ASQ 7 month follow-up - Korean

Form Approved

OMB No. 0920-0856

Exp. Date xx/xx/XXXX

Asian Smokers’ Quitline (ASQ)

7-Month Follow-Up Intake Questionnaire (Korean)

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 KOREAN

안녕하십니까? 저는 UC 샌디에고에 근무하는 ________입니다. 한인금연센터의 프로그램이 어땠는지 평가 받기 위해서 전화 드렸습니다. 책자와 서비스에 대한 귀하의 고견을 들어 봤으면 합니다. 주시는 모든 응답은 비밀이 보장되고, 좀더 나은 서비스를 위해서 전화가 모니터, 녹음 될 수도 있습니다. 몇 분만 시간을 내주실 수 있으시겠습니까?

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. 생님/사모님께서 처음으로 가주 금연 상담소에 전화를 하셨을때, 어떤 종류의 서비스를 기대하셨습니까? 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

책자에 관련된 질문을 몇 가지 드리겠습니다.

I'd like to ask you some questions about the written materials . . . .

2. 한인금연센터에서 보내드리는 책자는 받으셨습니까?

Did you receive the materials sent by ASQ?

Yes   No / Never received

 Don't Know

 Refused

 Not asked

3. 책자를 읽어 보셨는지요?

Did you read the materials sent by ASQ?

 Yes (all or some)

 No

 Don't Know

 Refused

 Not asked

4. 책자에서 특별히 마음에 드는 점이 있으셨습니까?

Was there anything in particular that you LIKED about the materials?

Yes

 No   Don't Know   Refused

 Not asked

4a. 어떤 점이 가장 마음에 드셨나요?

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. 책자에서 특별히 마음에 안 드는 점이 있으셨습니까?

Was there anything in particular that you DISLIKED about the materials?

Yes 

 No

 Don't Know/ remember

 Refused

 Not asked

5a. 어떤 점이 가장 마음에 안 드셨나요?

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

금연 전문가와의 전화 상담에 관련된 질문을 몇 가지 드리겠습니다.

Now, I would like to ask you some questions regarding ASQ’s counseling services.

6. 금연 전문가와 카운슬링(상담)을 하셨나요?

Did you receive telephone counseling?

Yes

 No

 Don't Know

 Refused

 Not asked

6a. 금연 전문가와 카운슬링(상담)을 하지 않은 특별한 이유가 있으십니까?

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. 카운슬링(상담)을 받은 횟수에 대해 어떻게 생각하십니까? 아주 적었습니까, 적당하셨습니까, 너무

많으셨습니까?

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

 Just right

 Too many

 Don’t know

 Refused

 Not asked

8. 간단하게 선생님/사모님의 카운슬러에 대해 어떻게 설명하시겠습니까?

Briefly, how would you describe your counselor? _________________________________________

________________________________________________________________________________

9. 카운셀러가 선생님/사모님의 말씀을 얼마나 잘 들어 주었습니까? 아주 잘 들어주었습니까, 보통 들어주었습니까, 전혀 들어주지 않았습니까?

How was your counselor in terms of being a good listener, would you say very good, good or not good?

 Very good

 Good

 Not good

 Don’t know

 Refused

 Not asked

10. 전화 카운슬링중에 특별히 마음에 드신 부분이 있으십니까?

Was there anything in particular that you LIKED about the counseling?

Yes

 No

 Don't Know

 Refused

 Not asked

10a. 어떤 점이 가장 마음에 드셨나요?

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. 카운슬링중에 특별히 마음에 안 드신 부분이 있으십니까?

Was there anything in particular that you DISLIKED about the counseling?

Yes  No

 Don't Know

 Refused

 Not asked

11a. 어떤 점이 가장 마음에 안 드셨나요?

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. 전체적으로한인금연센터의 스태프와 통화하는것이 얼마나 편하셨습니까? 아주 편하셨습니까,

보통 편하셨습니까, 아니면 전혀 편하지 않으셨습니까?

Overall, how comfortable did you feel when talking with ASQ staff? Would you say very comfortable,

comfortable or not comfortable?

 Very comfortable

 Comfortable

 Not comfortable

� Don’t know

� Refused

� Not asked

13. 전반적으로 선생님/사모님께서 받으신 서비스에 대해 얼마나 만족하십니까? (매우만족, 만족, 보통,불만족

혹은) 매우 만족하십니까? 만족하십니까? 보통이십니까? 전혀 만족하지 않으십니까?

