Form Approved
OMB No. 0920-0856
Exp. Date xx/xx/XXXX
National Quitline Data Warehouse
Intake Questionnaire
Public reporting burden of this collection of information is estimated to range from 1-10 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)
This is a free service to help people quit using tobacco. We offer help through the mail and over the phone. To provide the best possible service, calls may be monitored and recorded, but will be kept secure. I need to ask you a few questions to see how we can assist you. All of your responses are voluntary. Is that OK?
IS RESPONDENT CONTINUING WITH THE INTERVIEW?
YES
NO – ASSIGN DISPOSITION CODE
How can I help you?
WANT HELP / INFORMATION ABOUT QUITTING
WANT HELP / INFORMATION ABOUT STAYING QUIT
WANT TO REFER SOMEONE FOR HELP
WANT GENERAL INFORMATION OR MATERIALS ABOUT QUITLINE SERVICE
OTHER: ___________________________________________
DON’T KNOW
REFUSED
Just to confirm, are you calling for yourself, or calling on behalf of or to help someone else?
Calling for yourself for help with quitting
Calling for yourself but not for help with quitting
Calling on behalf of or to help someone else
DON’T KNOW
REFUSED
How did you hear about the quitline? (CHECK ALL RESPONSES)
MEDIA
NEWSPAPER
RADIO
TELEVISION
INTERNET/WEB
OTHER: _________________________
OTHER ADVERTISING
PHONE DIRECTORY
FLYERS, BROCHURES
OTHER: _________________________
REFERRAL
HEALTH PROFESSIONAL (DOCTOR, DENTIST, ETC.)
FAMILY / FRIENDS
WORKPLACE
HEALTH INSURANCE
COMMUNITY ORGANIZATION
OTHER: _________________________
DON’T KNOW
REFUSED
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?
YES
NO
UNSURE
END INTERVIEW IF RESPONDENT IS NOT CALLING FOR THEMSELVES FOR HELP WITH QUITTING (SEE RESPONSE TO QUESTION 2).
Is this your first call to the quitline in the past 12 months?
YES
NO
DON’T KNOW
REFUSED
ASSESSMENT FOR TYPES OF TOBACCO USE
What types of tobacco have you used in the past 30 days? Cigarettes? (RECORD RESPONSE) Cigars, cigarillos, or little cigars? (RECORD RESPONSE) A pipe? (RECORD RESPONSE) Chewing tobacco, snuff, or dip? (RECORD RESPONSE) Any other type of tobacco? (RECORD RESPONSE)
CIGARETTES
YES
NO
DON’T KNOW
REFUSED
CIGARS, CIGARILLOS, OR LITTLE CIGARS
YES
NO
DON’T KNOW
REFUSED
PIPE [NOTE: THIS IS A TRADITIONAL PIPE, NOT A WATER PIPE OR “HOOKAH”]
YES
NO
DON’T KNOW
REFUSED
CHEWING TOBACCO, SNUFF, OR DIP
YES
NO
DON’T KNOW
REFUSED
OTHER
YES
NO
DON’T KNOW
REFUSED
NONE (NOTE: NO TO ALL ABOVE EQUALS NONE)
READ 7 IF CALLER RESPONDED “YES” TO CIGARETTES ABOVE.
Do you currently smoke CIGARETTES every day, some days, or not at all?
(CHECK ONE)
EVERYDAY (SKIP TO Q8)
SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 CIGARETTE PER DAY)
NOT AT ALL (SKIP TO Q10)
DON’T KNOW
REFUSED
How many days did you smoke in the last 30 days?
_____Days
DON’T KNOW
REFUSED
How many cigarettes do you smoke per day on the days that you smoke?
(cigarettes per day)___
DON’T KNOW
REFUSED
EVERYDAY CIGARETTE SMOKERS SKIP TO Q10-26 AS
INDICATED BY THE TYPE OF TOBACCO USE QUESTION ABOVE.
When was the last time you smoked a cigarette, even a puff?
______(dd/mm/yyyy)
NEVER
DON’T KNOW
REFUSED
READ 11 IF CALLER RESPONDED “YES” TO CIGARS, CIGARILLOS, OR LITTLE CIGARS ABOVE.
Do you currently smoke CIGARS, CIGARILLOS, OR LITTLE CIGARS every day, some days, or not at all?
