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?
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
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
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
END INTERVIEW IF RESPONDENT IS NOT CALLING FOR THEMSELVES FOR HELP WITH QUITTING (SEE RESPONSE TO QUESTION 1).
Introduction for questions series Q4 – Q36: Before asking question series Q4through Q36, Intake specialists should introduce the series of questions “Next I am going to ask you a series of questions about your use of tobacco. This information helps us better understand your needs in working towards quitting tobacco. When I ask about tobacco, I am not talking about tobacco related to sacred or tradition uses that are part of some American Indian/Alaskan Native tribal traditions.”
ASSESSMENT FOR TYPES OF TOBACCO USE
What types of tobacco have you used in the past 30 days? If you use more than one type of product, please indicate all products used in the past 30 days. Cigarettes? (RECORD RESPONSE) Electronic cigarettes (e-cigarettes) or other electronic vaping products, including e-hookahs, e-cigars, e-pipes, hookah pens, vape pens (e.g., JUUL, SMOK, Suorin, Vuse, blu)? We are only asking about products used to vape nicotine, not other substances like marijuana. (RECORD RESPONSE) Cigars, cigarillos, or little cigars that look like cigarettes, (e.g., Swisher Sweets, Black and Mild, Cheyenne, White Owl, Dutch Masters)? (RECORD RESPONSE) A pipe filled with tobacco? (RECORD RESPONSE) Smokeless tobacco, including chewing tobacco, snuff, dip, snus, or dissolvable tobacco (e.g., Copenhagen, Grizzly, Skoal, Longhorn)? (RECORD RESPONSE) Any other type of tobacco, such as heated tobacco products, also known as heated cigarettes or “heat-not-burn” tobacco products (e.g., IQOS, Glo, Eclipse), nicotine pouches (e.g., Zyn, on!, Velo), dissolvable nicotine lozenges (e.g., Velo, Revel), Bidis, Kreteks, tobacco orbs, tobacco strips, or waterpipe/hookahs? (RECORD RESPONSE)
CIGARETTES
YES
NO
DON’T KNOW
REFUSED
E-CIGARETTES OR OTHER ELECTRONIC “VAPING” PRODUCTS
YES
NO
DON’T KNOW
REFUSED
CIGARS, CIGARILLOS, OR LITTLE CIGARS
YES
NO
DON’T KNOW
REFUSED
PIPE FILLED WITH TOBACCO [NOTE: THIS IS A TRADITIONAL PIPE, NOT A WATER PIPE OR “HOOKAH”]
YES
NO
DON’T KNOW
REFUSED
SMOKELESS TOBACCO, INCLUDING CHEWING TOBACCO, SNUFF, DIP, SNUS, OR DISSOLVABLE TOBACCO
YES
NO
DON’T KNOW
REFUSED
OTHER TOBACCO PRODUCTS, SUCH AS SUCH AS HEATED TOBACCO PRODUCTS, NICOTINE POUCHES, BIDIS, KRETEKS, TOBACCO ORBS, TOBACCO STRIPS, OR WATERPIPE/HOOKAHS
YES
NO
DON’T KNOW
REFUSED
NONE (NOTE: NO TO ALL ABOVE EQUALS NONE)
READ Q5 IF PARTICIPANT RESPONDED “YES” TO CIGARETTES ABOVE.
Do you currently smoke CIGARETTES every day, some days, or not at all?
(CHECK ONE)
EVERYDAY (SKIP TO Q6)
SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 CIGARETTE PER DAY)
NOT AT ALL (SKIP TO Q9)
DON’T KNOW
How many days did you smoke cigarettes 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
READ Q8 IF PARTICIPANT RESPONDED “EVERYDAY” OR “SOME DAYS” TO Q5.
Currently, when you smoke cigarettes, do you usually smoke menthol cigarettes?
