Yes

No

Unsure
4. If your quitline asked the following question on the NQDW Intake Survey during Quarter
(X) {Q1, Q2 or Q3}, please provide the information requested in the table below (a-e). Please
respond to each item with “N/A” if your quitline did not ask this question during Quarter (X)
{Q1, Q2, or Q3}.
In the past three months, did you hear about 1-800-QUIT-NOW from any advertisements
with smokers telling personal stories and tips about living with health problems?

Yes

No

Unsure
a. Number of callers with a “yes” response
b. Number of callers with a “no” response
c. Number of callers with a “unsure” response
d. Number of callers with a missing response
e. Total number of callers who were asked the question above

N=
N=
N=
N=
N=

5. Was there a change to your quitline’s total budget from last fiscal year to your current fiscal
year, apart from the Recovery Act funding?
Note: quitline’s total budget can include services, medications, evaluation,
media/promotions, outreach and other quitline specific items.

Yes, an increase of ___________(please specify amount)

Yes, a decrease of ___________(please specify amount)

No, no increase or decrease in budget.
6. Does your quitline have a sustainability plan?

Yes

No
7. Please provide the days and hours of service of your quitline for the following categories
of service (Days and hours of service):
**For example, "Monday - Friday, 8:30am - 5:00pm"
N/A Days and hours of
service
Counseling service available
Live pick up of incoming calls (may or may not have counseling
services available)
Voicemail / answering service pick up of calls
8. Is your quitline closed on holidays?

Yes

No
9. How many total direct calls came in to the quitline during [TIME FILL]?
Note: Direct calls are your quitline’s total incoming calls, not referrals that generate an
outbound call from the quitline. Please report on number of calls, not number of
callers/unique individuals. This should include proxy callers, wrong numbers, prank calls,
and other calls to the quitline that are not accounted for in these categories.
a. Calls
Answered
live

b. Calls
Went to
voice
mail

c. Calls Hung up
or abandoned

N=

N=

N=

d. Other Calls
(e.g., listening to
taped messages,
etc.)
N=

e. Total direct calls
(E=A+B+C+D)

N=

10. Quitlines use many types of promotions and referral networks to increase their reach to
tobacco users. Please select all of the sources that generated referrals to your quitline
during [TIME FILL].
Note: Referrals are client referrals to the quitline from health professionals, other
intermediaries or services (including Web sites) that trigger a proactive call to the client
initiated by the quitline.

Fax referral system
Community organization networks
Online advertising (paid)
Web referrals (links from Web sites, not paid ads)
Central call center (“triage”) separate from the quitline
Other. Please describe:
11. How many referrals did the quitline receive during [TIME FILL]?

a. FAX referrals

N=

b. Other referrals
(e.g., web referrals, “click to call,”
online ads, etc.)
N=

c. Total referrals (C=A+B)

N=

12. How many TOBACCO USERS who called or were referred to the quitline received the
services listed below during [TIME FILL]?
Note: Report only on those who received service for the first time. For the purposes of this
question, we define “received” service as anyone who received quitline self-help materials
and/or began at least one counseling call with the quitline and/or received medications
through the quitline.
f. Self-help materials only with no counseling
g. Counseling provided (began at least one session)
by phone defined as a caller-centered, persontailored, in-depth, motivational interaction that
occurs between cessation
specialist/counselor/coach and caller
h. Counseling provided (began at least one session)
face-to-face, individual/group
i. Counseling provided (began at least one session)
by web
j. Counseling provided (began at least one session)
by OTHER mechanism
k. Medications provided (NRT or other FDAapproved medications for tobacco cessation)
through the quitline

N=
N=

N=
N=
N=
N=

l.

Total provided EITHER phone counseling OR
medications OR both (Note: this will likely not
total the sum of b and c because many of those
who receive medications will also have received
counselling. This is the number that will be used to
calculate treatment reach using standard
calculation.)

N=

13. Please list your quitline’s population(s) with disproportionate burden of tobacco use and
provide the number of tobacco users in the target population who called or were referred
to the quitline who received the services listed below for the first time in [TIME FILL].
Note: Report only on those who received service for the first time. For the purposes of this
question, we define “received” service as anyone who received quitline self-help materials
and/or began at least one counseling call with the quitline and/or received medications
through the quitline.
Population(s) with disproportionate burden of tobacco use ____________________
a. Self-help materials only with no counseling
b. Counseling provided (began at least one session)
by phone defined as a caller-centered, persontailored, in-depth, motivational interaction that
occurs between cessation
specialist/counselor/coach and caller
c. Counseling provided (began at least one session)
face-to-face, individual/group
d. Counseling provided (began at least one session)
by web
e. Counseling provided (began at least one session)
by OTHER mechanism
f. Medications provided (NRT or other FDAapproved medications for tobacco cessation)
through the quitline
g. Total provided EITHER phone counseling OR
medications OR both (Note: this will likely not
total the sum of b and c because many of those
who receive medications will also have received
counselling. This is the number that will be used to
calculate treatment reach using standard
calculation.)

