Form Approved
OMB No. 0920-0856
Exp. Date xx/xx/XXXX
National Quitline Data Warehouse
Intake Questionnaire
(Asian Smoker’s Quitline: Korean)
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)
Asian Smokers’ Quitline (ASQ) Korean Intake
This is a free service to help people quit smoking. We offer help through the mail and also over the phone. To provide the best possible service, calls may be monitored and recorded, but will be kept private. I need to ask you a few questions to see what we can do for you, and all of your responses are voluntary. Is that OK?
저희는 금연을 도와드리는 무료 서비스로서, UC샌디에고 의과 대학에 의해 운영되고 있습니다. 저희는 개개인이 필요로하는 다양한 서비스를 제공하고 있습니다. 저희가 선생님/ 사모님을 좀 더 효과적으로 도와드리기 위해 몆가지 질문을 하겠습니다. 통화하시는 모든 내용은 비밀이 보장되며 원치 않는 질문에는 대답하지 않으셔도 됩니다. 그리고 좀더 나은 서비스를 위해 전화가 모니터, 녹음될 수도 있습니다. 괜찮으십니까? Yes No
1) Are you calling for yourself or someone else?
본인을 위해서 전화하셨습니까? 아니면 다른 분을 위해서 전화하셨습니까?
Yourself Someone else…
2) What’s your year of birth?
생년월일이 어떻게 되십니까?
_______ Refused
IF REFUSED: Then how old are you?
연세는 어떻게 되십니까？_________ Refused Unwilling, but >= 18 yrs. old
3) How did you hear about us? 저희 상담소에 대해서 어떻게 알게 되셨습니까?
Ads: TV Radio Newspaper/ Magazine
Billboard/ Bus Sign
Phone Book Web
Referrals: VA Hospital Clinic/ Doctor’s Office
Dentist/ Dental Hygienist
Friend/ Family
WIC
Pharmacy School Non-profit Org.
Insurance/HMO/MediCal Other
Don’t know
Refused
Promotional Materials
Card (Gold, Salud, Quit Now)
Patch Voucher
Brochure/Pamphlet
Postcard
If any Referral source (e.g. VA through Insurance/HMO/MediCal above):
Did you receive anything, such as a card or brochure with our number on it?
저희 전화번호가 있는 카드나 브로셔를 받았습니까?
No Yes…Postcard Yes…Re-engagement letter
Yes… Card Yes…Magnet Don’t Know
Yes…Patch Voucher Yes…Brochure/ Pamphlet Refused
If PROMOTIONAL MATERIALS:
Where did you get it? 어디에서 받았습니까?
VA Hospital Clinic/ Doctor’s Office
Dentist/ Dental Hygienist Friend/ Family WIC
Pharmacy School Non-profit Org.
Insurance/HMO/MediCal CSH Other
4) Do you smoke cigarettes every day, some days, or not at all (already quit)?
담배를 매일 피우십니까, 가끔 피우십니까, 이미 끊었습니까?
Every day
Some Days
Not at all (already quit)
Other form of tobacco
a. If EVERY DAY: On average, how many cigarettes do you smoke per day?
평균 하루에 몇 개비 피우십니까? _____ Don’t know Refused
Do you usually smoke menthol or non-menthol cigarettes?
멘톨 담배(박하향)를 피우십니까? 아니면 일반담배를 피우십니까?
Menthol Non-menthol No usual type Don’t know Refused Not asked
b. If SOME DAYS: How many days per week do you smoke? ______ Refused
일주일에 며칠이나 담배를 피우십니까?
On average how many cigarettes do you smoke per day on the days you smoke? 담배를 피우는 날에는 평균 하루에 몇 개비 피우십니까?
______ Refused
Do you usually smoke menthol or non-menthol cigarettes?
멘톨 담배(박하향)를 피우십니까? 아니면 일반담배를 피우십니까?
Menthol Non-menthol No usual type Don’t know Refused Not asked
c. If NOT AT ALL: When did you quit? 언제 담배를 끊었습니까?
_______/_______/_______ Don’t know Refused [Not eligible if DK or R]
How many days per week did you smoke?
