NQDW Intake Questionnaire - Complete

Form Approved

OMB No. 0920-0856

Exp. Date xx/xx/XXXX

National Quitline Data Warehouse

Intake Questionnaire

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)

This is a free service to help people quit using tobacco. We offer help through the mail and over the phone. To provide the best possible service, calls may be monitored and recorded, but will be kept secure. I need to ask you a few questions to see how we can assist you. All of your responses are voluntary. Is that OK?

IS RESPONDENT CONTINUING WITH THE INTERVIEW?

• YES

• NO – ASSIGN DISPOSITION CODE

1. How can I help you?

• WANT HELP / INFORMATION ABOUT QUITTING

• WANT HELP / INFORMATION ABOUT STAYING QUIT

• WANT TO REFER SOMEONE FOR HELP

• WANT GENERAL INFORMATION OR MATERIALS ABOUT QUITLINE SERVICE

• OTHER: ___________________________________________

• DON’T KNOW

• REFUSED

2. Just to confirm, are you calling for yourself, or calling on behalf of or to help someone else?

• Calling for yourself for help with quitting

• Calling for yourself but not for help with quitting

• Calling on behalf of or to help someone else

• DON’T KNOW

• REFUSED

3. How did you hear about the quitline? (CHECK ALL RESPONSES)

MEDIA

• NEWSPAPER

• RADIO

• TELEVISION

• INTERNET/WEB

• OTHER: _________________________

OTHER ADVERTISING

• PHONE DIRECTORY

• FLYERS, BROCHURES

• OTHER: _________________________

REFERRAL

• HEALTH PROFESSIONAL (DOCTOR, DENTIST, ETC.)

• FAMILY / FRIENDS

• WORKPLACE

• HEALTH INSURANCE

• COMMUNITY ORGANIZATION

• OTHER: _________________________

• DON’T KNOW

• REFUSED

4. 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?

• YES

• NO

• UNSURE

END INTERVIEW IF RESPONDENT IS NOT CALLING FOR THEMSELVES FOR HELP WITH QUITTING (SEE RESPONSE TO QUESTION 2).

5. Is this your first call to the quitline in the past 12 months?

• YES

• NO

• DON’T KNOW

• REFUSED

ASSESSMENT FOR TYPES OF TOBACCO USE

6. What types of tobacco have you used in the past 30 days? Cigarettes? (RECORD RESPONSE) Cigars, cigarillos, or little cigars? (RECORD RESPONSE) A pipe? (RECORD RESPONSE) Chewing tobacco, snuff, or dip? (RECORD RESPONSE) Any other type of tobacco? (RECORD RESPONSE)

CIGARETTES

• YES

• NO

• DON’T KNOW

• REFUSED

CIGARS, CIGARILLOS, OR LITTLE CIGARS

• YES

• NO

• DON’T KNOW

• REFUSED

PIPE [NOTE: THIS IS A TRADITIONAL PIPE, NOT A WATER PIPE OR “HOOKAH”]

• YES

• NO

• DON’T KNOW

• REFUSED

CHEWING TOBACCO, SNUFF, OR DIP

• YES

• NO

• DON’T KNOW

• REFUSED

OTHER

• YES

• NO

• DON’T KNOW

• REFUSED

• NONE (NOTE: NO TO ALL ABOVE EQUALS NONE)

READ 7 IF CALLER RESPONDED “YES” TO CIGARETTES ABOVE.

7. Do you currently smoke CIGARETTES every day, some days, or not at all?

(CHECK ONE)

• EVERYDAY (SKIP TO Q8)

• SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 CIGARETTE PER DAY)

• NOT AT ALL (SKIP TO Q10)

• DON’T KNOW

• REFUSED
  
  
  

8. How many days did you smoke in the last 30 days?

_____Days

• DON’T KNOW

• REFUSED
  
  

9. How many cigarettes do you smoke per day on the days that you smoke?
   (cigarettes per day)___

• DON’T KNOW

• REFUSED
  
  

EVERYDAY CIGARETTE SMOKERS SKIP TO Q10-26 AS INDICATED BY THE TYPE OF TOBACCO USE QUESTION ABOVE.

10. When was the last time you smoked a cigarette, even a puff?
    ______(dd/mm/yyyy)

• NEVER

• DON’T KNOW

• REFUSED

READ 11 IF CALLER RESPONDED “YES” TO CIGARS, CIGARILLOS, OR LITTLE CIGARS ABOVE.

