ASQ Intake Questionnaire (Chinese - Subset)

Form Approved

OMB No. 0920-0856

Exp. Date xx/xx/XXXX

National Quitline Data Warehouse

Intake Questionnaire

(Asian Smoker’s Quitline: Chinese)

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)

Asian Smokers’ Quitline (ASQ) Chinese Intake

This is a free service to help people quit smoking. We offer help through the mail and also over the phone. To provide the best possible service, calls may be monitored and recorded, but will be kept private. I need to ask you a few questions to see what we can do for you, and all of your responses are voluntary. Is that OK?

這裡是提供免費協助戒煙的服務中心，由加州大學醫學院管理。我們的服務都是通過郵寄和電話提供的。為了提供最佳服務, 談話可能被旁聽和錄音。我想先問您一些問題，您的回答純屬自願，也就是說您有權不回答任何問題。您所有的回答都是保密的，可以嗎？  Yes  No

1) Are you calling for yourself or someone else? 您打電話來, 是您自己要戒煙, 還是為別人索取資料？

 Yourself  Someone else

2) May I have your name please? 請問您貴姓? 名字呢？

First Name ________________ MI ­­­_____ Last Name ______________________

3) What’s your date of birth? 請問您的出生年月日?

_______/_______/_______  Refused

IF REFUSED: Then how old are you?

那您今年幾歲？ _________  Refused Unwilling, but >= 18 yrs. old

4) How did you hear about us? 您是怎麼知道我們這個中心及所提供的服務？

Ads:  TV  Radio  Newspaper/ Magazine

 Billboard/ Bus Sign

 Phone Book  Web

Referrals:  VA  Hospital  Clinic/ Doctor’s Office

 Dentist/ Dental Hygienist

 Friend/ Family

 WIC

 Pharmacy  School  Non-profit Org.

 Insurance/HMO/MediCal  Other

 Don’t know

 Refused

Promotional Materials

 Card (Gold, Salud, Quit Now)

 Patch Voucher

Brochure/Pamphlet

 Postcard

If any Referral source (e.g. VA through Insurance/HMO/MediCal above):

Did you receive anything, such as a card or brochure with our number on it?

您曾收到一張有我們電話號碼的卡片或小冊子嗎？

 No  Yes…Postcard  Yes…Re-engagement letter

 Yes… Card  Yes…Magnet  Don’t Know

 Yes…Patch Voucher  Yes…Brochure/ Pamphlet  Refused

If PROMOTIONAL MATERIALS:

Where did you get it?

您是從哪裏拿到金卡/小冊子/章程的呢？

 VA  Hospital  Clinic/ Doctor’s Office

 Dentist/ Dental Hygienist  Friend/ Family  WIC

 Pharmacy  School  Non-profit Org.

 Insurance/HMO/MediCal  CSH  Other

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