ASQ Intake Questionnaire (Korean - Subset)

Form Approved

OMB No. 0920-0856

Exp. Date xx/xx/XXXX

National Quitline Data Warehouse

Intake Questionnaire

(Asian Smoker’s Quitline: Korean)

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) Korean 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?

저희는 금연을 도와드리는 무료 서비스로서, UC샌디에고 의과 대학에 의해 운영되고 있습니다. 저희는 개개인이 필요로하는 다양한 서비스를 제공하고 있습니다. 저희가 선생님/ 사모님을 좀 더 효과적으로 도와드리기 위해 몆가지 질문을 하겠습니다. 통화하시는 모든 내용은 비밀이 보장되며 원치 않는 질문에는 대답하지 않으셔도 됩니다. 그리고 좀더 나은 서비스를 위해 전화가 모니터, 녹음될 수도 있습니다. 괜찮으십니까?  Yes  No

1) Are you calling for yourself or someone else?

본인을 위해서 전화하셨습니까? 아니면 다른 분을 위해서 전화하셨습니까?

 Yourself  Someone else…

2) May I have your name please?

성함이 어떻게 되십니까?

First Name ________________ MI ­­­_____ Last Name ______________________

3) What’s your date of birth?

생년월일이 어떻게 되십니까?

_______/_______/_______  Refused

IF REFUSED: Then how old are you?

연세는 어떻게 되십니까？_________  Refused Unwilling, but >= 18 yrs. old

4) How did you hear about us? 저희 상담소에 대해서 어떻게 알게 되셨습니까?

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?

저희 전화번호가 있는 카드나 브로셔를 받았습니까?

 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? 어디에서 받았습니까?

 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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