NQDW Intake Questionnaire

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. 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?

1. How can I help you?

• SEEKING HELP / INFORMATION ABOUT QUITTING FOR SELF

• SEEKING HELP / INFORMATION FOR SELF ABOUT STAYING QUIT

• SEEKING HELP ON HOW TO REFER SOMEONE ELSE FOR ASSISTANCE WITH QUITTING

• SEEKING GENERAL INFORMATION OR MATERIALS ABOUT QUITLINE SERVICE

• OTHER: ___________________________________________

• DON’T KNOW

• REFUSED

2. How did you hear about the quitline? (CHECK ALL RESPONSES)

• HEALTH CARE PROVIDER/ HEALTH PROFESSIONAL (DOCTOR, DENTIST, ETC.)

• FAMILY / FRIENDS

• TELEVISION

• RADIO

• NEWSPAPER

• INTERNET/WEB/SOCIAL MEDIA

• OTHER: _________________________

• DON’T KNOW

• REFUSED

3. Did you hear about 1-800-QUIT-NOW from any Tips From Former Smokers® advertisements, which feature people telling personal stories about living with health problems that were caused by smoking?

• YES

• NO

• UNSURE