NQDW Intake Questionnaire Subset

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

1. 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

2. 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

3. 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

4. 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