Form E1(a) NQDW Intake Questionnaire

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)

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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

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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

END INTERVIEW IF RESPONDENT IS NOT CALLING FOR THEMSELVES FOR HELP
WITH QUITTING (SEE RESPONSE TO QUESTION 2).
5. Is this your first call to the quitline in the past 12 months?

YES

NO

DON’T KNOW

REFUSED

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ASSESSMENT FOR TYPES OF TOBACCO USE
6. 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 6 IF CALLER RESPONDED “YES” TO CIGARETTES ABOVE.
7. Do you currently smoke CIGARETTES every day, some days, or not at all?
(CHECK ONE)

EVERYDAY (SKIP TO Q8)

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SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 CIGARETTE PER
DAY)

NOT AT ALL (SKIP TO Q9)

DON’T KNOW

REFUSED
8. How many days did you smoke in the last 30 days?
_____Days

DON’T KNOW

REFUSED
9. How many cigarettes do you smoke per day on the days that you smoke?
(cigarettes per day)___

DON’T KNOW

REFUSED
EVERYDAY CIGARETTE SMOKERS SKIP TO Q10-26 AS INDICATED BY THE TYPE
OF TOBACCO USE QUESTION ABOVE.
10. When was the last time you smoked a cigarette, even a puff?
______(dd/mm/yyyy)

NEVER

DON’T KNOW

REFUSED
READ 10 IF CALLER RESPONDED “YES” TO CIGARS, CIGARILLOS, OR LITTLE
CIGARS ABOVE.
11. Do you currently smoke CIGARS, CIGARILLOS, OR LITTLE CIGARS 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 CIGAR PER DAY)

NOT AT ALL (SKIP TO Q13)

DON’T KNOW

REFUSED
12. How many days did you smoke a CIGAR, CIGARILLO, OR LITTLE CIGAR in the last 30
days?
____Days

DON’T KNOW

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REFUSED
13. 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
EVERY DAY CIGAR, CIGARILLOS, OR LITTLE CIGARS SMOKERS SKIP TO Q14-26 AS
INDICATED BY THE TYPE OF TOBACCO USE QUESTION ABOVE.
14. When was the last time you smoked a CIGAR, CIGARILLO, OR LITTLE CIGAR, even a
puff?
__________ (dd/mm/yyyy)

NEVER

DON’T KNOW

REFUSED
READ 14 IF CALLER RESPONDED “YES” TO A PIPE ABOVE.
15. Do you currently smoke PIPES every day, some days, or not at all? (CHECK ONE)

EVERYDAY (SKIP TO Q16)

SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 PIPE PER DAY)

NOT AT ALL (SKIP TO Q17)

DON’T KNOW

REFUSED
16. How many days did you smoke a pipe in the last 30 days?
___ Days

DON’T KNOW

REFUSED
17. How many pipes do you smoke per week during the weeks that you smoke?
(pipes per week) ________

DON’T KNOW

REFUSED
EVERY DAY PIPE SMOKERS SKIP TO Q18-26 AS INDICATED BY THE TYPE OF
TOBACCO USE QUESTION ABOVE.
18. When was the last time you smoked a pipe, even a puff?
________ (dd/mm/yyyy)

NEVER
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DON’T KNOW

REFUSED
READ 18 IF CALLER RESPONDED “YES” TO CHEWING TOBACCO, SNUFF, OR DIP
ABOVE.
19. Do you currently use CHEWING TOBACCO, SNUFF, OR DIP every day, some days, or
not at all?
(CHECK ONE)

EVERYDAY (SKIP TO Q20)

SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 POUCH OR PINCH
PER DAY)

NOT AT ALL (SKIP TO Q21)

DON’T KNOW

REFUSED
20. How many days did you use chewing tobacco, snuff or dip in the last 30 days?
_______(days)

