NQDW 7-Month Follow-Up Questionnaire - Vietnamese
National Quitline Data Warehouse
F-4 NQDW_ ASQ_7-Month follow-up questionnaire_VIETNAMESE_03_18_2016
Asian Smokers Quitline (ASQ) Seven-Month Follow-Up Questionnaire
OMB: 0920-0856
Form Approved
OMB No. 0920-0856
Exp. Date xx/xx/XXXX
Asian Smokers’ Quitline (ASQ)
7-Month Follow-Up Intake Questionnaire (Vietnamese)
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 VIETNAMESE
Chào bạn, tôi là __________, nhân viên cûa TrÜ©ng ñåi H†c California. Tôi g†i Ç‹ hÕi š ki‰n vŠ phÄm chÃt cûa nh»ng dÎch vø do Trung Tâm Cai ThuÓc Lá cung cÃp. ñ‹ cäi ti‰n chÜÖng trình giúp Ǫ cai thuÓc, chúng tôi mong nhÆn ÇÜ®c nh»ng š ki‰n vŠ các tài liŒu và nh»ng dÎch vø bån Çã nhÆn ÇÜ®c. Cu¶c ÇiŒn Çàm này chÌ ,mÃt vài phút và nh»ng chi ti‰t së ÇÜ®c gi» kín. Bån có ÇÒng š không?
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. LÀn ÇÀu tiên bån g†i vào Trung Tâm Cai Thuốc Lá, bạn nghï mình së nhÆn ÇÜ®c dÎch vø gì Ç‹ giúp bån cai thuÓc?
When you first called, what kind of services did you expect to receive to help you quit smoking?
Counseling No expectations
Patches / quitting aids Other ______
Certificate Don’t know
Materials/Booklets/Pamphlets Refused
Program Information Not Asked
I'd like to ask you some questions about the written materials . . . .
Tôi xin hÕi bån vài câu vŠ nh»ng tài liŒu cai thuÓc...
2. Bån có nhÆn ÇÜ®c tÆp tài liŒu mà Trung Tâm Cai ThuÓc Lá Çã gªi cho bån không?
Did you receive the materials sent by ASQ?
Yese Don't Know
No / Never received Refused
Not asked
3. Bån Çã džc nh»ng tài liŒn Çó chÜa?
Did you read the materials sent by ASQ?
Yes (all or some) Don't Know
No Refused
Not asked
4. Bån có thích nh»ng gì vŠ tÆp tài liŒu không?
Was there anything in particular that you LIKED about the materials?
Yes Don't Know
No Refused
Not asked
4a. Bån Çã thích nh»ng gì vŠ tÆp tài liŒu?
What was it that you liked (about the materials)?
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. Bån có không thích nh»ng gì vŠ tÆp tài liŒu không?
Was there anything in particular that you DISLIKED about the materials?
Yes Don't Know/ remember
No Refused
Not asked
5a. Bån Çã không thìch nh»ng gì vŠ tÆp tài liŒu?
What was it you disliked (about the materials)?
Didn’t help All of it / Everything
Nothing new Other ______
Too much info / reading Don’t know
Cartoons/comics Refused
Not asked
Now, I would like to ask you some questions regarding ASQ’s counseling services.
Bây gi©, tôi xin hÕi bån vài câu vŠ nh»ng cu¶c tÜ vÃn cûa Trung Tâm Cai ThuÓc Lá.
6. Bån có nhÆn ÇÜ®c tÜ vÃn qua ÇiŒn thoåi không?
Did you receive telephone counseling?
Yes Don't Know
No Refused
Not asked
6a. Lš do nào khi‰n bån không nhÆn ÇÜ®c tÜ vÃn qua ÇiŒn thoåi?
Was there any particular reason for not receiving counseling?
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. Bån cäm thÃy sao vŠ sÓ lÜ®ng tÜ vÃn qua ÇiŒn thoåi mà bån Çã nhÆn ÇÜ®c? Bån nghï là quá ít, vØa Çû, hay nhiŠu quá?
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. Tóm låi, bån së diÍn tä chuyên gia tÜ vÃn cûa bån nhÜ th‰ nào?
Briefly, how would you describe your counselor? ______________________________________
9. Chuyên gia tÜ vÃn cûa bån nhÜ th‰ nào trong länh v¿c l¡ng nghe bån nói chuyŒn?
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. Bån có thích nh»ng gì vŠ nh»ng cu¶c tÜ vÃn không?
Was there anything in particular that you LIKED about the counseling?
Yes Don't Know
No Refused
Not asked
10a. Bån Çã thích nh»ng gì vŠ nh»ng cu¶c tÜ vÃn?
What was it that you liked (about the counseling)?
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. Bån có không thích nh»ng gì vŠ nh»ng cu¶c tÜ vÃn không?
Was there anything in particular that you DISLIKED about the counseling?