(CHECK ONE)
EVERYDAY (SKIP TO Q12)
SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 CIGAR PER DAY)
NOT AT ALL (SKIP TO Q14)
DON’T KNOW
REFUSED
How many days did you smoke a CIGAR, CIGARILLO, OR LITTLE CIGAR in the last 30 days?
____Days
DON’T KNOW
REFUSED
How many CIGARS, CIGARILLOS, OR LITTLE CIGARS do you smoke per week during the weeks that you smoke?
(cigars, cigarillos, or little cigars per week)_______
DON’T KNOW
REFUSED
EVERY DAY CIGAR, CIGARILLOS, OR LITTLE CIGARS SMOKERS
SKIP TO Q14-26 AS INDICATED BY THE TYPE OF TOBACCO USE
QUESTION ABOVE.
When was the last time you smoked a CIGAR, CIGARILLO, OR LITTLE
CIGAR, even a puff?
__________ (dd/mm/yyyy)
NEVER
DON’T KNOW
REFUSED
READ 15 IF CALLER RESPONDED “YES” TO A PIPE ABOVE.
Do you currently smoke PIPES every day, some days, or not at all? (CHECK ONE)
EVERYDAY (SKIP TO Q16)
SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 PIPE PER DAY)
NOT AT ALL (SKIP TO Q18)
DON’T KNOW
REFUSED
How many days did you smoke a pipe in the last 30 days?
___ Days
DON’T KNOW
REFUSED
How many pipes do you smoke per week during the weeks that you smoke?
(pipes per week) ________
DON’T KNOW
REFUSED
EVERY DAY PIPE SMOKERS SKIP TO Q18-26 AS
INDICATED BY THE TYPE OF TOBACCO USE QUESTION ABOVE.
When was the last time you smoked a pipe, even a puff?
________ (dd/mm/yyyy)
NEVER
DON’T KNOW
REFUSED
READ 19 IF CALLER RESPONDED “YES” TO CHEWING TOBACCO, SNUFF, OR DIP ABOVE.
Do you currently use CHEWING TOBACCO, SNUFF, OR DIP every day, some days, or not at all?
(CHECK ONE)
EVERYDAY (SKIP TO Q20)
SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 POUCH OR PINCH PER DAY)
NOT AT ALL (SKIP TO Q22)
DON’T KNOW
REFUSED
How many days did you use chewing tobacco, snuff or dip in the last 30 days?
_______(days)
DON’T KNOW
REFUSED
How many POUCHES OR TINS do you use per week during the weeks that you use chewing tobacco or snuff?
(pouches/tins per week)_____
DON’T KNOW
REFUSED
EVERYDAY CHEW/SNUFF USERS SKIP TO Q22-26 AS
INDICATED BY THE TYPE OF TOBACCO USE QUESTION ABOVE.
When was the last time you used chewing tobacco, snuff or dip, even a pinch?
___________ (dd/mm/yyyy)
NEVER
DON’T KNOW
REFUSED
READ 23 IF CALLER RESPONDED “YES” TO OTHER CIGARETTES ABOVE.
Do you currently use OTHER TYPES OF TOBACCO every day, some days, or not at all?
(CHECK ONE)
EVERYDAY (SKIP TO 24)
SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 UNIT OF OTHER TYPE OF TOBACCO PER DAY)
NOT AT ALL (SKIP TO Q25)
DON’T KNOW
REFUSED
How many days did you use other types of tobacco in the last 30 days?
_______(days)
DON’T KNOW
REFUSED
How much [how many] [OTHER TOBACCO NAME] do you use per week during the weeks that you use other tobacco?
(other tobacco per week) ____
DON’T KNOW
REFUSED
EVERYDAY OTHER TOBACCO PRODUCT USERS SKIP TO Q29
When was the last time you used other types of tobacco, even a puff or pinch?
___________ (dd/mm/yyyy)
NEVER
DON’T KNOW
REFUSED
ASK OF CIGARETTE SMOKERS ONLY:
How soon after you wake up do you smoke your first cigarette?
WITHIN FIVE MINUTES
6 TO 30 MINUTES
31 TO 60 MINUTES
MORE THAN 60 MINUTES
DON’T KNOW
REFUSED
ASK ONLY IF PARTICIPANT REPLIED THEY HAVE USED CIGARETTES IN THE PAST 30 DAYS IN QUESTION 6.
Do you intend to quit using cigarettes within the next 30 days?
