ASQ Intake Questionnaire (Vietnamese - Subset)

Form Approved

OMB No. 0920-0856

Exp. Date xx/xx/XXXX

National Quitline Data Warehouse

Intake Questionnaire

(Asian Smoker’s Quitline: Vietnamese)

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) Vietnamese 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?

ñây là m¶t dÎch vø giúp cai thuÓc lá miÍn phí do trường ñåi H†c Y Khoa California ÇiŠu hành. Chúng tôi giúp Ç« b¢ng cách gªi tài liŒu qua bÜu ÇiŒn và tÜ vÃn qua ÇiŒn thoåi. ñ‹ giúp Ç« bån h»u hiŒu nhÃt, cu¶c thäo luÆn này có th‹ có ngÜ©i khác cùng nghe ho¥c Çược ghi âm, nhÜng së ÇÜ®c gi» kín. Tôi cÀn hÕi bån vài câu Ç‹ xem chúng tôi có th‹ giúp bån b¢ng cách nào và bån có muÓn trä l©i hay không tùy š. Bån có ÇÒng š không?

 Yes  No

1) Are you calling for yourself or someone else? Bån g†i cho chính bån hay cho ngÜ©i thân?

 Yourself  Someone else

2) May I have your name please? Xin bån cho bi‰t tên?

First Name ________________ MI ­­­_____ Last Name ______________________

3) What’s your date of birth? Ngày sinh cûa bån là ngày nào?

_______/_______/_______  Refused

IF REFUSED: Then how old are you?

VÆy bån cho bi‰t tu°i ÇÜ®c không? _________  Refused Unwilling, but >= 18 yrs. old

4) How did you hear about us? Do Çâu bån bi‰t ÇÜ®c chÜÖng trình này?

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?

Có phäi bån Çã nhÆn ÇÜ®c một tÃm thÈ hay t© quäng cáo trong Çó có sÓ ÇiŒn thoåi cûa chúng tôi không?

 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?

Bån Çã nhÆn ÇÜ®c tÃm thÈ hay t© quäng cáo Çó tØ Çâu?

 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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