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: |
|
Please respond to the following questions about your quitline during the quarter for which you are reporting.
Please provide your contact information
Name: |
|
Job Title: |
|
Employer / Organization: |
|
State: |
|
Email: |
|
Phone: |
|
Second Phone: |
|
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 (Total Number) |
|
a1. |
Within 30 seconds |
|
a2. |
More than 30 seconds |
|
b. |
Calls went to voice mail |
|
c. |
Calls hung up or abandoned (Total Number) |
|
c1. |
Within 30 seconds |
|
c2. |
More than 30 seconds |
|
d. |
Other Calls (e.g., listening to taped messages, etc.) |
|
e. |
Total direct calls (A+B+C+D) |
|
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?
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.)
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): |
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) |
|
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.
What is the name of your state quitline?
Please provide information about the quitline number(s) that your state used during the quarter.
Primary Quitline Telephone Number |
|||
Does your state use and promote 1-800-QUIT-NOW as its primary quitline number? |
|
||
If “No”, what is your state’s primary quitline number? |
|
||
Additional Quitline Telephone Numbers |
|||
Please list ALL additional quitline telephone numbers used by your state |
Description of quitline number |
||
1: |
|
|
|
2: |
|
|
|
3: |
|
|
|
4: |
|
|
|
5: |
|
|
Please provide the hours of service of your quitline for the following categories of service:
Day |
Hours of Operation |
||
Live Pick Up of
|
Counseling Services |
Voicemail / Answering Service Pick Up of Calls |
|
Monday: |
|
|
|
Tuesday: |
|
|
|
Wednesday: |
|
|
|
Thursday: |
|
|
|
Friday: |
|
|
|
Saturday: |
|
|
|
Sunday: |
|
|
|
† May or may not have counseling services available.
Is your quitline closed on holidays?
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 Languages (please describe): |
||
1: |
|
|
2: |
|
|
3: |
|
|
4: |
|
|
5: |
|
|
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. |
|||||
Criteria |
Yes / No |
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: |
|
|
|
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):
|
|
|
|
|
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.
|
|||||
Criteria |
Yes / No |
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 |
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: |
|
|
|
|
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. |
|||||
Criteria |
Yes / No |
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 |
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: |
|
|
|
|
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.
|
|||||
Criteria |
Yes / No |
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 |
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
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | ADMINISTRATIVE QUESTIONS |
Author | fpv4 |
File Modified | 0000-00-00 |
File Created | 2021-01-24 |