YES
NO
DON’T KNOW
REFUSED
ASK ONLY IF PARTICIPANT REPLIED THEY HAVE USED CIGARS, CIGARILLOS, OR LITTLE CIGARS IN THE PAST 30 DAYS IN QUESTION 6.
Do you intend to quit using cigars, cigarillos, or little cigars within the next 30 days?
YES
NO
DON’T KNOW
REFUSED
ASK ONLY IF PARTICIPANT REPLIED THEY HAVE USED A PIPE IN THE PAST 30 DAYS IN QUESTION 6.
Do you intend to quit using a pipe within the next 30 days?
YES
NO
DON’T KNOW
REFUSED
ASK ONLY IF PARTICIPANT REPLIED THEY HAVE USED CHEWING TOBACCO, SNUFF, OR DIP IN THE PAST 30 DAYS IN QUESTION 6.
Do you intend to quit using chewing tobacco, snuff, or dip within the next 30 days?
YES
NO
DON’T KNOW
REFUSED
ASK ONLY IF PARTICIPANT REPLIED THEY HAVE USED OTHER TOBACCO PRODUCTS IN THE PAST 30 DAYS IN QUESTION 6.
Do you intend to quit using [NAME OF OTHER TOBACCO PRODUCT] within the next 30 days?
YES
NO
DON’T KNOW
REFUSED
CALLER CHARACTERISTICS
I need to verify: are you male or female?
Male
Female
REFUSED
What year were you born? _ _ _ _
DON’T KNOW
REFUSED
What is your zip code? _ _ _ _ _
DON’T KNOW
REFUSED
What is the highest level of education you have completed?
LESS THAN GRADE 9
GRADE 9 TO 11, NO DEGREE
GED
HIGH SCHOOL DEGREE
SOME COLLEGE OR UNIVERSITY(includes some technical or trade school)
COLLEGE OR UNIVERSITY DEGREE (includes AA, BA, Masters, Ph.D.)
DON’T KNOW
REFUSED
Do you have any health insurance, including pre-paid (such as XXX – provide examples for your state) or government programs (such as Medicaid or Medicare)?
_ Yes (Continue to Q38)
_ No (SKIP TO Q39)
_ Don’t know
_ Refused
_ Not asked
What type of health insurance do you have?
Private Insurance
Medicaid
Medicare
Military insurance
Don’t know
Refused
Not Asked
Are you of Hispanic or Latino origin?
NO (Not of Hispanic or Latino origin)
YES(of Hispanic or Latino origin)
DON’T KNOW
REFUSED
What is your race? Which one or more of the following groups best describes you? (SELECT ONE OR MORE)
White
Black or African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
**OTHER RACE (SPECIFY _____________)
DON’T KNOW
REFUSED
We have some additional materials for pregnant women. Are you currently pregnant?
YES
NO
REFUSED
Do you have any mental health conditions, such as an anxiety disorder, depression disorder, bipolar disorder, alcohol/drug abuse, or schizophrenia?
YES
NO
REFUSED
CONSENT TO FOLLOW-UP
Do you agree to participate in a follow-up call to assess whether you are satisfied with the service? Please note that your participation in the follow-up survey is completely voluntary and whether you agree to participate or not will not affect the services you receive through the quitline.
YES
NO
INTAKE ADMINISTRATIVE DATA
Caller ID
Date questionnaire administered (dd/mm/yyyy): _ _/_ _/_ _ ___
Result of first contact: (Check all that apply):
Basic information provided (no materials sent)
Literature and/or self-help materials sent
Reactive counselling (one counselling session provided during first contact)
Proactive counselling requested (more than one counselling session) (first counselling session may or may not have taken place during first contact)
Medications sent (FDA approved)
Referral to another service (for tobacco cessation or other services, including web-based services, community clinics, etc.)
Other
Mode of entry to the quitline
Direct call to the number
Fax referral
Internet
Email solicitation/click-through
Other (specify__________)
Services RECEIVED by the caller (should be updated after every contact to provide cumulative services received by caller)
Counseling using an interpreter service
Counseling, in-language (please specify the language________________)
Counseling (any amount, should not include time spent asking intake questions or on content that is not directly related to counseling)
Web-based services (registered/logged in at least once to a cessation-focused website)
Medications (medications were shipped to the caller)
Materials (materials were mailed to the caller)
Other (as relevant to each quitline)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | NAQC MDS Intake Question 1: |
| Author | jsaul |
| File Modified | 0000-00-00 |
| File Created | 2021-01-16 |