N=
N=

N=
N=
N=
N=

N=

14. Does your quitline use a translation service (e.g., AT&T) when providing counseling?

Yes

No
15. Does your quitline use counselors who provide quitline services in languages other than
English?

Yes

No (skip to Q15)

16. If yes, in which of the following languages does your quitline offer counseling, not
translated through a third party? Select all that apply.
English
Spanish
French
Cantonese
Mandarin
Korean
Vietnamese
Russian
Greek
Amharic (Ethiopian)
Punjabi
Deaf and Hard of Hearing (TTY)
Deaf and Hard of Hearing with video relay
Other (please specify):_________
17. Many quitlines have eligibility criteria for receiving services based on state of residence,
age, insurance status, being a member of a special population or readiness to quit. Are
there eligibility criteria for receiving proactive counseling through your quitline?

Note: Counseling here refers to a caller-centered, person-tailored, in-depth, motivational
interaction that occurs between cessation specialist/counselor/coach and caller.

Yes

No, there are no restrictions on receiving proactive counseling – skip to Q17

18. The eligibility criteria include: Select all that apply.
Resident of state
Age: (please specify required age for services): ______ years and older
No insurance
Underinsured
Medicaid
Medicare
Privately insured (or private insurance holders)



Length of time quit: (please specify the eligibility criteria):__________
Readiness to quit: (please provide your quitline’s definition of readiness to quit):_______
Special population: (please specify which populations):________
Other (please specify):_________
19. Do the different levels of proactive counseling services for different?

Note: Many quitlines have different levels of criteria for different types of services which may be
based in-part on budgetary pressures. This question is designed to address this issue. Please
reply fully so we can understand the different types of eligibility for the different levels of service.

Yes: (please fill-in as many blanks as needed)
Number of sessions________ Eligibility Criteria _________
Number of sessions________ Eligibility Criteria _________
Number of sessions________ Eligibility Criteria _________

No
20. If your quitline addressed eligibility criteria for proactive counseling in other ways not
reported in Questions 16-17, please specify:
____________________________________________________________
Quitlines address quitting medications in a variety of ways. Questions 19-53 pertain to how your
quitline provided medications.
21. Did your quitline provide free quitting medications to clients?

Yes

No – skip to Q49
22. Did your quitline provide free nicotine patches to clients?

Yes

No (skip to Q24)

23. What criteria made a caller eligible to receive free nicotine patches from the quitline?
Select all that apply.
Resident of state
Age: (please specify required age for free nicotine patches): _____ years and older
Uninsured
Underinsured
Medicaid
Medicare
Privately insured (or private insurance holders)
Enrollment in counseling
Special population (please specify which populations):______________



Medical conditions
Readiness to quit
Limited supply – orders filled on first come / first served basis
Geographic area (please specify ____________)
Research study criteria
Other (please specify): _________
24. How many weeks of free nicotine patches per quit attempt did your quitline provide to
clients? Please fill-in as many blanks as needed.

Note: if your quitline provides varying amounts of free nicotine patches depending on eligibility
criteria, please specify your eligibility criteria.
Number of weeks of patches per quit attempt______ Eligibility Criteria _________
Number of weeks of patches per quit attempt ______ Eligibility Criteria_________
Number of weeks of patches per quit attempt ______ Eligibility Criteria_________
25. Was there a limit to the number of times a caller could receive free nicotine patches in
one year?

Yes (please specify ________)

No
26. Did your quitline provide nicotine gum to clients?