Yes Don't Know
No Refused
Not asked
11a. Bån Çã không thích gì vŠ nh»ng cu¶c tÜ vÃn?
What was it that you disliked (about the counseling)?
# 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. Nói chung, bån thÃy thoäi mái t§i Çâu khi nói chuyŒn v§i nh»ng nhân viên tr® giúp ª Trung Tâm Cai ThuÓc Lá? Bån
rÃt thoäi mái, thoäi mái, hay không thoäi mái?
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. Nói chung, bån hài lòng t§i Çâu v§i nh»ng dÎch vø mà bån Çã nhÆn ÇÜ®c? Bån rÃt hài lòng, khá hài lòng, tÜÖng ÇÓi
hài lòng, hay không hài lòng?
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. HiŒn gi©, bån hút thuÓc lá m‡i ngày, vài ngày trong tuÀn, hay Çã bÕ hút thuÓc rÒi?
Do you currently smoke cigarettes everyday, some days, or not at all?
Everyday Don’t know
Some days Refused
Not at all Not asked
Smoking
NOT SMOKING VIETNAMESE
1. Bån Çã bÕ hút thuÓc vào ngày nào?
When did you quit? Most recent quit date: _______/_______/_______
1a. Bån Çä bÕ bao lâu rÒi?
How long ago did you quit? ______ days/weeks/months/years
2.K‹ tØ lÀn ÇÀu tiên bån g†i vào Trung Tâm Cai ThuÓc Lá ngày (Screen date), bån Çã thº cai thuÓc lá ÇÜ®c mÃy lÀn (k‹ cä lÀn này)?
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. Trong nh»ng lÀn Çó, có mÃy lÀn bån cai ÇÜ®c 24 ti‰ng hay lâu hÖn?
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. K‹ tØ ngày (screen date), lÀn ÇÀu tiên bån cai thuÓc ÇÜ®c 24 ti‰ng hay lâu hÖn là ngày nào? When did you first quit for 24 hours or more since (Screen Date)? ______/______/______
a. Sau lÀn cai Çó (first attempt date), bån Çã hút låi thÜ©ng xuyên vào ngày nào? When did you start smoking on a daily basis after (first attempt date)? ______/______/______ b. Bån cai ÇÜ®c bao lâu? How long did you quit for?_____ days/weeks/months/ years Don’t know Refused Not asked
5. (FIRST QUIT ATTEMPT): Trong lÀn bån cai thuÓc lá ÇÜ®c (1st quit length), bån có hút m¶t Çi‰u (hay bÆp 1 hÖi) thuÓc nào không? 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): Bån hút Çi‰u thuÓc/bÆp hÖi thuÓc Çó vào ngày nào? When was your first cigarette/puff? ______/______/______
5b. (FIRST QUIT ATTEMPT): Bån Çã hút liên ti‰p mÃy ngày, k‹ cä ngày bån b¢t ÇÀu hút låi? How many days in a row did you smoke, including the first day? [________]
6. (FIRST QUIT ATTEMPT): Trong th©i gian này, bån có dung m¶t dÜ®c phäm cai thuÓc nào nhÜ bæng dán nicotine, kËo gum nicotine, thuÓc viên Zyban ho¥c thuÓc viên Chantix không? 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
|
******Last or Only Quit Attempt****** |
7. Sau ngày (recent quit date), bån có hút (hay bÆp) Çi‰u thuÓc nào không? Have you had a cigarette, or even a puff, since you quit on (most recent quit date)?
Yes . . . . . Bån hút Çi‰u thuÓc/hÖi thuÓc Çó vào ngày nào? When was your first cig./puff? _____/______/______ No Don’t know Refused Not asked
a. Ngay trܧc khi bån hút Çi‰u thuÓc Çó, bån ª trong hoàn cänh nào ho¥c có chuyŒn gì xäy ra? What was the situation just before you smoked that cigarette?
_____________________________________ b. Bån Çã lÃy Çi‰u thuÓc Çó tØ Çâu? 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. Bån Çã hút liên ti‰p mÃy ngày, k‹ cä ngày bån b¡t ÇÀu hút låi? 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. LÀn chót bån hút thuÓc, dù chÌ bÆp 1 hÖi là ngày nào? 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. Ngay trܧc khi bån hút Çi‰u thuÓc Çó, bån ª trong hoàn cänh nào ho¥c có chuyŒn gì xäy ra? What was the situation just before you smoked that cigarette?
_____________________________________ f. Bån Çã lÃy Çi‰u thuÓc Çó tØ Çâu? 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. Bån Çã hút liên ti‰p mÃy ngày, k‹ cä ngày bån b¡t ÇÀu hút låi? How many days in a row did you smoke, including the first day? ______ day(s). Ever Since o Don’t know Refused Not Asked |
|
8. ñÍ tôi xác nhÆn.. HiŒn gi© bån hút thuÓc h¢ng ngày hay vài ngày trong 1 tuÀn lÍ?
