NQDW 7-Month Follow-Up Questionnaire - Chinese

National Quitline Data Warehouse

F-2 NQDW_ASQ_7-month follow-up questionnaire_CHINESE_03_18_2016

Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire

OMB: 0920-0856

Document [docx]
Download: docx | pdf


Form Approved

OMB No. 0920-0856

Exp. Date xx/xx/XXXX







Asian Smokers’ Quitline (ASQ)

7-Month Follow-Up Intake Questionnaire (Chinese)











Public reporting burden of this collection of information is estimated to average 7 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)

7mo Evaluation

SERVICE CHINESE



您好,我的名字叫 ___________ 我是加州大學工作人員。我給您打電話是爲了評估華語戒煙專綫的服務品質。更為了提高服務品質,我想了解對戒煙專綫服務的看法。我們只需要幾分鐘與您通話。為了確保服務素質,我們的談話可能被旁聽或者被錄音, 但你的囘應是保密的。我能佔用幾分鐘的時間與交談嗎?

Hi, this is from the University of California. I'm calling to evaluate the quality of service provided by the Asian Smokers’ Quitline (ASQ). In order to improve the program, I would like to get your feedback on the services that you received. Your feedback will be summarized along with feedback provided by other people who have used the Quitline. You don’t have to answer any questions you don’t want to, and you can end the interview at any time. Also, answering or choosing not to answer questions will not change the quitline services you can or will receive. The call will take just few a minutes, may be monitored or recorded for quality assurance and all of your responses will be kept private. Is that OK?”

1. 當您第一次打電話到戒煙專線的時候,您是希望得到怎樣的服務來幫助您戒煙?

When you first called, what kind of services did you expect to receive to help you quit smoking?

Shape1

Counseling No expectations

Patches / quitting aids Other ______

Certificate Don’t know

  • Materials/Booklets/Pamphlets Refused

  • Program Information Not Asked












我想問你一些有關他們寄給你的戒煙資料的問題…………..

I'd like to ask you some questions about the written materials . . . .

2. 你是否收過華語戒煙專綫寄給你的戒煙資料?

Did you receive the materials sent by ASQ?


Yes Don't Know

No / Never received . Refused

Not asked

3. 你有否讀過華語戒煙專綫寄给你的戒煙資料?

Did you read the materials sent by ASQ?


Yes (all or some) Don't Know

No Refused

Not asked

4.戒煙資料中部份你覺得特別喜歡的?

Was there anything in particular that you LIKED about the materials?


Yes Don't Know

No Refused

Not asked







4a. 是哪些資訊呢?

What was it that you liked (about the materials)?

Shape2

Coping Strategies / Alternatives All of it / Everything

Facts / Info Other______

Suggestions / Tips / Advice Don’t Know

County list / other resources Refused

  • Pictures / comics Not Asked










5. 那一部份你最不喜歡的?

Was there anything in particular that you DISLIKED about the materials?

Yes Don't Know/ remember

No Refused

Not asked


5a. 您不喜歡的是哪些 What was it you disliked (about the materials)?

Shape3

Didn’t help All of it / Everything

Nothing new Other ___

Too much info / reading Don’t know

Cartoons/comics Refused

Not asked











現在,我想問你一些關於華語戒煙專綫提供戒煙諮詢服務

Now, I would like to ask you some questions regarding the ASQ’s counseling services.

6. 請問您是否有接受電話諮詢的服務?

Did you receive telephone counseling?

Yes Don't Know

No Refused .

Not asked

6a. 能否告訴我們您沒有接受電話諮詢服務的原因?

Was there any particular reason for not receiving counseling?

Shape4

No time / busy No reason at all

Counselor didn’t call me Other ___

I didn’t call / I missed counselor’s call Don’t know

  • Didn’t think I needed it /already quit Refused

  • Not ready Not Asked












7. 請問您覺得電話諮詢的次數是過少,適中,還是過多?

How did you feel about the number of counseling sessions you received, would you say there were too few, just right or too many?


Too few Don’t know

Just right Refused

Too many Not asked



8. 請您簡單的說一說,您會如何形容您的諮詢員?

Briefly, how would you describe your counselor? _________________________________________


________________________________________________________________________________


9. 請問您的諮詢員是否是一個很好的聆聽者,您會說很好,好,或者是不好?

How was your counselor in terms of being a good listener, would you say very good, good or not good?

Very good Don’t know

Good Refused

Not good Not asked

10. 電話諮詢中,您特別喜歡哪些部分?

Was there anything in particular that you LIKED about the counseling?

Yes Don't Know

No Refused

Not asked

10a. 哪些部分是您特別喜歡的?