11. Do you currently smoke CIGARS, CIGARILLOS, OR LITTLE CIGARS every day, some days, or not at all?

(CHECK ONE)

• EVERYDAY (SKIP TO Q12)

• SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 CIGAR PER DAY)

• NOT AT ALL (SKIP TO Q14)

• DON’T KNOW

• REFUSED

12. How many days did you smoke a CIGAR, CIGARILLO, OR LITTLE CIGAR in the last 30 days?

____Days

• DON’T KNOW

• REFUSED
  
  

13. How many CIGARS, CIGARILLOS, OR LITTLE CIGARS do you smoke per week during the weeks that you smoke?

(cigars, cigarillos, or little cigars per week)_______

• DON’T KNOW

• REFUSED

EVERY DAY CIGAR, CIGARILLOS, OR LITTLE CIGARS SMOKERS SKIP TO Q14-26 AS INDICATED BY THE TYPE OF TOBACCO USE QUESTION ABOVE.

14. When was the last time you smoked a CIGAR, CIGARILLO, OR LITTLE CIGAR, even a puff?
    __________ (dd/mm/yyyy)

• NEVER

• DON’T KNOW

• REFUSED

READ 15 IF CALLER RESPONDED “YES” TO A PIPE ABOVE.

15. Do you currently smoke PIPES every day, some days, or not at all? (CHECK ONE)

• EVERYDAY (SKIP TO Q16)

• SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 PIPE PER DAY)

• NOT AT ALL (SKIP TO Q18)

• DON’T KNOW

• REFUSED

16. How many days did you smoke a pipe in the last 30 days?

___ Days

• DON’T KNOW

• REFUSED
  
  

17. How many pipes do you smoke per week during the weeks that you smoke?

(pipes per week) ________

• DON’T KNOW

• REFUSED

EVERY DAY PIPE SMOKERS SKIP TO Q18-26 AS INDICATED BY THE TYPE OF TOBACCO USE QUESTION ABOVE.

18. When was the last time you smoked a pipe, even a puff?

________ (dd/mm/yyyy)

• NEVER

• DON’T KNOW

• REFUSED

READ 19 IF CALLER RESPONDED “YES” TO CHEWING TOBACCO, SNUFF, OR DIP ABOVE.

19. Do you currently use CHEWING TOBACCO, SNUFF, OR DIP every day, some days, or not at all?

(CHECK ONE)

• EVERYDAY (SKIP TO Q20)

• SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 POUCH OR PINCH PER DAY)

• NOT AT ALL (SKIP TO Q22)

• DON’T KNOW

• REFUSED

20. How many days did you use chewing tobacco, snuff or dip in the last 30 days?

_______(days)

• DON’T KNOW

• REFUSED
  
  

21. How many POUCHES OR TINS do you use per week during the weeks that you use chewing tobacco or snuff?

(pouches/tins per week)_____

• DON’T KNOW

• REFUSED

EVERYDAY CHEW/SNUFF USERS SKIP TO Q22-26 AS INDICATED BY THE TYPE OF TOBACCO USE QUESTION ABOVE.

22. When was the last time you used chewing tobacco, snuff or dip, even a pinch?

___________ (dd/mm/yyyy)

• NEVER

• DON’T KNOW

• REFUSED

READ 23 IF CALLER RESPONDED “YES” TO OTHER CIGARETTES ABOVE.

23. Do you currently use OTHER TYPES OF TOBACCO every day, some days, or not at all?

(CHECK ONE)

• EVERYDAY (SKIP TO 24)

• SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 UNIT OF OTHER TYPE OF TOBACCO PER DAY)

• NOT AT ALL (SKIP TO Q25)

• DON’T KNOW

• REFUSED

24. How many days did you use other types of tobacco in the last 30 days?

_______(days)

• DON’T KNOW

• REFUSED
  
  

25. How much [how many] [OTHER TOBACCO NAME] do you use per week during the weeks that you use other tobacco?

(other tobacco per week) ____

• DON’T KNOW

• REFUSED

EVERYDAY OTHER TOBACCO PRODUCT USERS SKIP TO Q29

26. When was the last time you used other types of tobacco, even a puff or pinch?

___________ (dd/mm/yyyy)

• NEVER

• DON’T KNOW

• REFUSED

ASK OF CIGARETTE SMOKERS ONLY:

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

• WITHIN FIVE MINUTES

• 6 TO 30 MINUTES

• 31 TO 60 MINUTES

• MORE THAN 60 MINUTES

• DON’T KNOW

• REFUSED

ASK ONLY IF PARTICIPANT REPLIED THEY HAVE USED CIGARETTES IN THE PAST 30 DAYS IN QUESTION 6.