YES
NO
DON’T KNOW / NOT SURE
REFUSED
EVERYDAY CIGARETTE SMOKERS SKIP TO Q9-32 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 Q10 IF PARTICIPANT RESPONDED “YES” TO E-CIGARETTES OR OTHER ELECTRONIC “VAPING” PRODUCTS
Do you currently use E-CIGARETTES OR OTHER ELECTRONIC “VAPING” PRODUCTS every day, some days, or not at all?
(CHECK ONE)
EVERYDAY (SKIP TO Q11)
SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 E-CIGARETTE OR OTHER ELECTRONIC “VAPING” PRODUCTCIGAR PER DAY)
NOT AT ALL (SKIP TO Q14)
DON’T KNOW
REFUSED
How many days did you use a E-CIGARETTES OR OTHER ELECTRONIC “VAPING” PRODUCTS in the last 30 days?
____Days
DON’T KNOW
REFUSED
How many times per day do you use E-CIGARETTES OR OTHER ELECTRONIC “VAPING” PRODUCTS on the days that you use?
(e-cigarettes or other electronic “vaping” products per day)_______
DON’T KNOW
REFUSED
READ Q13 IF PARTICIPANT RESPONDED “EVERYDAY” OR “SOME DAYS” TO Q10.
Currently, when you use e-cigarettes, do you usually use menthol e-cigarettes?
YES
NO
DON’T KNOW / NOT SURE
REFUSED
EVERY DAY E-CIGARETTES OR OTHER ELECTRONIC “VAPING”
PRODUCTS USERS SKIP TO Q14-32
AS INDICATED BY THE TYPE OF TOBACCO USE QUESTION ABOVE.
When was the last time you used a E-CIGARETTES OR OTHER
ELECTRONIC “VAPING” PRODUCTS, even a puff?
__________ (dd/mm/yyyy)
NEVER
DON’T KNOW
REFUSED
People use e-cigarettes/e-vaping products for a variety of reasons, are you currently using e-cigarettes/e-vaping products to quit smoking?
YES
NO
DON’T KNOW
REFUSED
READ Q16 IF PARTICIPANT 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 Q17)
SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 CIGAR PER DAY)
NOT AT ALL (SKIP TO Q19)
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 Q19-32 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 Q20 IF PARTICIPANT RESPONDED “YES” TO A PIPE ABOVE.
Do you currently smoke PIPES every day, some days, or not at all? (CHECK ONE)
EVERYDAY (SKIP TO Q21)
SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 PIPE PER DAY)
NOT AT ALL (SKIP TO Q23)
DON’T KNOW
REFUSED
How many days did you smoke a pipe in the last 30 days?
___ Days
DON’T KNOW
REFUSED
How many times per week do you smoke a pipe during the weeks that you smoke?
(pipes per week) ________
DON’T KNOW
REFUSED
EVERY DAY PIPE SMOKERS SKIP TO Q24-32 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 Q24 IF PARTICIPANT RESPONDED “YES” TO SMOKELESS TOBACCO, INCLUDING CHEWING TOBACCO, SNUFF, DIP, SNUS, OR DISSOLVABLE TOBACCO ABOVE.
Do you currently use SMOKELESS TOBACCO, INCLUDING CHEWING TOBACCO, SNUFF, DIP, SNUS, OR DISSOLVABLE TOBACCO every day, some days, or not at all?
(CHECK ONE)
EVERYDAY (SKIP TO Q25)
SOME DAYS (IF LESS THAN 7 DAYS PER WEEK OR LESS THAN 1 POUCH OR PINCH PER DAY)
NOT AT ALL (SKIP TO Q27)
DON’T KNOW
REFUSED
How many days did you use chewing tobacco, snuff, dip, snus, or dissolvable tobacco 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, snuff, snus, or dissolvable tobacco?
(pouches/tins per week)_____
DON’T KNOW
REFUSED
EVERYDAY SMOKELESS TOBACCO USERS SKIP TO Q27-32
AS INDICATED BY THE TYPE OF TOBACCO USE QUESTION ABOVE.
When was the last time you used chewing tobacco, snuff, dip, snus, or dissolvable tobacco, even a pinch?
