Form Approved
OMB No. 0920-0856
Exp. Date 08/31/2012
National Quitline Data Warehouse
7-Month Follow-up 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)
Hello, my name is [NAME FILL]. I am calling from [EVALUATOR NAME FILL]. We are evaluating the quality of service provided by the [NAME OF YOUR QUITLINE FILL]. In order to improve the program, I would like to get your feedback on the services that you received. We will not use personal information (e.g., your last name, address, or phone number) to identify you. Your feedback will be summarized along with feedback provided by other people who have used the Quitline. You don’t have to answer any question you don’t want to, and you can end the interview at any time. Also, answering or choosing not to answer questions will not change the quitline services you can or will receive. The interview takes approximately 7 minutes and any information you give me will be kept secure.
IS RESPONDENT CONTINUING WITH THE INTERVIEW?
YES
NO – ASSIGN DISPOSITION CODE
Overall, how satisfied were you with the service you received from the quitline?
(CHECK ONE ONLY)
Very satisfied
Mostly satisfied
Somewhat satisfied
Not at all satisfied
DON’T KNOW
REFUSED
Have you smoked any cigarettes or used other tobacco, even a puff or pinch, in the last 30 days?
YES
NO
DON’T KNOW
REFUSED
What types of tobacco have you used in the past 30 days? Cigarettes? (RECORD RESPONSE) Cigars, cigarillos, or little cigars? (RECORD RESPONSE) A pipe? (RECORD RESPONSE) Chewing tobacco, snuff, or dip? (RECORD RESPONSE) Any other type of tobacco? (RECORD RESPONSE)
CIGARETTES
YES
NO
DON’T KNOW
REFUSED
CIGARS, CIGARILLOS, OR LITTLE CIGARS
YES
NO
DON’T KNOW
REFUSED
PIPE [NOTE: THIS IS A TRADITIONAL PIPE, NOT A WATER PIPE OR “HOOKAH”]
YES
NO
DON’T KNOW
REFUSED
CHEWING TOBACCO, SNUFF, OR DIP
YES
NO
DON’T KNOW
REFUSED
OTHER
YES
NO
DON’T KNOW
REFUSED
NONE (NOTE: NO TO ALL ABOVE EQUALS NONE)
READ 4 IF CALLER RESPONDED “YES” TO CIGARETTES ABOVE.
Do you currently smoke CIGARETTES every day, some days, or not at all?
(CHECK ONE)
EVERYDAY (SKIP TO Q6)
SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 CIGARETTE PER DAY)
NOT AT ALL (SKIP TO Q7)
DON’T KNOW
REFUSED
How many days did you smoke in the last 30 days?
_____Days
DON’T KNOW
REFUSED
How many cigarettes do you smoke per day on the days that you smoke?
(cigarettes per day)___
DON’T KNOW
REFUSED
READ 7 IF CALLER RESPONDED “YES” TO CIGARS, CIGARILLOS, OR LITTLE CIGARS ABOVE.
Do you currently smoke CIGARS, CIGARILLOS, OR LITTLE CIGARS every day, some days, or not at all?
(CHECK ONE)
EVERYDAY (SKIP TO Q9)
SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 CIGAR PER DAY)
NOT AT ALL (SKIP TO Q10)
DON’T KNOW
REFUSED
How many days did you smoke a CIGAR, CIGARILLO, OR LITTLE CIGAR in the last 30 days?
____Days
DON’T KNOW
REFUSED
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
READ 10 IF CALLER RESPONDED “YES” TO A PIPE ABOVE.
Do you currently smoke PIPES every day, some days, or not at all? (CHECK ONE)
EVERYDAY (SKIP TO Q12)
SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 PIPE PER DAY)
NOT AT ALL (SKIP TO Q13)
DON’T KNOW
REFUSED
How many days did you smoke a pipe in the last 30 days?
___ Days
DON’T KNOW
REFUSED
How many pipes do you smoke per week during the weeks that you smoke?
(pipes per week) ________
DON’T KNOW
REFUSED
READ 13 IF CALLER RESPONDED “YES” TO CHEWING TOBACCO, SNUFF, OR DIP ABOVE.
Do you currently use CHEWING TOBACCO, SNUFF, OR DIP every day, some days, or not at all?