28. Do you intend to quit using cigarettes within the next 30 days?

• YES

• NO

• DON’T KNOW

• REFUSED

ASK ONLY IF PARTICIPANT REPLIED THEY HAVE USED CIGARS, CIGARILLOS, OR LITTLE CIGARS IN THE PAST 30 DAYS IN QUESTION 6.

29. Do you intend to quit using cigars, cigarillos, or little cigars within the next 30 days?

• YES

• NO

• DON’T KNOW

• REFUSED

ASK ONLY IF PARTICIPANT REPLIED THEY HAVE USED A PIPE IN THE PAST 30 DAYS IN QUESTION 6.

30. Do you intend to quit using a pipe within the next 30 days?

• YES

• NO

• DON’T KNOW

• REFUSED

ASK ONLY IF PARTICIPANT REPLIED THEY HAVE USED CHEWING TOBACCO, SNUFF, OR DIP IN THE PAST 30 DAYS IN QUESTION 6.

31. Do you intend to quit using chewing tobacco, snuff, or dip within the next 30 days?

• YES

• NO

• DON’T KNOW

• REFUSED

ASK ONLY IF PARTICIPANT REPLIED THEY HAVE USED OTHER TOBACCO PRODUCTS IN THE PAST 30 DAYS IN QUESTION 6.

32. Do you intend to quit using [NAME OF OTHER TOBACCO PRODUCT] within the next 30 days?

• YES

• NO

• DON’T KNOW

• REFUSED

CALLER CHARACTERISTICS

33. I need to verify: are you male or female?

• Male

• Female

• REFUSED

34. What year were you born? _ _ _ _

• DON’T KNOW

• REFUSED

35. What is your zip code? _ _ _ _ _

• DON’T KNOW

• REFUSED

36. What is the highest level of education you have completed?

• LESS THAN GRADE 9

• GRADE 9 TO 11, NO DEGREE

• GED

• HIGH SCHOOL DEGREE

• SOME COLLEGE OR UNIVERSITY(includes some technical or trade school)

• COLLEGE OR UNIVERSITY DEGREE (includes AA, BA, Masters, Ph.D.)

• DON’T KNOW

• REFUSED

37. Do you have any health insurance, including pre-paid (such as XXX – provide examples for your state) or government programs (such as Medicaid or Medicare)?

• _ Yes (Continue to Q38)

• _ No (SKIP TO Q39)

• _ Don’t know

• _ Refused

• _ Not asked

38. What type of health insurance do you have?

• Private Insurance

• Medicaid

• Medicare

• Military insurance

• Don’t know

• Refused

• Not Asked

39. Are you of Hispanic or Latino origin?

• NO (Not of Hispanic or Latino origin)

• YES(of Hispanic or Latino origin)

• DON’T KNOW

• REFUSED

40. What is your race? Which one or more of the following groups best describes you? (SELECT ONE OR MORE)

• White

• Black or African American

• Asian

• Native Hawaiian or other Pacific Islander

• American Indian or Alaska Native

• **OTHER RACE (SPECIFY _____________)

• DON’T KNOW

• REFUSED

41. We have some additional materials for pregnant women. Are you currently pregnant?

• YES

• NO

• REFUSED

42. Do you have any mental health conditions, such as an anxiety disorder, depression disorder, bipolar disorder, alcohol/drug abuse, or schizophrenia?

• YES

• NO

• REFUSED

CONSENT TO FOLLOW-UP

Do you agree to participate in a follow-up call to assess whether you are satisfied with the service? Please note that your participation in the follow-up survey is completely voluntary and whether you agree to participate or not will not affect the services you receive through the quitline.

• YES

• NO

INTAKE ADMINISTRATIVE DATA

Caller ID

Date questionnaire administered (dd/mm/yyyy): _ _/_ _/_ _ ___

Result of first contact: (Check all that apply):

• Basic information provided (no materials sent)

• Literature and/or self-help materials sent

• Reactive counselling (one counselling session provided during first contact)

• Proactive counselling requested (more than one counselling session) (first counselling session may or may not have taken place during first contact)

• Medications sent (FDA approved)

• Referral to another service (for tobacco cessation or other services, including web-based services, community clinics, etc.)

• Other

Mode of entry to the quitline

• Direct call to the number

• Fax referral

• Internet

• Email solicitation/click-through

• Other (specify__________)

Services RECEIVED by the caller (should be updated after every contact to provide cumulative services received by caller)

• Counseling using an interpreter service

• Counseling, in-language (please specify the language________________)

• Counseling (any amount, should not include time spent asking intake questions or on content that is not directly related to counseling)

• Web-based services (registered/logged in at least once to a cessation-focused website)

• Medications (medications were shipped to the caller)

• Materials (materials were mailed to the caller)

• Other (as relevant to each quitline)

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