Quitline Services Questionnaire

Form Approved

OMB No. 0920-0856

Exp. Date 10/31/2015

National Quitline Data Warehouse (NQDW)

Quitline Services Survey

Year
Quarter
State	     

Public reporting burden of this collection of information is estimated to average 20 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 your quitline during the quarter for which you are reporting.

1. Please provide your contact information

Name	     
Job Title	     
Employer / Organization	     
State	     
Email	     
Phone	     
Second Phone	     

2. How many total direct calls came in to the quitline?

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.

	Type of Call	Number of Calls
a.	Calls answered live	     
b.	Calls went to voice mail	     
c.	Calls hung up or abandoned	     
d.	Other Calls (e.g., listening to taped messages, etc.)	     
e.	Total direct calls (A+B+C+D)	     

3. Of the total DIRECT calls into the quitline during the quarter for which you are reporting, how many UNIQUE tobacco users called the quitline during the quarter for which you are reporting?

     

4. How many TOBACCO USERS who called or were referred to the quitline received the services listed below?

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.

Service	Number of Tobacco Users
Self-help materials only with no counseling	     
Counseling Provided (began at least one session)
Phone1	     
Face-to-Face, Individual/Group	     
Web	     
Other Mechanism	     
Medications provided through the quitline2	     
Provided with phone counseling OR medications OR both phone counseling and medications3	     

¹ Defined as a caller-centered, person-tailored, in-depth, motivational interaction that occurs between cessation specialist/counselor/coach and caller.

² NRT or other FDA-approved medications for tobacco cessation.

³ Total provided EITHER phone counseling OR medications OR both (Note: this will likely not total the sum of b and f because many of those who receive medications will also have received counseling. This is the number that will be used to calculate treatment reach using standard calculation.)

5. 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.

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):      

6. How many referrals did the quitline receive?

	Type of Referral	Number Received
a.	Fax referrals	     
b.	Other referrals (e.g., web referrals, “click to call,” online ads, etc.)	     
c.	Total referrals (A+B)	     

7. Did your quitline ask the following question on the NQDW Intake Survey?

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?

If your quitline asked this question on the NQDW Intake Survey, please provide the information requested in the table below (a-e).

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

The remaining questions deal with the services offered by your Quitline. These questions have been pre-populated with information you have previously reported about your quitline. Please review the following questions and correct/update anything that is incorrect or has changed since you previously reported.

8. Please provide the hours of service of your quitline for the following categories of service:

Day	Live Pick Up of Incoming Calls*
	Available	Hours Available
Monday		      -      
Tuesday		      -      
Wednesday		      -      
Thursday		      -      
Friday		      -      
Saturday		      -      
Sunday		      -      
Day	Counseling Services
	Available	Hours Available
Monday		      -      
Tuesday		      -      
Wednesday		      -      
Thursday		      -      
Friday		      -      
Saturday		      -      
Sunday		      -      
Day	Voicemail / Answering Service Pick Up of Calls
	Available	Hours Available
Monday		      -      
Tuesday		      -      
Wednesday		      -      
Thursday		      -      
Friday		      -      
Saturday		      -      
Sunday		      -      

* May or may not have counseling services available

9. Is your quitline closed on holidays?

10. In which of the following languages does your quitline offer counseling?

Language	Offered
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 describe):      

11. How many counseling sessions does your quitline offer? Please fill in as many rows as needed.

Note: Many quitlines provide different numbers of counseling sessions for different groups of callers. Please reply fully so we can understand the counseling services provided by your quitline along with the eligibility for counseling services.

