Form E1(b) NQDW Intake Questionnaire Subset Final

Form Approved
OMB No. 0920-0856
Exp. Date 08/31/2012

National Quitline Data Warehouse
Intake Questionnaire

Public reporting burden of this collection of information is estimated to range from 1-10 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)

This is a free service to help people quit using tobacco. We offer help through the mail and
over the phone. To provide the best possible service, calls may be monitored and recorded,
but will be kept secure. I need to ask you a few questions to see how we can assist you. All
of your responses are voluntary. Is that OK?
IS RESPONDENT CONTINUING WITH THE INTERVIEW?

YES

NO – ASSIGN DISPOSITION CODE
1. 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
2. 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

3. 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

OTHER: _________________________

DON’T KNOW

REFUSED
4. 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