Yes

No (skip to Q28)

27. What criteria made a caller eligible to receive free nicotine gum from the quitline? Select
all that apply.
Resident of state
Age: (please specify required age for free nicotine gum): _____ years and older
Uninsured
Underinsured
Medicaid
Medicare
Privately insured (or private insurance holders)
Enrollment in counseling
Special population (please specify which populations):______________
Medical conditions
Readiness to quit
Limited supply – orders filled on first come / first served basis
Geographic area (please specify ____________)
Research study criteria
Other (please specify): _________

28. How many weeks of free nicotine gum per quit attempt did your quitline provide to
clients?
Please fill-in as many blanks as needed.
Note: if your quitline provides varying amounts of free nicotine gum depending on eligibility
criteria, please specify your eligibility criteria.
Number of weeks of gum per quit attempt ______ Eligibility Criteria _________
Number of weeks of gum per quit attempt ______ Eligibility Criteria _________
Number of weeks of gum per quit attempt ______ Eligibility Criteria _________
29. Was there a limit to the number of times a caller could receive free nicotine gum in one
year?

Yes

No
30. Did your quitline provide free Nicotine Lozenges to clients?

Yes

No (skip to Q32)

31. What criteria made a caller eligible to receive free Nicotine Lozenges from the quitline?
Select all that apply.
Resident of state
Age: (please specify required age for free Nicotine Lozenges): _____ years and older
Uninsured
Underinsured
Medicaid
Medicare
Privately insured (or private insurance holders)
Enrollment in counseling
Special population (please specify which populations):______________
Medical conditions
Readiness to quit
Limited supply – orders filled on first come / first served basis
Geographic area (please specify ____________)
Research study criteria
Other (please specify): _________
32. How many weeks of free Nicotine Lozenges per quit attempt did your quitline provide
to clients? Please fill-in as many blanks as needed.

Note: if your quitline provides varying amounts of free Nicotine Lozenges depending on
eligibility criteria, please specify your eligibility criteria.
Number of weeks of Nicotine Lozenges per quit attempt ______ Eligibility Criteria _________

Number of weeks of Nicotine Lozenges per quit attempt ______ Eligibility Criteria _________
Number of weeks of Nicotine Lozenges per quit attempt ______ Eligibility Criteria _________
33. Was there a limit to the number of times a caller could receive free Nicotine Lozenges in
one year?

Yes

No
34. Did your quitline provide free Zyban® (Bupropion) to clients?

Yes

No (skip to Q36)

35. What criteria made a caller eligible to receive free Zyban® (Bupropion) from the
quitline? Select all that apply.
Resident of state
Age: (please specify required age for free Zyban® (Bupropion)): _____ years and older
Uninsured
Underinsured
Medicaid
Medicare
Privately insured (or private insurance holders)
Enrollment in counseling
Special population (please specify which populations):______________
Medical conditions
Readiness to quit
Limited supply – orders filled on first come / first served basis
Geographic area (please specify ____________)
Research study criteria
Other (please specify): _________
36. How many weeks of free Zyban® (Bupropion) per quit attempt did your quitline
provide to clients? Please fill-in as many blanks as needed.

Note: if your quitline provides varying amounts of free Zyban® (Bupropion) depending on
eligibility criteria, please specify your eligibility criteria.
Number of weeks of Zyban per quit attempt ______ Eligibility Criteria _________
Number of weeks of Zyban per quit attempt ______ Eligibility Criteria _________
Number of weeks of Zyban per quit attempt ______ Eligibility Criteria _________
37. Was there a limit to the number of times a caller could receive free Zyban®
(Bupropion) in one year?

Yes

No

38. Did your quitline provide free Chantix® (Varenicline) to clients?

Yes

No (skip to Q40)

39. What criteria made a caller eligible to receive free Chantix® (Varenicline) from the
quitline? Select all that apply.
Resident of state
Age: (please specify required age for free Chantix® (Varenicline)): _____ years and older
Uninsured
Underinsured
Medicaid
Medicare
Privately insured (or private insurance holders)
Enrollment in counseling
Special population (please specify which populations):______________
Medical conditions
Readiness to quit
Limited supply – orders filled on first come / first served basis
Geographic area (please specify ____________)
Research study criteria
Other (please specify): _________
40. How many weeks of free Chantix® (Varenicline) per quit attempt did your quitline
provide to clients? Please fill-in as many blanks as needed.

Note: if your quitline provides varying amounts of free Chantix® (Varenicline) depending on
eligibility criteria, please specify your eligibility criteria.
Number of weeks of Chantix per quit attempt ______ Eligibility Criteria _________
Number of weeks of Chantix per quit attempt ______ Eligibility Criteria _________
Number of weeks of Chantix per quit attempt ______ Eligibility Criteria _________
41. Was there a limit to the number of times a caller could receive free Chantix®
(Varenicline) in one year?