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

 Mostly satisfied

 Somewhat satisfied

 Don’t know

 Refused Not asked

 Not at all satisfied

14. 현재담배를 매일 피우십니까? 가끔 피우십니까? 전혀 피우지 않으십니까?

Do you currently smoke cigarettes everyday, some days, or not at all?

 Everyday

 Some days

 Not at all

 Don’t know

 Refused

 Not asked

 Smoking

NOT SMOKING KOREAN

1. 언제 금연을 시작하셨습니까?

When did you quit? Most recent quit date: _______/_______/_______

1a. 금연을 시작하신지 얼마 되셨습니까?

How long ago did you quit? ______ days/weeks/months/years

2. 한인금연센터에 처음 전화주신 이후 몇 번이나 금연을 시도하셨습니까?

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. 그 중에서 24시간 이상 성공하신 경우가 몇번 이십니까?

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. 한인금연센터에 전화주신 이후 처음으로 24시간 이상 금연에 성공하셨던 때가 언제였습니까?

When did you first quit for 24 hours or more since (Screen Date)? ______/______/______

a. 그때 금연 하셨다가 다시 담배를 매일 피우시게 된 것은 언제였습니까?

When did you start smoking on a daily basis after (first attempt date)? ______/______/______

b. 얼마 동안 금연을 하셨습니까?

How long did you quit for?_____ days/weeks/months/ years

Don’t know

Refused

Not asked

5. (FIRST QUIT ATTEMPT): 그때 금연 하시는 동안 (한 모금이라도) 담배를 피우신 적이 있으십니까?

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): 언제 첫 담배를 피우셨습니까?

When was your first cigarette/puff? ______/______/______

5b. (FIRST QUIT ATTEMPT): 첫날을 포함해서 몇일이나 연속적으로 담배를 피우셨습니까?

How many days in a row did you smoke, including the first day? [________]

6. (FIRST QUIT ATTEMPT): 이번에 금연 하셨을때, 니코틴 패치, 껌, 자이반 혹은 챈틱스와 같은 다른 금연 보조 약품을 사용하셨습니까?

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

Which ones? 어떤 종류의 금연 보조 약품을 사용 하셨습니까?	How long did you use them for? 얼마 동안 사용하셨습니까?	On average, how many did you use per day? 평균적으로 하루에 얼마나 사용 하셨습니까?	What dosage did you use? 몇 밀리그램짜리로 시작하셨습니까?	Did you use them BEFORE, DURING and/or AFTER your quit attempt? 금연 시도 전, 시도중, 혹은 시도후에 사용하셨습니까?	Where did you get them? 금연 보조 약품을 어디서 구하셨습니까?	How much money did you spend on them? 그 금연 보조 약품의 값으로 얼마나 지불하셨습니까?
Patch	_______ 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	_______ days/weeks/months Don’t Know Refused Not Asked	_______/day D R Z	2mg 4mg 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
Zyban	_______ days/weeks/months Don’t Know Refused Not Asked	NOT ASKED	NOT ASKED	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
Chantix/ Varenicline	_______ days/weeks/months Don’t Know Refused Not Asked	NOT ASKED	NOT ASKED	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
Lozenge	_______ days/weeks/months Don’t Know Refused Not Asked	_______/day D R Z	2mg 4mg 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
Other: ____________________________________ _________	_______ days/weeks/months Don’t Know Refused Not Asked	NOT ASKED	NOT ASKED	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
D R Z

******Last or Only Quit Attempt******

7. (Most recent quit date) 최근에 금연하신 이후로 (한 모금이라도) 담배를 피우신 적이 있으십니까?

Have you had a cigarette, or even a puff, since you quit on (most recent quit date)?

 Yes . . . . . 그때가 언제셨나요?

When was your first cig./puff? _____/______/______

 No

 Don’t know.

 Refused

 Not asked

a..당시 담배를 피우시게 되신 상황에 대해서 설명을 좀 해주시겠습니까?

What was the situation just before you smoked that cigarette?

_____________________________________

b. 담배를 어디서 구하셨습니까?

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. 첫날을 포함해서 몇일이나 연속적으로 담배를 피우셨습니까?

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. 가장 최근에 담배를 피우신게 언제입니까?

