Form 4 Appendix 1C Smoking Cessation Questions

Collection of Customer Service, Demographic and Smoking/Tobacco Use Information from NCI's Contact Center, Cancer Information Service (CIS) Clients

Appendix 1C Smoking Cessation Questions SCIF

Smoking Cessation Clients Demographic Questions

OMB: 0925-0208

Document [docx]
Download: docx | pdf

NCI/Office of Communications and Public Liaison

APPENDIX 1C

SMOKING CESSATION INTAKE QUESTIONS AND DEMOGRAPHIC QUESTIONS (SCIF)






Public Burden Statement




Demographic Questions







Smoking Cessation Intake Questions








Dependency – Symptoms








Dependency – Triggers







Dependency – Past Meds






Dependency – Future Meds







Motivation




Service

  • Subject of Interaction

  • Subject 1

  • No Value

  • Hospital/Clinic/Physician/Second Opinion

  • General Cancer Site Information

  • Treatment/Side Effects

  • Hospice/Palliative Care/Home Care/Supplies

  • Financial Assistance

  • Monetary/Personal Property Donations

  • Publication Request

  • Other Inquiry

  • Screening Mammogram

  • Diagnostic Mammogram

  • Pap Test

  • PSA Test

  • Screening Colonoscopy

  • Screening Spiral CT for Lung

  • Screening MRI for Breast

  • Diagnostic MRI for Breast

  • Other Diagnostic Test

  • Other Screening Test

  • CT-General Information Only

  • CT-General Information and Search

  • CT-CCR Clinical Trials

  • CT-Results and Outcomes

  • Support Groups/Counseling Services

  • Emotional Wellness

  • Other Psychosocial Issue

  • Suicidal Client

  • HPV

  • Heredity/Genetics/Family History

  • Environmental Risk Factors

  • Diet and Nutrition for Prevention

  • Exercise/Obesity for Prevention/Risk

  • Hormone Use and Cancer Risk

  • HIV/AIDS

  • EMF – Cell Phones

  • EMF – Other

  • Other Risk Factors

  • CAM General Information

  • CAM – Biologically Based Products

  • CAM-Mind Body/Spirituality/Energy Med

  • CAM-Manual Therapies

  • CAM-Whole Systems

  • Medical Marijuana

  • Body/Tissue/Hair Donations

  • Genetic Services

  • Report/Statistics

  • Proton Beam Radiation (txt/side effects)

  • NCI Programs & Initiatives

  • Employment at NCI

  • NCI Budget

  • NCI Funding Opportunities

  • Scientific Materials for Researchers

  • NCI & ARRA

  • Cancer.gov Comments or Questions

  • Problems with CT Search

  • NCI Logo Request

  • Artwork Request

  • NCI Other

  • Cigarettes

  • Cigars, Cigarillos or Little Cigars

  • Pipes

  • Chewing Tobacco, Snuff, or Dip

  • Other Tobacco

  • Secondhand Smoke

  • Marijuana (recreational use)

  • Cessation Counseling/Information

  • Subject 2 Same as 1

  • Subject 3 Same as 1

  • Subject 4 Same as 1

  • Subject 5 Same as 1


  • Cancer Site 1

  • Aids-related cancers

  • ALL

  • AML

  • Anal

  • Biliary tract

  • Bladder

  • Brain

  • Breast

  • Carcinoma of unknown primary

  • Cervical

  • CLL

  • CML

  • Colorectal

  • Endometrial/Uterine

  • Esophageal

  • Eye

  • Gastrointestinal carcinoid tumor/GIST

  • Head and neck

  • Hodgkin lymphoma

  • Myeloma/Plasma cell neoplasm

  • Non-Hodgkin lymphoma

  • Ovarian

  • Pancreas

  • Prostate

  • Renal (kidney) and renal pelvis

  • Skin cancer (nonmelanoma)

  • Small intestine

  • Soft tissue

  • Stomach/Gastric

  • Thyroid

  • Break off

  • Other – Central nervous system

  • Other – Digestive

  • Other – Endocrine system

  • Other – Hematologic system

  • Other – Leukemia

  • Other – Lymphoma

  • Other – Musculoskeletal and connective tissue

  • Other – Reproductive, female

  • Other – Reproductive, mal

  • Other – Respiratory

  • Other – Urinary organs

  • Other cancers

  • Childhood cancers

  • Not applicable/No specific site mentioned


  • Special Codes

  • Special Code

  • No Value

  • CTCA Calls

  • Affordable Care Act (ACA)

  • In the news

  • Cancer Bulletin Ending

  • Recalcitrant Cancer Research Act

  • UCSF Study Call

  • Special Code 2 (same as 1)



  • Referrals Given

  • Referral 1

  • No Value

  • CIS information service

  • Smoking Quitline

  • Public Inquiries

  • POS

  • NCI Doc/Program

  • NCI Designated Cancer Center

  • NCI CCR/Clinical Center

  • NCCCP

  • CDC-BCCEDP

  • CDC-BCCEDP – Missouri

  • Genetics Services

  • Other Healthcare Facility

  • National or Community Org/Other Gov. Program

  • International Referral

  • Other

  • None

  • Break Off

  • Referral 2 (same as 1)

  • Referral 3 (same as 1)

  • Referral 4 (same as 1)

  • Referral 5 (same as 1)