___________ (dd/mm/yyyy)
NEVER
DON’T KNOW
REFUSED
READ Q28 IF PARTICIPANT 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 Q29)
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 Q31)
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 Q38
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 4.
Do you plan to quit using cigarettes within the next 30 days?
YES
NO
DON’T KNOW
REFUSED
ASK ONLY IF PARTICIPANT REPLIED THEY HAVE USED E-CIGARETTES OR OTHER ELECTRONIC “VAPING” PRODUCTS IN THE PAST 30 DAYS IN QUESTION 4.
Do you plan to quit using e-cigarettes/e-vaping products 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 4.
Do you plan 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 4.
Do you plan to quit using a pipe within the next 30 days?
YES
NO
DON’T KNOW
REFUSED
ASK ONLY IF PARTICIPANT REPLIED THEY HAVE USED SMOKELESS TOBACCO, INCLUDING CHEWING TOBACCO, SNUFF, DIP, SNUS, OR DISSOLVABLE TOBACCO IN THE PAST 30 DAYS IN QUESTION 4.
Do you plan to quit using chewing tobacco, snuff, dip, snus, or dissolvable tobacco 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 4.
Do you plan to quit using [NAME OF OTHER TOBACCO PRODUCT] within the next 30 days?
YES
NO
DON’T KNOW
REFUSED
PARTICIPANT CHARACTERISTICS
Which of the following best represents how you think of yourself?
GAY (LESBIAN OR GAY)
STRAIGHT, THIS IS NOT GAY (OR LESBIAN OR GAY)
BISEXUAL
SOMETHING ELSE
I DON’T KNOW THE ANSWER
What is your gender? Please select all that apply
MALE
FEMALE
TRANSGENDER
ANOTHER GENDER (PLEASE SPECIFY) _____________
What sex were you assigned at birth, on your original birth certificate?
MALE
FEMALE
SOMETHING ELSE (PLEASE SPECIFY) _____________
PREFER NOT TO SAY
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
What type of health insurance do you have?
PRIVATE INSURANCE (E.G., EMPLOYER-BASED OR SELF-PAY)
MEDICAID
MEDICARE
MILITARY OR TRI-CARE INSURANCE
OTHER
CURRENTLY DO NOT HAVE HEALTH INSURANCE
DON’T KNOW
REFUSED
Are you of Hispanic or Latino origin?
YES (of Hispanic or Latino origin)
NO (Not 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)
AMERICAN INDIAN OR ALASKA NATIVE
ASIAN
BLACK OR AFRICAN AMERICAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
WHITE
**OTHER RACE (SPECIFY _____________)
DON’T KNOW
REFUSED
We have some additional materials for pregnant women. Are you currently pregnant?
YES
NO
DON’T KNOW
REFUSED
Do you have any behavioral health conditions, such as an anxiety disorder, bipolar disorder, depression, posttraumatic stress disorder (PTSD), schizophrenia, and/ or a substance use disorder (other than tobacco use disorder)?
Have you ever served on active duty in the U.S. Armed Forces, Reserves or National Guard?
NEVER SERVED IN THE MILITARY
ONLY ON ACTIVE DUTY FOR TRAINING IN THE RESERVES OR NATIONAL GUARD
NOW ON ACTIVE DUTY
ON ACTIVE DUTY IN THE PAST, BUT NOT NOW (i.e., VETERAN)
DON’T KNOW
REFUSED
CONSENT TO FOLLOW-UP
Do you agree to participate in a follow-up call to assess your experience 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
Participant 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 counseling (one counseling session provided during first contact)
Proactive counseling requested (more than one counseling session) (first counseling 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
Email or On-line referral
EHR referral/ e-Referral
Text message
Live chat
Other referral modes (specify__________)
Services RECEIVED by the participant (should be updated after every contact to provide cumulative services received by participant)
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 participant
Materials (materials were mailed to the participant)
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 | 2022-07-26 |