What was it that you liked (about the counseling)?

Shape5

Counselor/Someone to talk to/Support All of it / Everything

Information/Advice Other _____

# of Counseling Sessions Don’t know

Counselor Availability Refused

Not asked










11. 電話諮詢中,您特別不喜歡哪些部分?

Was there anything in particular that you DISLIKED about the counseling?


Yes Don't Know

No Refused

Not asked


11a. 哪些部分是您特別不喜歡的?

What was it that you disliked (about the counseling)?

Shape6

# of counseling sessions (high or low) All of it / Everything

Wanted face to face, not phone Other ______

Counselor style / personality Don’t know

Counselor Availability / follow through Refused

Not asked











12. 總括來説,跟華語戒煙專綫的工作人員談話您覺得很自在,自在, 还是不自在


Overall, how comfortable did you feel when talking with ASQ staff? Would you say very comfortable, comfortable or not comfortable?

Very comfortable Don’t know

Comfortable Refused

Not comfortable Not asked


13. 總括來說,您對華語戒煙專綫線的服務是非常滿意,相當滿意,尚且滿意,或者不滿意?


Overall, how satisfied were you with the services you received? Would you say you were very satisfied, mostly satisfied, somewhat satisfied or not at all satisfied?

Very satisfied Don’t know

Mostly satisfied Refused

Somewhat satisfied Not asked

Not at all satisfied


14. 您現在是每天抽煙,有些日子抽煙還是完全沒抽煙?

Do you currently smoke cigarettes everyday, some days, or not at all?


Everyday Don’t know

Some days Refused

Not at all Not asked


NOT SMOKING CHINESE


1. 您最近一次戒煙是甚麼時候?

When did you quit? Most recent quit date: _______/_______/_______

1a. 戒了多久?

How long ago did you quit? ______ days/weeks/months/years

2. 自從第一次打電話給華語戒煙専缐到現在,您試過(包括這次)戒幾次煙?

Since you first called ASQ on (screen date), how many times have you tried to quit (including this time)?


Number of times: [ ]

Don't remember exactly, at least: [ ]

Number of imposed/unintended quits: [ ]

Refused

Not Asked


3. 所試的這幾次戒煙過程中,有幾次戒煙長達一天或一天以上?

Out of those times, how many were for 24 hours or more?


Number of times: [ ]

Don't remember exactly, at least: [ ]

Number of imposed/unintended quits: [ ]

Never quit for > 24 hours .

Refused

Not Asked



First Quit Attempt

4. 您第一次戒煙長達24小時或更久是甚麼時候? (自從您第一次給戒煙中心打電話到現在)

When did you first quit for 24 hours or more since (Screen Date)? ______/______/______

a. 第一次嘗試戒煙後,甚麼時候又開始每天吸煙?

When did you start smoking on a daily basis after (first attempt date)? ______/______/______

b. 戒了多長的時間?

How long did you quit for?_____ days/weeks/months/ years

Don’t know

Refused

Not asked

5. (FIRST QUIT ATTEMPT): 在第一次戒煙(1st quit length)過程當中曾否偶爾吸一支煙或一口煙?

During the time you quit for (1st quit length), did you have a cigarette (or puff)?


Yes

No

Don’t know

Refused

Not asked

5a.(FIRST QUIT ATTEMPT): 是甚麼時候?

When was your first cigarette/puff? ______/______/______

5b. (FIRST QUIT ATTEMPT): 您曾連續多少天吸幾支煙或幾口煙(包括第一天),或您一開始戒煙就這樣做?

How many days in a row did you smoke, including the first day? [________]


6.(FIRST QUIT ATTEMPT): 在這次戒煙期間,您曾用過其它的輔助藥物,例如尼古丁貼片,口香糖,Zyban Chantix嗎?

For this quit attempt, did you use anything like the Nicotine Patch, Gum, Zyban or Chantix to help you quit?

Yes

No

Don’t know

Refused

Not Asked


是哪一種?


Which ones?



用了多久?


How long did you use them for?



平均來說您用了多少?


On average, how many did you use per day?

您用的劑量是多少?


What dosage did you use?


您是在戒煙之前,戒煙期間,還是戒煙之後使用的?


Did you use them BEFORE, DURING and/or AFTER your quit attempt?

您是如何得到的?


Where did you get them?



大約花了多少錢?


How much money did you spend on them?