Let me confirm… Are you currently smoking cigarettes everyday or some days?
Everyday Don’t know
Some days Refused
Not asked
9a. Trung bình m‡i ngày bån hút mÃy Çi‰u?
On average, how many cigarettes do you smoke per day?_______
9b. Bån hút thuÓc mÃy ngày m¶t tuÀn?
How many days per week do you smoke? ________
9c. Trong nh»ng ngày bån hút thuÓc, trung bình m‡i ngày bån hút mÃy Çi‰u?
On average how many cigarettes do you smoke per day on the days you smoke? ______
10. M‡i sáng sau khi thÙc dÆy, khoäng bao lâu thì bån hút Çi‰u thuÓc ÇÀu tiên trong ngày?
How soon after you wake up do you usually smoke your first cigarette?
0-5 mins 6-30 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?
K‹ tØ ngày (screen date), bån có dùng m¶t dÜ®c phÄm cai thuÓc nào nhÜ là bæng dán nicotine, kËo gum nicotine, thuốc viên Zyban ho¥c thuÓc viên Chantix không?
For this quit attempt, did you use anything like the Nicotine Patch, Gum, Zyban or Chantix to help you quit?
Trong th©i gian này, bån có dùng m¶t dÜ®c phÄm cai thuÓc nào nhÜ là bæng dán nicotine, kËo gum nicotine, thuÓc viên Zyban ho¥c thuÓc viên Chantix không?
Bån có dùng các dÜ®c phÄm cai thuÓc lá nhÜ là bæng dán nicotine, kẹo gum nicotine, thuốc viên Zyban ho¥c thuÓc viên Chantix không?
Did you use anything like the Nicotine Patch, Gum, Zyban or Chantix to help you quit?
Yes
No
Don’t know
Refused
Not Asked
ThÙ nào? Which ones?
|
Bån có Çang dùng hay không?
Are you currently using them?
|
Bån dùng trong bao lâu? How long did you use them for?
|
Trung bình, bån dùng bao nhiêu m‡i ngày? On average, how many did you use per day? |
Bån dung liŠu Ƕ nào? What dosage did you use?
|
Bån có dùng trܧc khi bån cai không? Did you use them BEFORE your quit attempt? |
Bån lÃy ÇÜ®c tØ Çâu? Where did you get them?
|
Bån Çã tÓn bao nhiêu tiŠn? 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. Trong khoäng th©i gian này, bån có tham gia nh»ng chÜÖng trình khác ho¥c dùng nh»ng phÜÖng pháp khác Ç‹ giúp bån cai không?
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..
Lš do nào khi‰n bån không dùng bÃt cÙ m¶t loåi dÜ®c phÄm cai thuÓc nào?
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 Trung Tâm Cai ThuÓc Lá
o Delivery took too long
o Other
o Don’t Know
o Refused
o Not Asked
14. Bån có Çang dùng các loåi thuÓc khác có chÙa nicotine nhÜ thuÓc nhai, thuÓc lá b¶t, xì gà, Óng Çi‰u (Óng píp) không?
Do you currently use any other form of tobacco, such as chew/snuff, cigars or pipes?
Yes
No
Don’t know
Refused
Loåi nào?
Which ones?
Chew
Cigars
Pipes
Other: ______________
If CHEW/SNUFF: Bån nhai hay hít bao nhiêu thuÓc m‡i tuÀn?
How much tobacco do you use per week?
______________
Don’t know Refused
If CHEW/SNUFF: ñó là h¶p hay túi nhÕ?
Is that cans or pouches?
If CIGARS: M‡i tuÀn, bån hút mÃy Çi‰u xì gà?
How many do you smoke per week?
_______________
Don’t know Refused
15. N‰u b¡t ÇÀu cai thuÓc lá hôm nay, bån t¿ tin ÇÜ®c bao nhiêu là bån có th‹ bÕ hút thuÓc tr†n m¶t tuÀn lÍ?
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?
Bån t¿ tin ÇÜ®c bao nhiêu là bån có th‹ ti‰p tøc cai tr†n m¶t tuÀn t§i? Bån nghï là bån rÃt t¿ tin, t¿ tin, hay không t¿ tin?
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. Bån có l©i khuyên nào quan tr†ng nhÃt Ç‹ nh¡n låi cho nh»ng ngÜ©i Çang cÓ g¡ng cai thuÓc lá (NhÛng gì Çã giúp bån cai thuÓc)?
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: ñây là tÃt cä nh»ng câu chúng tôi cÀn hÕi bån. Cám bån Çã bÕ chút thì gi© trä l©i chúng tôi.
Those are all the questions I have for you, thank you for your time.
Comments:______________________________________________________________________________
________________________________________________________________________________________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | California Smokers' Helpline |
| Author | Victor |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |
© 2024 OMB.report | Privacy Policy