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. 당시 담배를 피우시게 되신 상황에 대해서 설명을 좀 해주시겠습니까?

What was the situation just before you smoked that cigarette?

___________________________________

f. 담배를 어디서 구하셨습니까?

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. 첫날을 포함해서 몇일이나 연속적으로 담배를 피우셨습니까?

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. 잠시 확인을 하겠습니다. 현재 담배를 매일 피우십니까, 가끔 피우십니까 아니면 전혀 안 피우십니까?

Let me confirm… Are you currently smoking cigarettes everyday or some days?

 Everyday  Don’t know

 Some days  Refused

 Not asked

9a. 하루에 평균 담배를 몇 개비나 피우십니까?

On average, how many cigarettes do you smoke per day?_______

9b. 일주일에 몇일이나 흡연 하십니까?

How many days per week do you smoke? ­­­________

9c. 담배를 피우는 날에는 평균 하루에 몇 개비 정도 피우십니까?

On average how many cigarettes do you smoke per day on the days you smoke? ______

10. 아침에 일어나신지 얼마후 보통 첫 담배를 피우십니까?

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? :

한인금연센터에 처음 전화주신 이후 니코틴 패치, 껌, 자이반 혹은 챈틱스와 같은 다른 금연 보조 약품을 사용하셨습니까?

For this quit attempt, did you use anything like the Nicotine Patch, Gum, Zyban or Chantix to help you quit?

이번에 금연 하셨을때, 니코틴 패치, 껌, 자이반 혹은 챈틱스와 같은 다른 금연 보조 약품을 사용하셨습니까?

Did you use anything like the Nicotine Patch, Gum, Zyban or Chantix to help you quit?

니코틴 패치, 껌, 자이반 혹은 챈틱스와 같은 금연 보조 약품을 사용하셨습니까?

Yes

No

Don’t know

Refused

Not Asked

Which ones? 어떤 종류의 금연 보조 약품을 사용 하셨습니까?	Are you currently using them? 현재 사용 중이십니까?	How long did you use them for? 얼마 동안 사용하셨습니까?	On average, how many did you use per day? 평균적으로 하루에 얼마나 사용 하셨습니까?	What dosage did you use? 몇 밀리그램짜리로 시작하셨습니까?	Did you use them BEFORE your quit attempt? 금연 시도 전에 사용하셨습니까?	Where did you get them? 금연 보조 약품을 어디서 구하셨습니까?	How much money did you spend on them? 그 금연 보조 약품의 값으로 얼마나 지불하셨습니까?
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
D R Z

12. 이번에 금연 하셨을때 다른 금연 프로그램이나 특별한 금연방법을 사용하셨습니까?

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...

금연 보조 약품을 사용하지 않으신 특별한 이유가 있습니까?

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 (한인금연센터)

o Delivery took too long

o Other

o Don’t Know

o Refused

o Not Asked

14. 담배 이외에 다른 타바코 제품을 사용하십니까?

Do you currently use any other form of tobacco, such as chew/snuff, cigars or pipes?

Yes

No

Don’t know

Refused

어떤 종류의 타바코 제품을 사용하고 계십니까?

Which ones?

Chew

Cigars

Pipes

Other: ______________

If CHEW/SNUFF: 일주일에 몇통 혹은 몇봉지나 사용하고 있습니까?(사용하셨습니까)? How much tobacco do you use per week?

______________

Don’t know Refused

If CHEW/SNUFF: 캔에 들어 있습니까 아니면 봉지에 들어 있습니까?

Is that cans or pouches?

If CIGARS: 일주일에 몇 개 사용하십니까?

How many do you smoke per week?

_______________

 

Don’t know Refused

15. 만일 오늘 금연을 시작하신다면, 담배를 피우지 않고 일주일을 버틸수 있는 자신감이 얼마나 있으신지요? 자신감이 아주 많으세요? 보통 있으세요?전혀 없으세요?

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?

지금과 같이 일주일 동안 금연을 유지할 수있는 자신감이 얼마나 있으세요? 아주 많으세요, 보통 있으세요 아니면 전혀 없으세요?

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. 담배를 끊으려고 하는 분들께 조언을 해 주신다면, 어떤 조언을 주시겠습니까?

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: 모든 질문이 끝났습니다. 시간 내어주셔서 감사 합니다.

Those are all the questions I have for you, thank you for your time.

Comments: ______________________________________________________________________________

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