Patch




_______ days/weeks/months


Don’t Know

Refused

Not Asked




NOT ASKED


21mg (step1)

14mg (step2)

7mg (step3)

Other: ____________

D

R

Z



Before

During

After

D

R

Z




Bought

Given to me

Help/Quit line

Insurance

Other: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z



Gum




_______ days/weeks/months


Don’t Know

Refused

Not Asked



_______/day


D

R

Z



2mg 4mg

Other: ____________

D

R

Z



Before

During

After

D

R

Z





Bought

Given to me

Help/Quit line

Insurance

Other: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z




Zyban


_______ days/weeks/months


Don’t Know

Refused

Not Asked



NOT ASKED



NOT ASKED


Before

During

After

D

R

Z




Bought

Given to me

Help/Quit line

Insurance

Other: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z



Chantix/

Varenicline


_______ days/weeks/months


Don’t Know

Refused

Not Asked




NOT ASKED



NOT ASKED



Before

During

After

D

R

Z




Bought

Given to me

Help/Quit line

Insurance

Other: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z




Lozenge


_______ days/weeks/months


Don’t Know

Refused

Not Asked




_______/day


D

R

Z



2mg 4mg

Other: ____________

D

R

Z



Before

During

After

D

R

Z


Bought

Given to me

Help/Quit line

Insurance

Other: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z



Other: ____________________________________

_________



_______ days/weeks/months


Don’t Know

Refused

Not Asked



NOT ASKED



NOT ASKED



Before

During

After

D

R

Z




Bought

Given to me

Help/Quit line

Insurance

Other: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z


D

R

Z








******Last or Only Quit Attempt******

7. 當您在最後一次戒煙過程中, 您曾吸過一支煙或一口煙嗎?

Have you had a cigarette, or even a puff, since you quit on (most recent quit date)?

Yes . . . .是甚麼時候?

When was your first cig./puff? _____/______/______


No

Don’t know

Refused

Not asked

a. 在您抽那支煙以前,您處於甚麼情境之下?

What was the situation just before you smoked that cigarette?

_______________________________________________


____________________________________

b. 您從哪裏拿到香煙?

Where did you get the cigarette?

Bought a pack Asked or took from someone

Bought one or a few Other source

Old cigarette pack Don't know

Someone offered one Refused


c.在最後一次戒煙過程中,連續多少天吸幾支煙或幾口煙(包括第一天),或一開始戒煙就這樣做?

How many days in a row did you smoke, including the first day? _____ day(s). Ever Since

o Don’t know

Refused Not Asked

d. 您最後一次吸一支煙或一口煙是甚麼時候?

When was the last time you had a cigarette, or even a puff?

______/______/______


10 was the last time

Don’t know

Refused

Not asked

e. 在您抽那支煙以前,您處於甚麼情境之下?

What was the situation just before you smoked that cigarette?

______________________________________________


__________________________________

f. 您從哪裏拿到香煙?

Where did you get the cigarette?


Bought a pack Asked or took from someone

Bought one or a few Other source

Old cigarette pack Don't know

Someone offered one Refused

g. How many days in a row did you smoke, including the first day? ______ day(s).

在最後一次戒煙過程中,連續多少天吸幾支煙或幾口煙(包括第一天)一開始戒煙就這樣做? Ever Since

o Don’t know

Refused

Not Asked



8. 我想確認一下,您現在每天抽煙或是有些日子抽煙呢?


Let me confirm… Are you currently smoking cigarettes everyday or some days?


Everyday Don’t know

Some days Refused

Not asked

9a. 平均來講,您每天會抽幾支香煙?

On average, how many cigarettes do you smoke per day?_______

9b. 您現在每一個星期有幾天您會吸煙?

How many days per week do you smoke? ­­­________

9c. 在您吸煙的日子,平均來講每天您會抽幾枝煙?

On average how many cigarettes do you smoke per day on the days you smoke? ______


10. 您一般起床後多久開始抽第一支煙?

How soon after you wake up do you usually smoke your first cigarette?

0-5 mins6-30 mins 31-60 mins More than 60 mins

Don’t know Refused



11. Since <insert screen date>, did you use anything like the Nicotine Patch, Gum, Zyban or Chantix?

至從<insert screen date>,你有沒有用任何補助藥物,例如尼古丁貼片,口香糖,Zyban或者Chantix嗎?


For this quit attempt, did you use anything like the Nicotine Patch, Gum, Zyban or Chantix to help you quit? 在這次戒煙期間,您曾用過任何輔助藥物,例如尼古丁貼片,口香糖,Zyban Chantix嗎?


Did you use anything like the Nicotine Patch, Gum, Zyban or Chantix to help you quit?

在這次戒煙期間,您曾用過任何輔助藥物,例如尼古丁貼片,口香糖,Zyban Chantix嗎?

Yes

No

Don’t know

Refused

Not Asked


是哪一種?


Which ones?



您現在還在使用嗎?

Are you currently using them?