일주일에 며칠이나 담배를 피우셨습니까? ______ Don’t know Refused
On average how many cigarettes did you smoke per day on the days you smoked? 담배를 피우신 날에는 평균 하루에 몇 개비 피우셨습니까? ______
Don’t know Refused [Not Eligible if DK or R]
Did you usually smoke menthol or non-menthol cigarettes?
멘톨 담배(박하향)를 피우셨습니까? 아니면 일반담배를 피우셨습니까?
Menthol Non-menthol No usual type Don’t know Refused Not asked
5) How soon after you wake up do/did you usually smoke
your first cigarette?
아침에 일어난 후 보통 얼마만에 첫 담배를 피우십니까?
0-5 mins 6-30 mins 31-60 mins +60 mins Don’t know Refused
6a) Do you currently use any other form of tobacco, such as chew/snuff, cigars, or pipes?
씹는담배나, 시가, 파이프와 같은 다른 종류의 타바코 제품도 사용하십니까?
Yes No Don’t know Refused
6b) Do you currently use any other form of tobacco, such as chew/snuff, cigars, or pipes?
씹는담배나, 시가, 파이프와 같은 다른 종류의 타바코 제품도 사용하십니까?
Yes No Don’t know Refused…
6c) Which ones? 어떤 종류의 타바코 제품을 사용하고 계십니까?
Chew/snuff Cigars Pipes Other: ________
If CHEW/SNUFF: How much tobacco do you use per week? _____
씹는답배는 일주일에 얼마나 사용하십니까? _____
Is that cans or pouches?
캔제품입니까? 파우치로 된 제품입니까? Don’t know Refused
If NO to current use (7b): When did you quit? 언제 끊었습니까?_____/_____/______
Refused
If CIGARS: How many do you smoke per week?
시가는 일주일에 몇 번이나 사용하십니까?________
Don’t know Refused
7) Have you ever used an e-cigarette?
전자 담배를 사용해 보신 적이 있으십니까?
Yes…
No…
Don’t know
Refused
Not asked
Do you currently use e-cigarettes every day, some days, or not at all?
전자담배를 매일 사용하십니까, 가끔 사용하십니까, 아니면 전혀 사용하지 않으십니까?
Every day….
Some days….
Not at all…
Don’t know
Refused
Not asked
When was the last time you used an e-cigarette?
언제 마지막으로 사용하셨습니까?
____/____/________.
Don’t know…
Refused…
Not asked
In the last 30 days, how many days did you use an e-cigarette?
지난 30일 동안 전자담배를 사용한 날은 며칠이나 되십니까?
______ days (0-30)
Don’t know
Refused
Not asked
Do you think you will quit using e-cigarettes within 1 year?
전자담배를 앞으로 1년 안에 끊을 생각이십니까?
Yes…
No…
Don’t know…
Refused…
Not asked
Do you think you will quit within a month, within 6 months, or after 6 months?
전자담배를 앞으로 한달안에, 6개월안에 혹은 6개월후에 끊을 생각이십니까?
Within a month
Within 6 months
After 6 months
Don’t know
Refused
Not asked
8) One of two options depending if AQ or not:
a) IF ALREADY QUIT: Are you currently using the nicotine gum, patch, or Zyban or Chantix?
니코틴 껌, 패치, 자이반이나 챈틱스(한국명: 챔픽스) 중 사용하고 있는 제품이 있습니까?
Yes No Don’t know Refused
b) If YES: Which ones?
어떤 종류의 금연 보조약품을 사용하고 계십니까?
Patch Gum Zyban Chantix Other: ________
c) IF NOT ALREADY QUIT: Do you plan to quit smoking within a month?
한달안으로 금연하실 계획이 있습니까? Yes No Don’t know Refused
9) Do you plan to use any quitting aids such as the nicotine gum, patch, or Zyban or Chantix to help you quit this time? 이번에 금연하실 때 니코틴 껌, 패치, 자이반 혹은 챈틱스와 같은 금연 보조약품을 사용할 계획이 있습니까? Yes No Don’t Know Refused
If YES: Which ones? 어떤 종류의 금연 보조약품을 사용할 예정이십니까?
