1 Partner Survey

OMB Number: 0925-XXXX

Expiration Date: __________

attachment 2d

State Quitline Partner Data Collection Instrument

Contact Information

Partner organization:	______________________________________________________
Respondent name:	______________________________________________________
Phone number:	______________________________________________________
Email:	______________________________________________________
Interview result:	______________________________________________________
Quitline State:	______________________________________________________
Official Name of State Quitline:	______________________________________________________

Name of referring

Individual: _____________________________________________________________

Date of interview:	________________________________________________________
Interviewer:	________________________________________________________

Public reporting burden for this collection of information is estimated to average 30 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*). Do not return the completed form to this address.

OMB Number: #########

Expires: mm/dd/yyyy

Intro Script

Hello, my name is ______________________. I am a researcher from Westat, a national health research organization.

The National Cancer Institute and the Centers for Disease Control and Prevention have contracted with Westat to conduct an evaluation of the National Network of Tobacco Cessation Quitlines Initiative. As part of this Initiative, the Federal government established a national toll-free tobacco quitline number in November, 2004. This number, 1-800-QUIT-NOW, can be dialed from anywhere in the U.S., and the caller is automatically routed the quitline operated by the state where he or she is calling from. The Federal government also provided extra funds to each state to support their capability to provide quitline services, as well as furnishing additional training and technical assistance around quitline operations. For convenience, I will refer to this as the Initiative.

From the outset, one of the key objectives of the Initiative has been to foster partnerships between the state quitlines and public and private entities who share a common interest with them or with whom they can achieve mutual benefits. Since the partners are integral to Initiative, it is critical to reflect their views and experiences in the evaluation of the Initiative. {Name of state referring source} suggested that we speak with you, as a key partner of the {state} quitline. I would like to interview you about your activities in conjunction with the {state} quitline and the initial effect of the Initiative. I would ask for about 30 minutes of your time.

I would like to obtain your views on a number of questions and topics related to the Initiative. Our interview should last about 30 minutes. Is this a convenient time for you? [IF NO: please tell me when you would like me to call back.]

Thank you for agreeing to be interviewed about the Initiative. If you agree, I’d like to record our conversation so that I can pay close attention to what you are telling me without having to stop and write extensive notes. The recording will only be used to review our discussion for a more detailed analysis. Do you agree to have this interview recorded?

[Check here if respondent agrees to recording: ________ ]

Your participation in this interview is voluntary and there are no penalties if you decide not to respond to the information collection as a whole or any particular question.

You can refuse to answer any question and “I don’t know” is an acceptable response. The information you provide will be kept confidential and will not be disclosed in identifiable form to anyone. Responses to this interview will be reported in summary form only or will be presented in a way that their source cannot be identified. Do you have any questions before we begin?

In this interview I will be asking you to provide your opinion about some items or events as well as some factual pieces of information. In some instances I will ask you to think about the Initiative as a whole, which includes the process of applying for and receiving funds, the launch of the national 1-800-QUIT-NOW number, and other activities your state has engaged in with the various federal agencies involved with the Initiative. At other times, I will ask you to specifically think about the time since the launch of 1-800-QUIT-NOW number.

Organizational Profile

1.	First, I’d lime to get an idea of the main focus or function of your organization. Please briefly describe your organization’s principal purpose and activities.

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

2.	[CIRCLE THE CORRECT CATEGORY IF KNOWN OR STATED IN THE ANSWER TO QUESTION 1; OTHERWISE, OFFER THE LIKELY CHOICES AND CIRCLE THE ANSWER CATEGORY BELOW.] Which of the following best describes your organization? Is your organization…

Public health agency or clinic?	01
Other health care delivery organization or system, such as a hospital or HMO?	02
Health insurer?	03
Public or non-profit social service agency	04
Volunteer service organization?	05
Special interest or advocacy organization?	06
Volunteer health organization, such as the American Lung Association?	07
Anti-tobacco coalition or advocacy group?	08
Other community-based coalition?	09
School, church, or related organization?	10
Pharmaceutical company?	11
Public or private employer?	12
Labor union or workers group?	13
Media, advertising, or PR organization?	14
Community or business leadership organization?	15
REF	97
DK	98

3.	[CIRCLE THE CORRECT CATEGORY IF KNOWN OR STATED IN THE ANSWER TO QUESTION 1; OTHERWISE, OFFER THE LIKELY CHOICES AND CIRCLE THE ANSWER CATEGORY BELOW.] Which one of the following best describes your organization’s structure? Are you…

A public agency,	1
A not-for-profit organization,	2
A private, for-profit company,	3
A coalition or association, or	4
Something else? SPECIFY: ________________________________________	5

Awareness of Initiative

4.	I would like to get a sense of how familiar are you with the Initiative right now. Using a scale of 1 to 5, where 1 is not at all familiar and 5 is very familiar, how would you rate your familiarity?