用了多久?


How long did you use them for?



平均來說您用了多少?


On average, how many did you use per day?

您用的劑量是多少?


What dosage did you use?


您是在戒煙之前使用的嗎?


Did you use them BEFORE your quit attempt?

您是如何得到的?


Where did you get them?


大約花了多少錢?


How much money did you spend on them?




Patch




Yes

No

D

R

Z



_______ days/weeks/months


Don’t Know

Refused

Not Asked




NOT ASKED


21mg (step1)

14mg (step2)

7mg (step3)

Other: ____________

D

R

Z



Yes

No

D

R

Z




Bought

Given to me

Help/Quit line

Insurance

Other: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z



Gum




Yes

No

D

R

Z



_______ days/weeks/months


Don’t Know

Refused

Not Asked



_______/day


D

R

Z



2mg 4mg

Other: ____________

D

R

Z



Yes

No

D

R

Z





Bought

Given to me

Help/Quit line

Insurance

Other: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z




Zyban


Yes

No

D

R

Z



_______ days/weeks/months


Don’t Know

Refused

Not Asked



NOT ASKED



NOT ASKED


Yes

No

D

R

Z




Bought

Given to me

Help/Quit line

Insurance

Other: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z



Chantix/

Varenicline


Yes

No

D

R

Z



_______ days/weeks/months


Don’t Know

Refused

Not Asked




NOT ASKED



NOT ASKED



Yes

No

D

R

Z




Bought

Given to me

Help/Quit line

Insurance

Other: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z




Lozenge


Yes

No

D

R

Z



_______ days/weeks/months


Don’t Know

Refused

Not Asked




_______/day


D

R

Z



2mg 4mg

Other: ____________

D

R

Z



Yes

No

D

R

Z



Bought

Given to me

Help/Quit line

Insurance

Other: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z



Other: ____________________________________

_________



Yes

No

D

R

Z



_______ days/weeks/months


Don’t Know

Refused

Not Asked



NOT ASKED



NOT ASKED



Yes

No

D

R

Z




Bought

Given to me

Help/Quit line

Insurance

Other: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z


D

R

Z










12. 在這段時間裏,您還用過其他計劃或方法來幫助您戒煙嗎?

During this time, did you use any other programs or methods to quit smoking?

(Note to evaluator: these should be separate from quit aids)


Yes… Which one? ­­­­­­­­__________________________

No

Don't know

Refused

Not asked



13. IF DIDN’T USE ANY QUITTING AID...


這次戒煙,決定不用任何輔助藥物的主要原因是什麽呢?

What was your main reason for deciding not to use any quitting aids?

o Medi-Cal/Insurance plan

o Too expensive

o Side effects

o Do it on my own

o Decided not to quit

o Won’t work for me

o Never received from ASQ華語戒煙專綫

o Delivery took too long

o Other

o Don’t Know

o Refused

o Not Asked


14. 您現在有用其他的煙草嗎?(嚼煙,鼻煙,雪茄或煙斗)

Do you currently use any other form of tobacco, such as chew/snuff, cigars or pipes?


Yes

No

Don’t know

Refused


是哪一種? Which ones?


Chew

Cigars

Pipes

Other: ______________


If CHEW/SNUFF: 每個星期用多少?

How much tobacco do you use per week?

______________

Code: less than 1 as 1 (Amount of cans/pouches)


Don’t know Refused

If CHEW/SNUFF: 是罐還是袋?

Is that cans or pouches?

If CIGARS: 每個星期抽幾枝?

How many do you smoke per week?

 

Don’t know Refused


15. 假如您決定從今天起戒煙, 您有多少信心能在一個星期内不抽煙?是非常有信心,有信心,還是沒有信心?

If you were to quit today, how confident are you that you could go without smoking for one week, would you say: very confident, confident, or not confident?


您有多少信心能繼續在一個星期内保持不抽煙?是非常有信心,有信心,還是沒有信心?

How confident are you that you could continue without smoking for one week, would you say: very confident, confident, or not confident?


Very Confident

Confident

Not Confident

Don’t know

Refused

16. 請簡短的講一講你會給想要戒煙的人甚麼樣的最重要提示

Briefly what is the most important advice you would offer to someone who‘s trying to quit smoking?

(Was there anything in particular that helped you?)



Advice: _____________________________________________________________________

None

Don’t know

Refused


END EVAL: 這是我們所有的問題了,非常感謝您的時間

Those are all the questions I have for you, thank you for your time.


Comments:______________________________________________________________________________


________________________________________________________________________________________

Revised 07/29/2010 2010 Regents of the University of California, ALL RIGHTS RESERVED Page 1 of 19

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