  • Referral 6 (same as 1)

  • Follow-up Actions

  • Action 1

  • No Value

  • Sent information by mail

  • Emailed information

  • Social Media post

  • Warm transfer POS

  • Warm transfer org/agency

  • Scheduled call back

  • Other

  • Action 2 (same as 1)

  • Action 3 (same as 1)

  • Action 4 (same as 1)

  • Action 5 (same as 1)


  • Clinical Trials

  • Yes

  • No



  • Background Screen

  • Cigarettes per Day

  • Age

  • Gender

  • Male

  • Female

  • Substance Use Disorder

  • Yes

  • No

  • Mental Health Disorder

  • Yes

  • No


Dependency Screen:

  • Age when starting smoking cigarettes

  • First cigarette of the day after awakening

  • In life, number of quit attempts for 1 day or longer

  • Duration (beyond a day) of successful quitting

  • In past year, number of quit attempts

        • First call to the quit line in the past 12 months?

  • Longest time quit



  • Types of tobacco have you used in the past 30 days

        1. Cigarettes

          • Menthol cigarettes?

            • Yes, I usually smoke menthol cigarettes

            • No, I usually smoke other types of cigarettes (non-menthol)

            • Don’t know

            • Refused

            • Not asked

        2. Cigars, cigarillos, or little cigars

        3. A pipe

        4. Chewing tobacco, snuff, or dip

        5. Any other type of tobacco


  • Last time smoked a cigarette, even a puff :

        1. dd/mm/yyyy

        2. Don’t know

        3. Refused

        4. Not asked


  • Avg. Number of cigarettes smoked each day ___


  • Currently smoke cigarettes every day, some days, or not at all? (Note: “currently” refers to right now, today.)

        1. Everyday

        2. Some days

          • Number of days smoked in the last 30 days: ___

            • Don’t know

            • Refused

            • Not asked

        3. Not at all

        4. Don’t know

        5. Refused

        6. Not asked

  • Age?

  • Sex?

  • If female, are you pregnant right now?



  • Symptoms experienced after quitting

        • Feeling irritable, angry, agitated

        • Mood swings, depressed, down, or blue

        • Nervous, anxious, jumpy

        • Cravings

        • Trouble sleeping, nightmares, dreams

        • Has not tried to quit before (1st quit attempt)

        • Weight gain

        • Increased appetite or hunger

        • Tired, fatigued

        • Feeling ill, sick, nausea, general malaise

        • Headache

        • Chest pain, shortness of breath

        • Stress

        • Unable to concentrate

        • Dizzy, lightheaded

        • Shakes

        • Other (please explain)


  • Triggers

  • Did not ask triggers

  • After meals

  • Alcohol

  • Other substance abuse

  • Anxiety

  • Coffee

  • Driving

  • Fatigue

  • Driving

  • Phone calls

  • Sadness

  • Stress

  • Watching TV

  • Work breaks

  • Nightmares

  • Intrusive thoughts

  • Other (please explain)


  • Past medication to quit

  • Did not ask

  • Used in past

  • Bupropion hydrochloride (e.g.Zyban, Wellbutrin)

  • Chantrix

  • Herbal

  • Inhalers

  • Lozenges

  • Nasal sprays

        • Patches

        • Policrilex gums

  • 2 NRT combinations

  • Bup+NRT combination

  • Other


  • Future Meds

  • Did not ask

  • Not interested

  • Bupropion hydrochloride

  • Chantrix

  • Herbal

  • Inhalers

  • Lozenges

  • Nasal sprays

        • Patches

        • Policrilex gums

  • 2 NRT combinations

  • Bup+NRT combination

  • Other


  • Comorbidity

  • Substance Abuse

  • Other


Motivation Screen Questions:


  • Most important reason for wanting to quit

        • Restrictions placed on smokers in restaurants, at work, and other public places

        • Family or friends

        • To feel more in control of your life

        • To improve your health

        • To save money

        • To improve your health

        • Because your doctor told you to

        • Because of your children (grandkids)

        • For a healthy pregnancy

        • Just tired of smoking

        • Professionalism, Role model

        • Religious reasons

        • Extracurricular activities (e.g. basketball, jogging, dancing, volleyball, etc.)

        • Age

        • Concern about cancer prompted by death of family member or public figure

        • Dirty/bad habit

        • Other (please explain)

        • Did not ask


  • Secondary Reason?

        • See examples from last question

        • No other reason

        • Did not ask


  • Others in the household currently using tobacco products (one or more)

  • Other Users?

        • Child?

        • Friend?

        • Parent?

        • Partner?


  • Household Tobacco Products Used

  • Chewing

  • Cigarettes

  • Cigars

  • Pipes

  • Snuff


  • Quitting

  • Quitting next 30 days?

  • Quit date

  • Confidence in Quitting

  • No value

  • Somewhat confident

  • Confident

  • Neutral

  • Not confident at all


  • Call Backs?

  • Interested in call back?

  • Agree to terms of service?


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleSmoking Cessation Intake Form (SCIF Screen Shots
SubjectSMOKING CESSATION INTAKE FORM (SCIF) with SCREEN SHOTS
AuthorBurstyn, Ilene (NIH/NCI) [E]
File Modified0000-00-00
File Created2021-01-24

© 2024 OMB.report | Privacy Policy