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

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 (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 bn, 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 Thuc Lá, bn 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?

Shape1

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)?

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. 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)?

Shape3

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?

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. 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)?

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. 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)?

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. 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





ThÙ nào?

Which ones?



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 dùng trܧc khi cai, trong lÀn cai, ho¥c sau lÀn cai Çó?

Did you use them BEFORE, DURING and/or AFTER 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




_______ 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. 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 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?

K‹ tØ ngày (screen date), bån có dùng m¶t dÜ®c phÄm cai thuÓc nào nhÜ là bæng dán nicotine, kËo gum nicotine, thuc 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, ko gum nicotine, thuc 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:______________________________________________________________________________


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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleCalifornia Smokers' Helpline
AuthorVictor
File Modified0000-00-00
File Created2021-01-24

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