1	2	3	4	5
NOT AT ALL FAMILIAR				VERY FAMILIAR

5.	Please think back to when the 1-800-QUIT-NOW number was launched, in November, 2004. Using the same scale, how would you rate your familiarity at that time?

1	2	3	4	5
NOT AT ALL FAMILIAR				VERY FAMILIAR

Partnership

6.	Now I would like to discuss your partnership with the state of {STATE QUITLINE NAME}. When did your relationship with {STATE QUITLINE NAME} begin?

MONTH	YEAR

7.	Would you briefly describe how this relationship came about?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

[ASK QUESTION 8 IF PARTNERSHIP BEGAN BEFORE 2004 (QUESTION 6); OTHERIWISE, SKIP TO QUESTION 10.]

8.	In your opinion, was the Initiative a factor in the initial formation of this relationship between your organization and the quitline?

YES	1
NO	2
REF	7
DK	8

9.	In what way did the Quitline Network Initiative help form this relationship?

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

[SKIP TO QUESTION 12]

10.	[ASKED ONLY IF RELATIONSHIP BEGAN BEFORE 2004 (QUESTION 6)] Did the Initiative have any kind of affect on your relationship with the quitline, in terms of the nature of the relationship, specific activities, funding, and so forth?

YES	1
NO	2
REF	7
DK	8

11.	Please briefly describe how the Initiative affected this relationship.

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

12.	Do you have a formal relationship with the {STATE QUITLINE NAME}, that is, is there a written agreement, memorandum of understanding, or other written documentation of your respective roles and responsibilities?

YES	1
NO	2
REF	7
DK	8

Partnership Activities

[IF PARTNERSHIP BEGAN BEFORE NOVEMBER 2004 ASK QUESTION 13; ELSE SKIP TO QUESTION 16]

13.	In general, how would you describe your relationship to the {STATE QUITLINE NAME} before the launch of the 1-800-QUIT-NOW number in November 2004? That is, what functions or activities did you participate in with the quitline prior to November, 2004?

					IF 13a IS YES, ASK 13b
RECORD FUNCTIONS/ACTIVITIES BEFORE INITIATIVE	13a. Did you continue this activity during 2005?				13b. In 2005, did the extent of this activity increase, decrease or stay about the same as before 2005?					13c. In your opinion, how much of an influence did the Initiative have on {increasing/ decreasing/sustaining} this level of activity? Would you say…
	YES	NO	REF	DK	INC	DEC	SAME	REF	DK	A lot,	Some, or	None?	REF	DK
	1	2	7	8	1	2	3	7	8	1	2	3	7	8
	1	2	7	8	1	2	3	7	8	1	2	3	7	8
	1	2	7	8	1	2	3	7	8	1	2	3	7	8
	1	2	7	8	1	2	3	7	8	1	2	3	7	8
	1	2	7	8	1	2	3	7	8	1	2	3	7	8
	1	2	7	8	1	2	3	7	8	1	2	3	7	8

14.	Did you begin any new activities in conjunction with the quitline as of November 2004 or later?

Y ES	1
NO	2
REF	7
DK	8

1 5.	What were they?

RECORD FUNCTIONS/ACTIVITIES SINCE NOVEMBER 2004	In your opinion, how much of a factor was the Initiative in prompting or enabling this activity? Would you say…
	A significant factor,	A moderate factor,	A minor factor, or	Not a factor at all?	REF	DK
	1	2	3	4	7	8
	1	2	3	4	7	8
	1	2	3	4	7	8
	1	2	3	4	7	8
	1	2	3	4	7	8
	1	2	3	4	7	8

[IF PARTNERSHIP BEGAN DURING OR AFTER NOVEMBER 2004 ASK 16; ELSE SKIP TO 17]

16.	In general, how would you describe your relationship to the {STATE QUITLINE NAME}? That is, what functions or activities did you participate in with the quitline at any time during 2005?