Patch Gum Zyban Chantix Other: ___
10) Do you have any form of health insurance, such as Kaiser or MediCal?
카이저나 정부 보험과 같은 의료보험을 가지고 계십니까?
Yes No Don’t know Refused
IF YES: What is the plan name? 플랜 이름이 무엇입니까? ______
Now I have a few health questions that are related to smoking.
흡연과 연관된 건강에 대해 몇가지 질문을 하겠습니다.
11) Have you ever been told by a doctor that you have HIGH BLOOD PRESSURE?
의사와 검진후, 고혈압 진단을 받으신 적이 있습니까?
Yes No Don’t know Refused
IF YES: Is it under control? 고혈압이 조절되십니까?
Yes, with medication
Yes, w/o medication
No, not controlled
Don’t know
Refused
12) Have you ever been told by a doctor that you have DIABETES
의사와 검진후, 당뇨병 진단을 받으신 적이 있습니까?
Yes No Don’t know Refused
If YES: Do you use insulin or take pills for it?
인슐린을 투여하거나 약을 복용하고 계십니까?
Yes, pills
Yes, insulin
Yes, both pills and insulin
No, neither pills nor insulin
Don’t know
Refused
13) Have you ever had a heart attack?
심근경색이(심장마비가) 일어난적이 있습니까?
Yes No Don’t know Refused
If YES: Was it within the last 6 months? 지난 6개월 안에 겪으셨습니까?
Yes No Don’t know Refused
14) Have you ever had a stroke? 뇌줄중(중풍)이 있습니까?
Yes No Don’t know Refused
If YES: Was it within the last 6 months? 지난 6개월 안에 겪으셨습니까?
Yes No Don’t know Refused
15) We send free materials to everyone, so may I have your zip code? ____________
금연 안내서를 무료로 보내드리겠습니다, 그럼 먼저 zip code 는 어떻게 되십니까？
Refused No phone
16) I have a few demographic questions. First, I need to verify…Are you male or female?
통계상 질문 몇 가지만 드리겠습니다. 선생님/사모님은 남성/여성분이십니까?
Male Female Refused Not asked
If FEMALE and </= 45 yrs. old: We also have special information for pregnant clients, is there any chance you may be pregnant? 임산부를 위한 자료도 준비되어 있습니다. 혹시 임신중이거나 임신했을 가능성이 있습니까?
No Yes Don’t know Refused Not asked
If YES: When is your baby due? 출산 예정일이 언제십니까?____/____/____
DK R Not asked
17a) What is your racial background?
어느 인종이십니까?
White Black/African American
Asian
What is your specific Asian background? (drop down menu)
구체적으로 어느 아시아계입니까?
Native Hawaiian/Other Pacific Islander
American Indian or Alaska Native
More than one of the above
Check ANY/ALL that apply:
White
Asian
What is your specific Asian background? (drop down menu)
Native Hawaiian/Other Pacific Islander
Black/African American
American Indian/Alaska Native (tribe menu)
Other ____________________
17b) What is your ethnic background?
어느 인종이십니까?
Hispanic/Latino Not Hispanic/Latino
18a) In which country were you born?
어느 나라에서 태어나셨습니까?
U.S. Other
Korea Don’t know
Vietnam Refused
China Not asked
18b) What year did you come to U.S?
몇 년도에 미국에 오셨습니까? _________ Don’t know Refused
19) What is the highest level of education that you have completed?
최종 학력은 어떻게 되십니까?
Never attended school 2-yr College degree (AA)
Grades 1-8 4-yr, College or Univ degree (BA, BS)
Grades 9-12 (No Diploma) Post-Graduate degree (Masters, Ph.D)
GED Refused
High School Diploma Don’t know
Some College or Trade School, No Degree Not asked
20) What is the age of the youngest person in your household? ________ D R Z
함께 거주하는 분들중에 연세가 가장 적은 분의 나이는 어뗳게 되십니까?
21) Have you been told you have arrhythmia (an irregular heart beat/rhythm that requires medication)? 부정맥(불규칙적인 심장 박동수/ 약을 필요로 하는 심장 박동수)이 있습니까?