Number of Counseling Sessions Offered	Eligibility Criteria
	Geography	Age	Readiness to Quit	Pregnancy Status	Insurance		Other
     	Specify:      	Specify:      	Specify:      	Specify:      	Uninsured Medicaid	Medicare Private Ins.	     
					Specify:      
     	Specify:      	Specify:      	Specify:      	Specify:      	Uninsured Medicaid	Medicare Private Ins.	     
					Specify:      
     	Specify:      	Specify:      	Specify:      	Specify:      	Uninsured Medicaid	Medicare Private Ins.	     
					Specify:      
     	Specify:      	Specify:      	Specify:      	Specify:      	Uninsured Medicaid	Medicare Private Ins.	     
					Specify:      
     	Specify:      	Specify:      	Specify:      	Specify:      	Uninsured Medicaid	Medicare Private Ins.	     
					Specify:      
     	Specify:      	Specify:      	Specify:      	Specify:      	Uninsured Medicaid	Medicare Private Ins.	     
					Specify:      

12. Did your quitline provide quitting medications to clients?

Medication	Provided by Quitline
Nicotine Patches	Specify:      
Nicotine Gum	Specify:      
Nicotine Lozenges	Specify:      
Other Medications (please specify):      	Specify:      

13. How many weeks of free Nicotine Patches per quit attempt did your quitline provide to clients? Please fill in as many rows as needed.

Weeks of Free Nicotine Patches Offered Per Quit Attempt	Max. Number of Times Per Year	Eligibility Criteria
		Geography	Age	Readiness to Quit	Enroll in Counseling	No Medical Conditions Preventing Use	Pregnancy Status	Insurance		Other
     	     	     	     	     			     	Uninsured Medicaid	Medicare Private Ins.	     
								Specify:      
     	     	     	     	     			     	Uninsured Medicaid	Medicare Private Ins.	     
								Specify:      
     	     	     	     	     			     	Uninsured Medicaid	Medicare Private Ins.	     
								Specify:      
     	     	     	     	     			     	Uninsured Medicaid	Medicare Private Ins.	     
								Specify:      
     	     	     	     	     			     	Uninsured Medicaid	Medicare Private Ins.	     
								Specify:      
     	     	     	     	     			     	Uninsured Medicaid	Medicare Private Ins.	     
								Specify:      

14. How many weeks of free Nicotine Gum per quit attempt did your quitline provide to clients? Please fill in as many rows as needed.

Weeks of Free Nicotine Gum Offered Per Quit Attempt	Max. Number of Times Per Year	Eligibility Criteria
		Geography	Age	Readiness to Quit	Enroll in Counseling	No Medical Conditions Preventing Use	Pregnancy Status	Insurance		Other
     	     	     	     	     			     	Uninsured Medicaid	Medicare Private Ins.	     
								Specify:      
     	     	     	     	     			     	Uninsured Medicaid	Medicare Private Ins.	     
								Specify:      
     	     	     	     	     			     	Uninsured Medicaid	Medicare Private Ins.	     
								Specify:      
     	     	     	     	     			     	Uninsured Medicaid	Medicare Private Ins.	     
								Specify:      
     	     	     	     	     			     	Uninsured Medicaid	Medicare Private Ins.	     
								Specify:      
     	     	     	     	     			     	Uninsured Medicaid	Medicare Private Ins.	     
								Specify:      

15. How many weeks of free Nicotine Lozenges per quit attempt did your quitline provide to clients? Please fill in as many rows as needed.

Weeks of Free Nicotine Lozenges Offered Per Quit Attempt	Max. Number of Times Per Year	Eligibility Criteria
		Geography	Age	Readiness to Quit	Enroll in Counseling	No Medical Conditions Preventing Use	Pregnancy Status	Insurance		Other
     	     	     	     	     			     	Uninsured Medicaid	Medicare Private Ins.	     
								Specify:      
     	     	     	     	     			     	Uninsured Medicaid	Medicare Private Ins.	     
								Specify:      
     	     	     	     	     			     	Uninsured Medicaid	Medicare Private Ins.	     
								Specify:      
     	     	     	     	     			     	Uninsured Medicaid	Medicare Private Ins.	     
								Specify:      
     	     	     	     	     			     	Uninsured Medicaid	Medicare Private Ins.	     
								Specify:      
     	     	     	     	     			     	Uninsured Medicaid	Medicare Private Ins.	     
								Specify:      

NQDW Quitline Services Survey 9