LIST FUNCTIONS/ACTIVITIES DURING 2005	In your opinion, how much of a factor was the Initiative in prompting or enabling this activity? Would you say…
	A significant factor,	A moderate factor,	A minor factor, or	Not a factor at all?	REF	DK
	1	2	3	4	7	8
	1	2	3	4	7	8
	1	2	3	4	7	8
	1	2	3	4	7	8
	1	2	3	4	7	8
	1	2	3	4	7	8

17.	Of all the activities you engage in with the quitline, which do you consider the most important? Please tell me a little more about that activity and why it is important.

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

18.

To make sure I’ve correctly categorized the nature of your partnership with the quitline, I’m going to ask if you worked with the quitline in some specific areas. For each area you were involved with, I will then ask if you were involved only before November 2004, only after November, 2004, or both before and after. Has your partnering with the quitline involved…

	ONLY BEFORE NOVEMBER 2004	ONLY AFTER NOVEMBER 2004	BOTH BEFORE AND AFTER NOVEMBER 2004	NOT AT ALL	REF	DK
Referring your patients or clients to the quitline?	1	2	3	4	7	8
Getting patients referred to you from the quitline?	1	2	3	4	7	8
A formal arrangement in which you contract with the quitline to provide tobacco cessation services to your patients?	1	2	3	4	7	8
A formal arrangement in which the quitline contracts with you to provide in-person or other types of tobacco cessation services to its callers?	1	2	3	4	7	8
Furnishing over-the-counter nicotine replacement products to the quitline or its callers?	1	2	3	4	7	8
Furnishing prescription nicotine replacement or pharmacotherapy products to the quitline’s callers?	1	2	3	4	7	8
Promoting the quitline to your members, constituents, or employees?	1	2	3	4	7	8
Promoting the quitline to the general public?	1	2	3	4	7	8
Promoting the quitline to health care providers?	1	2	3	4	7	8
Promoting other tobacco cessation to your members, constituents, or employees?	1	2	3	4	7	8
Promoting other tobacco cessation to the general public?	1	2	3	4	7	8
Promoting other tobacco cessation to health care providers?	1	2	3	4	7	8
Collaborating on general tobacco-related health outreach or education campaigns?	1	2	3	4	7	8
Collaborating on broad anti-tobacco coalitions or missions, such as smoke-free air, tobacco taxation policies, or regulation of tobacco advertising?	1	2	3	4	7	8
Participating in conferences or workgroups related to quitline programs, activities, and services?	1	2	3	4	7	8

19.	During 2005, did your organization explicitly promote or publicize the national 1-800-QUIT-NOW number in any way? This could include printing it on materials, suggesting it to individual smokers, mentioning it in group meetings, or including it in promotions campaigns.

Y ES	1
NO	2
REF	7
DK	8

1 9a.

Please describe the principal ways in which you promoted 1-800-QUIT-NOW.

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Funding Relationship

20.

During 2005, did your organization have either a formal or informal financial relationship with the {STATE} quitline? [IF NEEDED: A financial relationship could mean that one or both of you make direct payments or subsidies to the other, provide reduced-price services or goods, or make reimbursements. It could also involve furnishing in-kind goods or services, such as pro bono professional services.]

Y ES	1
NO	2
REF	7
DK	8

2 0a.

Would you describe in very general terms the nature of this financial relationship, that is, just describe the type of financial support each of you provided to the other in 2005, not the amounts?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

[IF THE PARTNER RECEIVES ANY TYPE OF FINANCIAL SUPPORT FROM THE QUITLINE ASK 21 ELSE GO TO 23.]

21.	To the best of your knowledge, did the Quitline Network Initiative serve as a funding source for the support or contribution that the quitline provided to your organization?

YES	1
NO	2
REF	7
DK	8

22.	During 2005, did you share the cost of any mutual activities or special programs with the quitline?

YES	1
NO	2
REF	7
DK	8

Reaction to Initiative

23.	In general, how did you regard the announcement of the Initiative when you first heard of it?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

24.	In general, how do you regard it now?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

25.	In general, how would you describe the effect of the Initiative on your organization’s activities and objectives?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

26.	How would you summarize the impact that the Initiative had on your partnership with the {STATE QUITLINE NAME}, particularly through the end of 2005?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

27.	How would you describe the Initiative’s overall effect on tobacco cessation in {STATE}?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

28.	In your opinion, what would be the most significant difference if the Initiative had not occurred?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

29.	Finally, is there anything else about the Initiative you would like to discuss?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Thank you very much for your time. Your experience and insights will make an important contribution to our evaluation of the Initiative. If you would like to contact me, my name is ______________________, at 301-251-1500 or 800-937-8281.

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