Yes No
22) Have you been told you have angina (serious heart pain/chest pain with exertion)?
협심증(심장 혹은 가슴의 통증)이 있습니까?
Yes No
Don’t know Refused
23) Have you ever had an allergic reaction to adhesive tape?
파스나 반창고와 같은 의료용 테이프로 인한 피부발진이 일어난적이 있습니까?
Yes, severe (problems breathing or hospitalization)
Yes, mild (rash)
No
Don’t know
Refused
24a) What dosage are you on? 몇 mg 니코틴 패치를 사용하고 계십니까?
If patch: 21 mg (Step 1)
14 mg (Step 2)
7 mg (Step 3)
Don’t know
Refused
[Not Eligible if DK or R]
24b) What dosage are you on? 몇 mg 니코틴 껌을 사용하고 계십니까?
If gum: 4 mg
2 mg
Don’t know
Refused
[Not Eligible if DK or R]
If has medical contraindications (any box needing MD OK checked) :
25) We need to get a Doctor’s OK for you to use patches. Is that OK?
패치를 사용해도 괜찮다는 의사의 승인을 받아야 저희가 패치를 보내드릴 수 있습니다.
괜찮겠습니까?
Yes
Doesn’t have an MD
No
If Yes…
What is his/her name? (or clinic/hospital name?)
의사의 이름이 어떻게 되십니까?
Name______________________ _______________ Don’t know Refused
And the phone Number? 전화번호가 어떻게 되십니까?
_______________________ Don’t know (…go to (30a)) Refused
Do you happen to know the fax number? 팩스 번호가 어떻게 되십니까?
_____________________ Don’t know Refused
26a) If Ok to get MD consent, but no MD or Don’t Know
If you call us back with your MD phone or fax number, you may be able to receive patches sent directly to you. Or, in most cases, Medi-Cal will pay for the patches or other quitting aids if you have two things: 의사의 전화번호나 팩스번호를 저희에게 알려 주시면, 저희가 의사의 승인을 받은 후 패치를 보내 드릴 수도 있습니다. 아니면 다음의 두 가지를 약국으로 가져가시면 메디칼에서 대부분의 경우 패치나 다른 금연 보조약품에 대해 지불을 할 것입니다.
A prescription from your doctor 의사의 처방전
A certificate from us.
Take these to your pharmacy.
한인금연센터의 수료증
26b) If Not okay to get MD consent:
Ok, we still want to offer you our free phone counseling. The session is about a half hour and helps you prepare to quit/stay quit. Would you like to speak to a smoking cessation counselor?
저희는 무료 전화 상담을 통해서도 금연을 도와드리고 싶습니다. 상담은 보통 30분 정도 소요되며 금연을 준비하시고 유지하시는데에 도움이 될 것입니다. 금연전문가와 함께 대화를 나눠 보시겠습니까?
Yes (counseling) No (materials)
27) We like to call back a small number of people to see how well our services work over time. Would it be alright to contact you sometime in the next year? (skip this consent question for cx’s that refuse ph# or no phone # is given) 저희가 몇 개월 후에 선생님/사모님께 다시 전화 드려서 보내드린 자료가 도움이 되셨는지 의견을 여쭤봐도 괜찮겠습니까?
Yes No Refused Not asked
You’ll be receiving your materials in the mail in about a week and we’ll let you know when we hear from your doctor. 금연 안내서는 일주일 안으로 받을 것입니다. 그리고 의사와 통화후 연락드리겠습니다.
The next step is to talk with a smoking cessation counselor for about 30 minutes and they’ll help you prepare to quit/stay quit. Do you have time to do the counseling now if a counselor is available?
다음은 금연전문가와 대화하실 차례입니다. 상담은 보통 30분 정도 소요되며 금연을 준비하시고 유지하시는데에 도움이 될 것입니다. 지금 금연 전문가와 대화 나눌 시간이 괜찮겠습니까?
