Form 5 Smoking Cessation Reactive Service Demographic Questions

Collection of Customer Service, Demographic and Smoking/Tobacco Use Information from NCI Cancer Information Service (CIS) Clients (NCI)

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APPENDIX 1 C

DATA COLLECTION INSTRUMENTS and

electronic contact Record Form (ECRF)

REACTIVE SMOKING CESSATION Questions

(customer service and demographics questions)

Public Burden Statement

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Smoking Cessation Intake Form (SCIF): Dependency Tab > Summary

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Smoking Cessation Intake Form (SCIF): Dependency Tab Symptoms

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Smoking Cessation Intake Form (SCIF): Dependency Tab > Triggers

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Smoking Cessation Intake Form (SCIF): Dependency Tab > Past Meds

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Smoking Cessation Intake Form (SCIF): Dependency Tab > Future Meds

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Smoking Cessation Intake Form (SCIF): Motivation Tab

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Electronic Coding Records Form (ECRF): seen within the Service Tab

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Spanish Version

Electronic Coding Records Form (ECRF): seen within the Service Tab

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Customer Service Questions

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File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	ilene Holly Burstyn
File Modified	0000-00-00
File Created	2021-01-30