G3 Quitline Services Survey

Form Approved

OMB No. 0920-0856

Exp. Date 10/31/2015

National Quitline Data Warehouse (NQDW)

Quitline Services Survey

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)

Year:
Quarter:
State:	     

Instructions for Completing Survey:
Throughout this survey, please fill in -1 to indicate that data are not available for a particular question. Responses of -1 will be interpreted and presented in future reporting as “NA”.

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.

	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-f).

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

The remaining questions deal with the services offered by your Quitline during the quarter for which you are reporting. For your convenience, the answers to these questions have been pre-populated with the responses you reported on your most recent prior submission. Please review and make any necessary revisions so that the answers to these questions accurately reflect the services offered by your quitline during the quarter for which you are reporting.

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

Day	Hours of Operation
	Live Pick Up of Incoming Calls †	Counseling Services	Voicemail / Answering Service Pick Up of Calls
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 reply fully so we can understand the counseling services provided by your quitline along with the eligibility for counseling services.)

Eligibility Criteria This is the minimum eligibility criteria that applies to ALL callers who receive any amount of counseling. Additional eligibility criteria for groups of callers that receive different amounts of counseling specified in the section below.
		Criteria	Comments
Resident of state:			     
Age:			     
Readiness to Quit:			     
Uninsured:			     
Underinsured:			     
Medicaid:			     
Medicare:			     
Privately Insured:			     
Other:			     
Number of Counseling Sessions Offered †
Eligibility Criteria				Number	Comments
All Eligible Callers (based on eligibility criteria listed above)				     	     
Additional Eligibility Criteria If your quitline provides different numbers of counseling sessions for different groups of callers, please specify the additional eligibility criteria, above and beyond the eligibility criteria already listed above, for each group along with the number of counseling sessions offered to those groups.
1:	     			     	     
2:	     			     	     
3:	     			     	     
4:	     			     	     
5:	     			     	     

† These are the maximum number of counseling sessions offered per quit attempt.

12. Did your quitline provide quitting medications to clients?

Medication	Available Medications
	Free	Discounted	Voucher/Coupon	Comments
Nicotine Patches:				     
Nicotine Gum:				     
Nicotine Lozenges:				     
Other (please specify):      				     

13. How many weeks of free Nicotine Patches per quit attempt did your quitline provide to clients? (Please skip this question if your quitline did not provide free nicotine patches.)

Free Nicotine Patches - Eligibility Criteria This is the minimum eligibility criteria that applies to ALL callers who receive any amount of free nicotine patches. Additional eligibility criteria for groups of callers that receive different amounts of nicotine patches specified in the section below.
		Criteria	Comments
Resident of state:			     
Geographic area:			     
Age:			     
Readiness to quit:			     
Enrollment in counseling:			     
Medical conditions:			     
Uninsured:			     
Underinsured:			     
Medicaid:			     
Medicare:			     
Privately Insured:			     
Limited supply:			     
Research study:			     
Other:			     
Free Nicotine Patches - Amount Offered
Eligibility Criteria			Weeks Per Quit Attempt	Limit Per Year	Comments
All Eligible Callers (based on eligibility criteria listed above)			     	     	     
Additional Eligibility Criteria If your quitline provides different amounts of free nicotine patches for different groups of callers, please specify the additional eligibility criteria, above and beyond the eligibility criteria already listed above, for each group along with the number of weeks of free nicotine patches per quit attempt offered to those groups.
1:	     		     	     	     
2:	     		     	     	     
3:	     		     	     	     
4:	     		     	     	     
5:	     		     	     	     

14. How many weeks of free Nicotine Gum per quit attempt did your quitline provide to clients? (Please skip this question if your quitline did not provide free nicotine gum.)

Free Nicotine Gum - Eligibility Criteria This is the minimum eligibility criteria that applies to ALL callers who receive any amount of free nicotine gum. Additional eligibility criteria for groups of callers that receive different amounts of nicotine gum specified in the section below.
		Criteria	Comments
Resident of state:			     
Geographic area:			     
Age:			     
Readiness to quit:			     
Enrollment in counseling:			     
Medical conditions:			     
Uninsured:			     
Underinsured:			     
Medicaid:			     
Medicare:			     
Privately Insured:			     
Limited supply:			     
Research study:			     
Other:			     
Free Nicotine Gum - Amount Offered
Eligibility Criteria			Weeks Per Quit Attempt	Limit Per Year	Comments
All Eligible Callers (based on eligibility criteria listed above)			     	     	     
Additional Eligibility Criteria If your quitline provides different amounts of free nicotine gum for different groups of callers, please specify the additional eligibility criteria, above and beyond the eligibility criteria already listed above, for each group along with the number of weeks of free nicotine gum per quit attempt offered to those groups.
1:	     		     	     	     
2:	     		     	     	     
3:	     		     	     	     
4:	     		     	     	     
5:	     		     	     	     

15. How many weeks of free Nicotine Lozenges per quit attempt did your quitline provide to clients? (Please skip this question if your quitline did not provide free nicotine lozenges.)

Free Nicotine Lozenges - Eligibility Criteria This is the minimum eligibility criteria that applies to ALL callers who receive any amount of free nicotine lozenges. Additional eligibility criteria for groups of callers that receive different amounts of nicotine lozenges specified in the section below.
		Criteria	Comments
Resident of state:			     
Geographic area:			     
Age:			     
Readiness to quit:			     
Enrollment in counseling:			     
Medical conditions:			     
Uninsured:			     
Underinsured:			     
Medicaid:			     
Medicare:			     
Privately Insured:			     
Limited supply:			     
Research study:			     
Other:			     
Free Nicotine Lozenges - Amount Offered
Eligibility Criteria			Weeks Per Quit Attempt	Limit Per Year	Comments
All Eligible Callers (based on eligibility criteria listed above)			     	     	     
Additional Eligibility Criteria If your quitline provides different amounts of free nicotine lozenges for different groups of callers, please specify the additional eligibility criteria, above and beyond the eligibility criteria already listed above, for each group along with the number of weeks of free nicotine lozenges per quit attempt offered to those groups.
1:	     		     	     	     
2:	     		     	     	     
3:	     		     	     	     
4:	     		     	     	     
5:	     		     	     	     

NQDW Quitline Services Survey 16