Yes

No
42. Did your quitline provide free nicotine nasal spray to clients?

Yes

No (skip to Q44)
43. What criteria made a caller eligible to receive free nicotine nasal spray from the
quitline? Select all that apply.



Resident of state
Age: (please specify required age for free nicotine nasal spray): _____ years and older
Uninsured
Underinsured
Medicaid
Medicare
Privately insured (or private insurance holders)
Enrollment in counseling
Special population (please specify which populations):______________
Medical conditions
Readiness to quit
Limited supply – orders filled on first come / first served basis
Geographic area (please specify ____________)
Research study criteria
Other (please specify): _________
44. How many weeks of free nicotine nasal spray per quit attempt did your quitline
provide to clients? Please fill-in as many blanks as needed.

Note: if your quitline provides varying amounts of free nicotine nasal spray depending on
eligibility criteria, please specify your eligibility criteria.
Number of weeks of nasal spray per quit attempt ______ Eligibility Criteria _________
Number of weeks of nasal spray per quit attempt ______ Eligibility Criteria _________
Number of weeks of nasal spray per quit attempt ______ Eligibility Criteria _________
45. Was there a limit to the number of times a caller could receive free nicotine nasal spray
in one year?

Yes (please specify ________)

No
46. Did your quitline provide free nicotine inhaler to clients?

Yes

No (skip to Q48)

47. What criteria made a caller eligible to receive free nicotine inhaler from the quitline?
Select all that apply.
Resident of state
Age: (please specify required age for free nicotine inhaler): _____ years and older
Uninsured
Underinsured
Medicaid
Medicare
Privately insured (or private insurance holders)



Enrollment in counseling
Special population (please specify which populations):______________
Medical conditions
Readiness to quit
Limited supply – orders filled on first come / first served basis
Geographic area (please specify ____________)
Research study criteria
Other (please specify): _________
48. How many weeks of free nicotine inhaler per quit attempt did your quitline provide to
clients? Please fill-in as many blanks as needed.

Note: if your quitline provides varying amounts of free nicotine inhaler depending on eligibility
criteria, please specify your eligibility critieria.
Number of weeks of inhaler per quit attempt ______ Eligibility Criteria _________
Number of weeks of inhaler per quit attempt ______ Eligibility Criteria _________
Number of weeks of inhaler per quit attempt ______ Eligibility Criteria _________
49. Was there a limit to the number of times a caller could receive free nicotine inhaler in
one year?

Yes (please specify ________)

No
50. Did your quitline provide other free quitting medications to clients?

Yes (please specify _____)

No
51. Besides offering free medications (as reported in Questions 19-48), did your quitline
provide discounted quitting medications?

Yes

No (skip to Q51)
52. What discounted quitting medications did you provide? Select all that apply.

Nicotine patch
Nicotine gum
Nicotine Lozenge
Zyban® (Bupropion)
Chantix® (Varenicline)
Nicotine Nasal spray
Nicotine Inhaler
Other (please specify _____________)

53. Did your quitline provide voucher/coupon or certificate to redeem quitting medications?

Yes

No (skip to Q53)
54. What quitting medications did you provide voucher/coupon or certificate for? Select all
that apply.

Nicotine patch
Nicotine gum
Nicotine Lozenge
Zyban® (Bupropion)
Chantix® (Varenicline)
Nicotine Nasal spray
Nicotine Inhaler
Other (please specify _____________)
55. If your quitline addressed quitting medications in other ways not reported in Questions
19-52, please specify:
____________________________________________________________

Questions 54-58 ask about how your quitline conducts 7-Month Follow-up Surveys. These
questions will be asked only once.
56. Does your quitline obtain consent for the 7-Month Follow-up survey at intake?

Yes

No
57. Does your quitline send out a pre-notification or advance letter to increase participation
in the 7-Month Follow-up Survey?

Yes

No
58. Does your quitline use incentives to increase participation in the 7-Month Follow-up
Survey?

Yes

No
59. What is the minimum number of attempts (i.e. “5”) your quitline makes to reach an
eligible quitline caller for follow-up evaluation before closing out the contact?
Quitline makes at least ________________ number of attempts

60. Does your quitline use a mix-mode to conduct the 7-Month Follow-up Survey?
Note: mixed-mode survey asks the same questions and offers the same response choices
using two or more survey modes, such as Internet, telephone, interactive voice response or
mail.

Yes

No
61. Do you plan to weight your 7-month follow-up survey data?

Yes, please specify your weighting strategy

No