(CHECK ONE)
EVERYDAY (SKIP TO Q15)
SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 POUCH OR PINCH PER DAY)
NOT AT ALL (SKIP TO Q16)
DON’T KNOW
REFUSED
How many days did you use chewing tobacco, snuff or dip in the last 30 days?
_______ (days)
DON’T KNOW
REFUSED
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
READ 16 IF CALLER RESPONDED “YES” TO OTHER TYPES OF TOBACCO ABOVE.
Do you currently use OTHER TYPES OF TOBACCO every day, some days, or not at all?
(CHECK ONE)
EVERYDAY (SKIP TO 18)
SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 UNIT OF OTHER TYPE OF TOBACCO PER DAY)
NOT AT ALL (SKIP TO Q19)
DON’T KNOW
REFUSED
How many days did you use other types of tobacco in the last 30 days?
_______(days)
DON’T KNOW
REFUSED
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
ASK OF CIGARETTE SMOKERS ONLY:
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
ASK ONLY IF PARTICIPANT REPLIED THEY HAVE USED CIGARETTES IN THE PAST 30 DAYS IN QUESTION 3.
Do you intend to quit using cigarettes within the next 30 days?
YES
NO
DON’T KNOW
REFUSED
ASK ONLY IF PARTICIPANT REPLIED THEY HAVE USED CIGARS, CIGARILLOS, OR LITTLE CIGARS IN THE PAST 30 DAYS IN QUESTION 3.
Do you intend to quit using cigars, cigarillos, or little cigars within the next 30 days?
YES
NO
DON’T KNOW
REFUSED
ASK ONLY IF PARTICIPANT REPLIED THEY HAVE USED A PIPE IN THE PAST 30 DAYS IN QUESTION 3.
Do you intend to quit using a pipe within the next 30 days?
YES
NO
DON’T KNOW
REFUSED
ASK ONLY IF PARTICIPANT REPLIED THEY HAVE USED CHEWING TOBACCO, SNUFF, OR DIP IN THE PAST 30 DAYS IN QUESTION 3.
Do you intend to quit using chewing tobacco, snuff, or dip within the next 30 days?
YES
NO
DON’T KNOW
REFUSED
ASK ONLY IF PARTICIPANT REPLIED THEY HAVE USED OTHER TOBACCO PRODUCTS IN THE PAST 30 DAYS IN QUESTION 3.
Do you intend to quit using [NAME OF OTHER TOBACCO PRODUCT] within the next 30 days?
YES
NO
DON’T KNOW
REFUSED
ASK OF ALL RESPONDENTS
Since you first called the quitline on (Date of first contact), seven months ago, did you stop using tobacco for 24 hours or longer because you were trying to quit?
(CHECK ONE ONLY)
YES
NO
DON’T KNOW
REFUSED
Since you first called the quitline seven months ago, have you used any of the following products or medications (Nicotine patches, Nicotine gum, Nicotine lozenges, Nicotine spray, Nicotine inhaler, Zyban, Chantix, or other medications/products) to help you quit?
YES
NO (SKIP TO Q28)
DON’T KNOW
REFUSED
Which of the following products or medications have you used to help you quit? (CHECK ALL THAT APPLY)
Nicotine patches
Nicotine gum
Nicotine lozenges
Nicotine spray
Nicotine inhaler
Zyban (also called Wellbutrin or bupropion)
Chantix (also called varenicline)
Other medications to help you quit (if yes, please specify_____)
DON’T KNOW
REFUSED
Other than the quitline or medications, did you use any other kinds of assistance to help you quit over the past seven months?
(CHECK ALL THAT APPLY)
Advice from a health professional
Website
Telephone program
Counselling program
Self-help materials
SOMETHING ELSE
DON’T KNOW
REFUSED
7-MONTH FOLLOW-UP ADMINISTRATIVE DATA
Caller ID
Date of first contact with quitline (dd/mm/yyyy): _ _/_ _/_ _ _ _
Date of Evaluation Interview: target is seven months after date of first contact with quitline (dd/mm/yyyy): _ _/_ _/_ _ _ _
Which of the following medications were provided?
Nicotine replacement patch
Nicotine replacement gum
Lozenge
Zyban® (Bupropion)
Chantix® (Varenicline)
Nasal spray
Inhaler
Other (please specify _____________)
Number of counselling sessions client received: ____ (number).
Page
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | FOLLOW-UP QUESTIONS |
| Author | jsaul |
| File Modified | 0000-00-00 |
| File Created | 2021-01-29 |