Quitline Services Survey

Form Approved

OMB No. 0920-0856

Exp. Date xx/xx/XXXX

National Quitline Data Warehouse (NQDW) Quitline Services Survey

Public reporting burden of this collection of information is estimated to average 20 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)

_{Year: Select data year} Instructions for Completing Survey:

Quarter: Select data quarter State:

Throughout this survey, please fill in -1 to indicate that data are not available for a particular question. Responses of -1 will be interpreted and presented in future reporting as “NA”.

Please respond to the following questions about your quitline during the quarter for which you are reporting.

1. Please provide your contact information

Name:
Job Title:
Employer / Organization:
State:
Email:
Phone:
Second Phone:

2. How many total direct calls came in to the quitline?

Note: Direct calls are your quitline’s total incoming calls, not referrals that generate an outbound call from the quitline. Please report on number of calls, not number of callers/unique individuals. This should include proxy callers, wrong numbers, prank calls, and other calls to the quitline.

Type of Call		Number of Calls
a.	Calls answered live (Total Number)
a1.	Within 30 seconds
a2.	More than 30 seconds
b.	Calls went to voice mail
c.	Calls hung up or abandoned (Total Number)
c1.	Within 30 seconds
c2.	More than 30 seconds
d.	Other Calls (e.g., listening to taped messages, etc.)
e.	Total direct calls (A+B+C+D)

3. Of the total DIRECT calls into the quitline during the quarter for which you are reporting, how many UNIQUE tobacco users called the quitline during the quarter for which you are reporting?

4. How many TOBACCO USERS who called or were referred to the quitline received the services listed below?

Note: Report only on those who received service for the first time. For the purposes of this question, we define “received” service as anyone who received quitline self-help materials and/or began at least one counseling call with the quitline and/or received medications through the quitline.

Service	Number of Tobacco Users
Self-help materials only with no counseling
Counseling Provided (began at least one session)
Phone1
Face-to-Face, Individual/Group
Web
Other Mechanism
Medications provided through the quitline2
Provided with phone counseling OR medications OR both phone counseling and medications3

¹ Defined as a caller-centered, person-tailored, in-depth, motivational interaction that occurs between cessation specialist/counselor/coach and caller.

² NRT or other FDA-approved medications for tobacco cessation.

³ Total provided EITHER phone counseling OR medications OR both (Note: this will likely not total the sum of b and f because many of those who receive medications will also have received counseling. This is the number that will be used to calculate treatment reach using standard calculation.)

5. Quitlines use many types of promotions and referral networks to increase their reach to tobacco users. Please select all of the sources that generated referrals to your quitline.

Note: Referrals are client referrals to the quitline from health professionals, other intermediaries or services (including Web sites) that trigger a proactive call to the client initiated by the quitline.

Fax referral system

Community organization networks Online advertising (paid)

Web referrals (links from web sites, not paid ads) Central call center (“triage”) separate from the quitline Other (please describe):

6. How many referrals did the quitline receive?

Type of Referral		Number Received
a.	Fax referrals
b.	Other referrals (e.g., web referrals, “click to call,” online ads, etc.)
c.	Total referrals (A+B)

7. Did your quitline ask the following question on the NQDW Intake Survey?

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?

Select a response

If your quitline asked this question on the NQDW Intake Survey, please provide the information requested in the table below (a-f).

a.	Number of callers with a “yes” response
b.	Number of callers with a “no” response
c.	Number of callers with a “unsure” response
d.	Number of callers with a “refused” response
e.	Number of callers with a missing response
f.	Total number of callers who were asked the question (a + b + c + d + e)

The remaining questions deal with the services offered by your Quitline during the quarter for which you are reporting. For your convenience, the answers to these questions have been pre-populated with the responses you reported on your most recent prior submission. Please review and make any necessary revisions so that the answers to these questions accurately reflect the services offered by your quitline during the quarter for which you are reporting.

8. What is the name of your state quitline?

9. Please provide information about the quitline number(s) that your state used during this quarter.

Primary Quitline Telephone Number
Does your state use and promote 1-800-QUIT-NOW as its primary quitline number?			Y/N
If “No”, what is your state’s primary quitline number?
Additional Quitline Telephone Numbers
Please list ALL additional quitline telephone numbers used by your state		Description of quitline number
1:
2:
3:
4:
5:

10. Please provide the hours of service of your quitline for the following categories of service:

Day	Hours of Operation
	Live Pick Up of Incoming Calls †	Counseling Services	Voicemail / Answering Service Pick Up of Calls
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:

† May or may not have counseling services available.

11. Is your quitline closed on holidays? Select a response

12. In which of the following languages does your quitline offer counseling?

Language		Offered
English:		Select a response
Spanish:		Select a response
French:		Select a response
Cantonese:		Select a response
Mandarin:		Select a response
Korean:		Select a response
Vietnamese:		Select a response
Russian:		Select a response
Greek:		Select a response
Amharic (Ethiopian):		Select a response
Punjabi:		Select a response
Deaf and Hard of Hearing (TTY):		Select a response
Deaf and Hard of Hearing with video relay:		Select a response
Other Languages (please describe):
1:		Select a response
2:		Select a response
3:		Select a response
4:		Select a response
5:		Select a response

13. How many counseling sessions does your quitline offer? (Please reply fully so we can understand the counseling services provided by your quitline along with the eligibility for counseling services.)