DON’T KNOW

REFUSED
21. 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
EVERYDAY CHEW/SNUFF USERS SKIP TO Q22-26 AS INDICATED BY THE TYPE OF
TOBACCO USE QUESTION ABOVE.
22. When was the last time you used chewing tobacco, snuff or dip, even a pinch?
___________ (dd/mm/yyyy)

NEVER

DON’T KNOW

REFUSED
READ 22 IF CALLER RESPONDED “YES” TO OTHER TYPES OF TOBACCO ABOVE.
23. Do you currently use OTHER TYPES OF TOBACCO every day, some days, or not at all?
(CHECK ONE)

EVERYDAY (SKIP TO 24)

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 Q25)

DON’T KNOW
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REFUSED
24. How many days did you use other types of tobacco in the last 30 days?
_______(days)

DON’T KNOW

REFUSED
25. 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
EVERYDAY OTHER TOBACCO PRODUCT USERS SKIP TO Q26
26. When was the last time you used other types of tobacco, even a puff or pinch?
___________ (dd/mm/yyyy)

NEVER

DON’T KNOW

REFUSED
ASK OF CIGARETTE SMOKERS ONLY:
27. 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 5.
28. 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 5.
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29. 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 5.
30. 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 5.
31. 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 5.
32. Do you intend to quit using [NAME OF OTHER TOBACCO PRODUCT] within the next 30
days?

YES

NO

DON’T KNOW

REFUSED
CALLER CHARACTERISTICS
33. I need to verify: are you male or female?

Male

Female

REFUSED
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34. What year were you born? _ _ _ _

DON’T KNOW

REFUSED
35. What is your zip code? _ _ _ _ _

DON’T KNOW

REFUSED
36. What is the highest level of education you have completed?
LESS THAN GRADE 9
GRADE 9 TO 11, NO DEGREE
GED
HIGH SCHOOL DEGREE
SOME COLLEGE OR UNIVERSITY(includes some technical or trade school)
COLLEGE OR UNIVERSITY DEGREE (includes AA, BA, Masters, Ph.D.)
DON’T KNOW
REFUSED

37. Are you of Hispanic or Latino origin?

NO (Not of Hispanic or Latino origin)

YES(of Hispanic or Latino origin)

DON’T KNOW

REFUSED
38. What is your race? Which one or more of the following groups best describes you? (SELECT
ONE OR MORE)

White

Black or African American

Asian

Native Hawaiian or other Pacific Islander

American Indian or Alaska Native

**OTHER RACE (SPECIFY _____________)

DON’T KNOW

REFUSED
**NOTE: The following response category is not read by the interviewer. It is only used if
the respondent provides a race that is not reflected in the 5 categories above.

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CONSENT TO FOLLOW-UP
Do you agree to participate in a follow-up call to assess whether you are satisfied with the
service? Please note that your participation in the follow-up survey is completely voluntary and
whether you agree to participate or not will not affect the services you receive through the
quitline.

YES

NO
INTAKE ADMINISTRATIVE DATA
Caller ID
Date questionnaire administered (dd/mm/yyyy): _ _/_ _/_ _ ___
Result of first contact: (Check all that apply):

Basic information provided (no materials sent)

Literature and/or self-help materials sent

Reactive counselling (one counselling session provided during first contact)

Proactive counselling requested (more than one counselling session) (first counselling
session may or may not have taken place during first contact)

Medications sent (FDA approved)

Referral to another service (for tobacco cessation or other services, including web-based
services, community clinics, etc.)

Other
Mode of entry to the quitline

Direct call to the number

Fax referral

Internet

Email solicitation/click-through

Other (specify__________)
Services RECEIVED by the caller (should be updated after every contact to provide cumulative
services received by caller)

Counseling using an interpreter service

Counseling (any amount, should not include time spent asking intake questions or on content
that is not directly related to counselling)

Web-based services (registered/logged in at least once to a cessation-focused website)

Medications (medications were shipped to the caller)

Materials (materials were mailed to the caller)

Other (as relevant to each quitline)

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