ASQ 7 month follow-up - English
National Quitline Data Warehouse
G-1 NQDW_ ASQ_7-Month follow-up questionnaire_ENGLISH_nm
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 (English)
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)
7-month Evaluation
SERVICE ENGLISH
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. 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 . . . .
2. Did you receive the materials sent by ASQ?
Yes Don't Know
No / Never received Refused
Not asked
3. Did you read the materials sent by ASQ?
Yes (all or some) Don't Know
No Refused
Not asked
4. Was there anything in particular that you LIKED about the materials?
Yes Don't Know
No / Never received Refused
Not asked
4a. 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. Was there anything in particular that you DISLIKED about the materials?
Yes Don't Know/ remember
No Refused
Not asked
5a. 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.
6. Did you receive telephone counseling?
Yes Don't Know
No Refused
Not asked
6a. 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. 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. Briefly, how would you describe your counselor? _________________________________________
________________________________________________________________________________
9. 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. Was there anything in particular that you LIKED about the counseling?
Yes Don't Know
No Refused
Not asked
10a. 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. Was there anything in particular that you DISLIKED about the counseling?
Yes Don't Know
No Refused
Not asked
11a. 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. 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. 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. 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 ENGLISH
1. When did you quit? Most recent quit date: _______/_______/_______
1a.How long ago did you quit? ______ days/weeks/months/years
2. Since you first called the Asian Smokers’ Quitline (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. 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. When did you first quit for 24 hours or more since (Screen Date)? ______/______/______
a. When did you start smoking on a daily basis after (first attempt date)? ______/______/______
b. How long did you quit for?_____ days/weeks/months/ years Don’t know Refused Not asked
5. (FIRST QUIT ATTEMPT): 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): When was your first cigarette/puff? ______/______/______
5b. (FIRST QUIT ATTEMPT): How many days in a row did you smoke, including the first day? [________] (Note to evaluator: if clients states they have smoked EVER SINCE: confirm & go to SMOKING form).
6. (FIRST QUIT ATTEMPT): For this quit attempt, did you use anything like the Nicotine Patch, Gum, Zyban, Chantix or E-cigarettes to help you quit?
Yes No Don’t know Refused Not Asked
|
******Last or Only Quit Attempt****** |
7. Have you had a cigarette, or even a puff, since you quit on (most recent quit date)?
Yes . . . . . When was your first cig./puff? _____/______/______
No Don’t know Refused Not asked
a. What was the situation just before you smoked that cigarette?
_______________________________________________
____________________________________
b. 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 Not asked
c. 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. When was the last time you had a cigarette, or even a puff? ______/______/______
10 was the last time. . . .Go to 11 Don’t know Refused Not asked
e. What was the situation just before you smoked that cigarette?
______________________________________________
__________________________________Code: ______
f. 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 Not asked
g. 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. Let me confirm… Are you currently smoking cigarettes everyday or some days?
Everyday Don’t know
Some days Refused
Not asked
9a. On average, how many cigarettes do you smoke per day?_______
9b. How many days per week do you smoke? ________
9c. On average how many cigarettes do you smoke per day on the days you smoke? ______
10. 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 Not asked
11. Since <insert screen date>, did you use anything like the Nicotine Patch, Gum, Zyban, Chantix or E-cigarettes?
IF E ON QUESTION 7c OR 7g & IF CLIENT HAS QUIT ATTEMPT LASTING OVER 24 HRS (that is, there is a value ≥ 1 in Q5): For this quit attempt, did you use anything like the Nicotine Patch, Gum, Zyban, or Chantix to help you quit?
OTHERWISE USE THIS VERSION Did you use anything like the Nicotine Patch, Gum, Zyban, or Chantix to help you quit?
Yes
No
Don’t know
Refused
Not Asked
Which ones?
|
Are you currently using them?
|
How long (did you use / have you used) them for?
|
On average, how many did you use per day?
|
What dosage did you use?
|
Did you use them BEFORE your quit attempt? |
Where did you get them?
|
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
|
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
|
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
|
E-cigarettes |
NOT ASKED |
_______ days/weeks/months
Don’t Know Refused Not Asked
|
NOT ASKED |
High/full/strong (≥ 19mg) Medium / regular (11-18mg) Low / Ultra low / light/ ultra light (1-10mg) Nicotine, unknown level No nicotine 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
|
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. 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: 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
o Delivery took too long
o Other
o Don’t Know
o Refused
o Not Asked
14. Do you currently use any other form of tobacco, such as chew/snuff, cigars or pipes?
Yes
No
Don’t know
Refused
Which ones?
Chew
Cigars
Pipes
Other: ______________
If CHEW/SNUFF: How much tobacco do you use per week?
______________
Don’t know Refused
If CHEW/SNUFF: Is that cans or pouches?
If CIGARS: How many do you smoke per week?
_______________
Don’t know Refused
15. 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?
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
Not asked
16. 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
Not asked
END EVAL: 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 | 2021-01-20 |
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