Eligibility Criteria This is the minimum eligibility criteria that applies to ALL callers who receive any amount of counseling. Additional eligibility criteria for groups of callers that receive different amounts of counseling specified in the section below.
Criteria		Yes / No	Comments
Resident of state:		Y/N
Age:		Y/N
Readiness to Quit:		Y/N
Uninsured:		Y/N
Underinsured:		Y/N
Medicaid:		Y/N
Medicare:		Y/N
Privately Insured:		Y/N
Other:		Y/N
Number of Counseling Sessions Offered
Eligibility Criteria				Number	Comments
All Eligible Callers (based on eligibility criteria listed above)
Additional Eligibility Criteria If your quitline provides different numbers of counseling sessions for different groups of callers, please specify the additional eligibility criteria, above and beyond the eligibility criteria already listed above, for each group along with the number of counseling sessions offered to those groups.
1:
2:
3:
4:
5:

14. Did your quitline provide quitting medications to clients?

Medication	Available Medications
	Free	Discounted	Voucher/Coupon	Comments
Nicotine Patches:	Y/N	Y/N	Y/N
Nicotine Gum:	Y/N	Y/N	Y/N
Nicotine Lozenges:	Y/N	Y/N	Y/N
Other (please specify):	Y/N	Y/N	Y/N

15. How many weeks of free Nicotine Patches per quit attempt did your quitline provide to clients? (Please skip this question if your quitline did not provide free nicotine patches.)

Free Nicotine Patches - Eligibility Criteria This is the minimum eligibility criteria that applies to ALL callers who receive any amount of free nicotine patches. Additional eligibility criteria for groups of callers that receive different amounts of nicotine patches specified in the section below.
Criteria		Yes / No	Comments
Resident of state:		Y/N
Geographic area:		Y/N
Age:		Y/N
Readiness to quit:		Y/N
Enrollment in counseling:		Y/N
Medical conditions:		Y/N
Uninsured:		Y/N
Underinsured:		Y/N
Medicaid:		Y/N
Medicare:		Y/N
Privately Insured:		Y/N
Limited supply:		Y/N
Research study:		Y/N
Other:		Y/N
Free Nicotine Patches - Amount Offered
Eligibility Criteria			Weeks Per Quit Attempt	Limit Per Year	Comments
All Eligible Callers (based on eligibility criteria listed above)
Additional Eligibility Criteria If your quitline provides different amounts of free nicotine patches for different groups of callers, please specify the additional eligibility criteria, above and beyond the eligibility criteria already listed above, for each group along with the number of weeks of free nicotine patches per quit attempt offered to those groups.
1:
2:
3:
4:
5:

16. How many weeks of free Nicotine Gum per quit attempt did your quitline provide to clients? (Please skip this question if your quitline did not provide free nicotine gum.)

Free Nicotine Gum - Eligibility Criteria This is the minimum eligibility criteria that applies to ALL callers who receive any amount of free nicotine gum. Additional eligibility criteria for groups of callers that receive different amounts of nicotine gum specified in the section below.
Criteria		Yes / No	Comments
Resident of state:		Y/N
Geographic area:		Y/N
Age:		Y/N
Readiness to quit:		Y/N
Enrollment in counseling:		Y/N
Medical conditions:		Y/N
Uninsured:		Y/N
Underinsured:		Y/N
Medicaid:		Y/N
Medicare:		Y/N
Privately Insured:		Y/N
Limited supply:		Y/N
Research study:		Y/N
Other:		Y/N
Free Nicotine Gum - Amount Offered
Eligibility Criteria			Weeks Per Quit Attempt	Limit Per Year	Comments
All Eligible Callers (based on eligibility criteria listed above)
Additional Eligibility Criteria If your quitline provides different amounts of free nicotine gum for different groups of callers, please specify the additional eligibility criteria, above and beyond the eligibility criteria already listed above, for each group along with the number of weeks of free nicotine gum per quit attempt offered to those groups.
1:
2:
3:
4:
5:

17. How many weeks of free Nicotine Lozenges per quit attempt did your quitline provide to clients? (Please skip this question if your quitline did not provide free nicotine lozenges.)

Free Nicotine Lozenges - Eligibility Criteria This is the minimum eligibility criteria that applies to ALL callers who receive any amount of free nicotine lozenges. Additional eligibility criteria for groups of callers that receive different amounts of nicotine lozenges specified in the section below.
Criteria		Yes / No	Comments
Resident of state:		Y/N
Geographic area:		Y/N
Age:		Y/N
Readiness to quit:		Y/N
Enrollment in counseling:		Y/N
Medical conditions:		Y/N
Uninsured:		Y/N
Underinsured:		Y/N
Medicaid:		Y/N
Medicare:		Y/N
Privately Insured:		Y/N
Limited supply:		Y/N
Research study:		Y/N
Other:		Y/N
Free Nicotine Lozenges - Amount Offered
Eligibility Criteria			Weeks Per Quit Attempt	Limit Per Year	Comments
All Eligible Callers (based on eligibility criteria listed above)
Additional Eligibility Criteria If your quitline provides different amounts of free nicotine lozenges for different groups of callers, please specify the additional eligibility criteria, above and beyond the eligibility criteria already listed above, for each group along with the number of weeks of free nicotine lozenges per quit attempt offered to those groups.
1:
2:
3:
4:
5:

NQDW Quitline Services Survey

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