Yes Let me see if one is available…. Available
No Not available
Refused Counseling
If no medical contraindications:
28) We like to call back a small number of people to see how well our services work over time. Would it be alright to contact you sometime in the next year? 저희가 몇 개월 후에 선생님/사모님께 다시 전화 드려서 보내드린 자료가 도움이 되셨는지 의견을 여쭤봐도 괜찮겠습니까?
Yes No Refused Not asked
You’ll be receiving your materials and patches in the mail in about a week, and by the way, they will come separately. 니코틴 패치와 금연 안내서는 두개의 패키지로 나뉘어서 일주일 안으로 받을 것입니다.
The next step is to speak with a smoking cessation counselor for about 30 minutes and they’ll help you prepare to quit/stay quit. Do you have time to do the counseling now if a counselor is available?
다음은 금연전문가와 대화하실 차례입니다. 상담은 보통 30분 정도 소요되며 금연을 준비하시고 유지하시는데에 도움을 드리고 있습니다. 지금 금연 전문가와 대화 나눌 시간이 괜찮겠습니까?
Yes Let me see if one is available…. Available
No Not available
Refused Counseling …
If not eligible for NRT (e.g., no phone, address, no voucher #, etc):
29a.We like to call back a small number of people to see how well our services work over time. Would it be alright to contact you sometime in the next year? 저희가 몇 개월 후에 선생님/사모님께 다시 전화 드려서 보내드린 자료가 도움이 되셨는지 의견을 여쭤봐도 괜찮겠습니까?
Yes No Refused Not asked
29b.You’ll be receiving your materials in the mail in about a week. Do you have time to do the counseling now if a counselor is available? 금연 안내서는 일주일 안으로 받을 것입니다. 지금 금연 전문가와 대화 나눌 시간이 괜찮겠습니까?
Yes No Not asked
a. No (materials only)
We like to call back a small number of people to see how well our services work over time. Would it be alright to contact you sometime in the next year? (skip this consent question for cx’s that refuse ph# or no phone # is given) 저희가 몇 개월 후에 선생님/사모님께 다시 전화 드려서 보내드린 자료가 도움이 되셨는지 의견을 여쭤봐도 괜찮겠습니까?
Yes No Refused Not asked
b. You’ll be receiving your materials in the mail in about a week. If you would like to receive counseling in the future, you can always call us back. 금연 안내서는 일주일 안으로 받을 것입니다. 추후에 상담을 받고 싶으시면 언제든지 저희에게 다시 전화주십시오.
30) We offer help over the phone. The session is about a half hour and helps you prepare to quit/stay quit. Would you like to speak to a smoking cessation counselor? 저희는 전화를 통해서도 금연을 도와드리고 있습니다. . 상담은 보통 30분 정도 소요되며 금연을 준비하시고 유지하시는데에 도움이 될 것입니다. 지금 금연 전문가와 대화를 나눠보시겠습니까?
Yes (counseling) No (materials)
Yes (counseling)
a.We like to call back a small number of people to see how well our services work over time. Would it be alright to contact you sometime in the next year? 저희가 몇 개월 후에 선생님/사모님께 다시 전화 드려서 보내드린 자료가 도움이 되셨는지 의견을 여쭤봐도 괜찮겠습니까?
Yes No Refused Not asked
b.You’ll be receiving your materials in the mail in about a week. Do you have time to do the counseling now if a counselor is available? 금연 안내서는 일주일 안으로 받을 것입니다. 지금 금연 전문가와 대화 나눌 시간이 괜찮겠습니까?
Yes No Not asked
No (materials only)
c. We like to call back a small number of people to see how well our services work over time. Would it be alright to contact you sometime in the next year? 저희가 몇 개월 후에 선생님/사모님께 다시 전화 드려서 보내드린 자료가 도움이 되셨는지 의견을 여쭤봐도 괜찮겠습니까?
Yes No Refused Not asked
d. You’ll be receiving your materials in the mail in about a week. If you would like to receive counseling in the future, you can always call us back. 금연 안내서는 일주일 안으로 받을 것입니다. 추후에 상담을 받고 싶으시면 언제든지 저희에게 다시 전화주십시오.
Updated 07/13/2012 Page
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | California Smoker’s Helpline |
| Author | anne |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |