ASQ 7 month follow-up - Chinese
National Quitline Data Warehouse
G-2 NQDW_ASQ_7-month follow-up questionnaire_CHINESE_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 (Chinese)
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 CHINESE
您好，我的名字叫 ___________ 我是加州大學工作人員。我給您打電話是爲了評估華語戒煙專綫的服務品質。更為了提高服務品質，我想了解您對戒煙專綫服務的看法。我們只需要幾分鐘與您通話。為了確保服務素質，我們的談話可能被旁聽或者被錄音， 但你的囘應是保密的。我能佔用您幾分鐘的時間與您交談嗎？
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. 當您第一次打電話到戒煙專線的時候，您是希望得到怎樣的服務來幫助您戒煙？
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
我想問你一些有關他們寄給你的戒煙資料的問題…………..
I'd like to ask you some questions about the written materials . . . .
2. 你是否收過華語戒煙專綫寄給你的戒煙資料？
Did you receive the materials sent by ASQ?
Yes Don't Know
No / Never received Refused
Not asked
3. 你有否讀過華語戒煙專綫寄给你的戒煙資料？
Did you read the materials sent by ASQ?
Yes (all or some) Don't Know
No Refused
Not asked
4.戒煙資料中那部份你覺得特別喜歡的？
Was there anything in particular that you LIKED about the materials?
Yes Don't Know
No Refused
Not asked
4a. 是哪些資訊呢？
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. 那一部份你最不喜歡的？
Was there anything in particular that you DISLIKED about the materials?
Yes Don't Know/ remember
No Refused
Not asked
5a. 您不喜歡的是哪些 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
現在，我想問你一些關於華語戒煙專綫提供戒煙諮詢服務
Now, I would like to ask you some questions regarding the ASQ’s counseling services.
6. 請問您是否有接受電話諮詢的服務？
Did you receive telephone counseling?
Yes Don't Know
No Refused
Not asked
6a. 能否告訴我們您沒有接受電話諮詢服務的原因？
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. 請問您覺得電話諮詢的次數是過少，適中，還是過多？
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. 請您簡單的說一說，您會如何形容您的諮詢員？
Briefly, how would you describe your counselor? _________________________________________
________________________________________________________________________________
9. 請問您的諮詢員是否是一個很好的聆聽者，您會說很好，好，或者是不好？
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. 電話諮詢中，您特別喜歡哪些部分？
Was there anything in particular that you LIKED about the counseling?
Yes Don't Know
No Refused
Not asked
10a. 哪些部分是您特別喜歡的？
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. 電話諮詢中，您特別不喜歡哪些部分？
Was there anything in particular that you DISLIKED about the counseling?
Yes Don't Know
No Refused
Not asked
11a. 哪些部分是您特別不喜歡的？
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. 總括來説，跟華語戒煙專綫的工作人員談話您覺得很自在,自在, 还是不自在？
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. 總括來說，您對華語戒煙專綫線的服務是非常滿意，相當滿意，尚且滿意，或者不滿意？
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. 您現在是每天抽煙，有些日子抽煙還是完全沒抽煙？
Do you currently smoke cigarettes everyday, some days, or not at all?
Everyday Don’t know
Some days Refused
Not at all Not asked
NOT SMOKING CHINESE
1. 您最近一次戒煙是甚麼時候？
When did you quit? Most recent quit date: _______/_______/_______
1a. 戒了多久？
How long ago did you quit? ______ days/weeks/months/years
2. 自從第一次打電話給華語戒煙専缐到現在，您試過（包括這次）戒幾次煙？
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. 在您所試的這幾次戒煙過程中，有幾次戒煙長達一天或一天以上？
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. 您第一次戒煙長達24小時或更久是甚麼時候？ （自從您第一次給戒煙中心打電話到現在） When did you first quit for 24 hours or more since (Screen Date)? ______/______/______
a. 第一次嘗試戒煙後，甚麼時候您又開始每天吸煙？ When did you start smoking on a daily basis after (first attempt date)? ______/______/______
b. 戒了多長的時間？ How long did you quit for?_____ days/weeks/months/ years Don’t know Refused Not asked
5. (FIRST QUIT ATTEMPT): 在第一次戒煙的 (1st quit length)過程當中，您曾否偶爾吸一支煙或一口煙？ 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): 是甚麼時候？ When was your first cigarette/puff? ______/______/______
5b. (FIRST QUIT ATTEMPT): 您曾連續多少天吸幾支煙或幾口煙（包括第一天），或您一開始戒煙就這樣做？ How many days in a row did you smoke, including the first day? [________]
6.(FIRST QUIT ATTEMPT): 在這次戒煙期間，您曾用過其它的輔助藥物，例如尼古丁貼片，口香糖，Zyban 或 Chantix嗎？ 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
|
******Last or Only Quit Attempt****** |
7. 當您在最後一次戒煙過程中， 您曾吸過一支煙或一口煙嗎？ Have you had a cigarette, or even a puff, since you quit on (most recent quit date)? Yes . . . .是甚麼時候？ When was your first cig./puff? _____/______/______
No Don’t know Refused Not asked a. 在您抽那支煙以前，您處於甚麼情境之下? What was the situation just before you smoked that cigarette?
_______________________________________________
____________________________________ b. 您從哪裏拿到香煙？ 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.當您在最後一次戒煙過程中，連續多少天吸幾支煙或幾口煙（包括第一天），或您一開始戒煙就這樣做？ 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. 您最後一次吸一支煙或一口煙是甚麼時候？ 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. 在您抽那支煙以前，您處於甚麼情境之下? What was the situation just before you smoked that cigarette?
______________________________________________
__________________________________ f. 您從哪裏拿到香煙？ 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. How many days in a row did you smoke, including the first day? ______ day(s). 當您在最後一次戒煙過程中，連續多少天吸幾支煙或幾口煙（包括第一天），或您一開始戒煙就這樣做？ Ever Since o Don’t know Refused Not Asked
|
8. 我想確認一下，您現在每天抽煙或是有些日子抽煙呢？
Let me confirm… Are you currently smoking cigarettes everyday or some days?
Everyday Don’t know
Some days Refused
Not asked
9a. 平均來講，您每天會抽幾支香煙？
On average, how many cigarettes do you smoke per day?_______
9b. 您現在每一個星期有幾天您會吸煙？
How many days per week do you smoke? ________
9c. 在您吸煙的日子，平均來講每天您會抽幾枝煙？
On average how many cigarettes do you smoke per day on the days you smoke? ______
10. 您一般起床後多久開始抽第一支煙？
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
11. Since <insert screen date>, did you use anything like the Nicotine Patch, Gum, Zyban or Chantix?
至從<insert screen date>，你有沒有用任何補助藥物，例如尼古丁貼片，口香糖，Zyban或者Chantix嗎？
For this quit attempt, did you use anything like the Nicotine Patch, Gum, Zyban or Chantix to help you quit? 在這次戒煙期間，您曾用過任何輔助藥物，例如尼古丁貼片，口香糖，Zyban 或 Chantix嗎？
Did you use anything like the Nicotine Patch, Gum, Zyban or Chantix to help you quit?
在這次戒煙期間，您曾用過任何輔助藥物，例如尼古丁貼片，口香糖，Zyban 或 Chantix嗎？
Yes
No
Don’t know
Refused
Not Asked
是哪一種？
Which ones?
|
您現在還在使用嗎? Are you currently using them?
|
您用了多久?
How long did you use them for?
|
平均來說您用了多少?
On average, how many did you use per day? |
您用的劑量是多少？
What dosage did you use?
|
您是在戒煙之前使用的嗎？
Did you use them BEFORE your quit attempt? |
您是如何得到的？
Where did you get them?
|
大約花了多少錢？
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 |
12. 在這段時間裏，您還用過其他計劃或方法來幫助您戒煙嗎？
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...
這次戒煙，決定不用任何輔助藥物的主要原因是什麽呢？
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華語戒煙專綫
o Delivery took too long
o Other
o Don’t Know
o Refused
o Not Asked
14. 您現在有用其他的煙草嗎？(例如咀嚼煙，鼻煙，雪茄或煙斗)
Do you currently use any other form of tobacco, such as chew/snuff, cigars or pipes?
Yes
No
Don’t know
Refused
是哪一種？ Which ones?
Chew
Cigars
Pipes
Other: ______________
If CHEW/SNUFF: 每個星期用多少？
How much tobacco do you use per week?
______________
Code: less than 1 as 1 (Amount of cans/pouches)
Don’t know Refused
If CHEW/SNUFF: 是罐還是袋？
Is that cans or pouches?
If CIGARS: 每個星期抽幾枝？
How many do you smoke per week?
Don’t know Refused
15. 假如您決定從今天起戒煙， 您有多少信心能在一個星期内不抽煙？是非常有信心，有信心，還是沒有信心？
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?
您有多少信心能繼續在一個星期内保持不抽煙？是非常有信心，有信心，還是沒有信心？
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. 請簡短的講一講，你會給想要戒煙的人甚麼樣的最重要提示？
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: 這是我們所有的問題了，非常感謝您的時間
Those are all the questions I have for you, thank you for your time.
Comments:______________________________________________________________________________
________________________________________________________________________________________
Revised
07/29/2010 2010
Regents of the University of California, ALL RIGHTS RESERVED
Page
| 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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