NQDW services questionnaire

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

National Quitline Data Warehouse

Quitline Services Questionnaire

Public reporting burden of this collection of information is estimated to average 7 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-xxxx)

THIS WILL BE IMPLEMENTED AS A WEB-BASED QUESTIONNAIRE

Please respond to the following questions about the services your quitline offered in [TIME PERIOD FILL].

1. Please provide your contact information

Name __________

Job Title _____________

Employer/Organization ___________

State____________

Email ___________

Phone ___________

Second phone __________

2. Please provide state and name of your quitline:

State _________

Name of quitline __________

3. Was there a change to your quitline’s total budget from [TIME PERIOD FILL], apart from the Recovery Act funding?

Note: quitline’s total budget can include services, medications, evaluation, media/promotions, outreach and other quitline specific items.

• Yes, an increase of ___________(please specify amount)

• Yes, a decrease of ___________(please specify amount)

• No, no increase or decrease in budget in [TIME PERIOD FILL]

4. Does your quitline have a sustainability plan?

• Yes

• No

5. Please provide the days and hours of service of your quitline for the following categories of service:

	N/A	Days and hours of service
Counselling service available
Live pick up of incoming calls (may or may not have counselling services available)
Voicemail / answering service pick up of calls

6. Is your quitline closed on holidays?

• Yes

• No

7. How many total direct calls came in to the quitline during [TIME PERIOD FILL]?

Note: Direct calls are your quitline’s total call volume. Please report on number of calls, not number of callers/unique individuals. This should include proxy callers, wrong numbers, prank calls, and other calls to the quitline that are not accounted for in these categories.

a. Calls Answered live	b. Calls Went to voice mail	c. Calls Hung up or abandoned	d. Other Calls	e. Total direct calls (D=A+B+C+D)
N=	N=	N=	N=	N=

8. Quitlines use many types of promotions and referral networks to increase their reach to tobacco users. Please select all of the sources that generated referrals to your quitline in the past three months.

Note: Referrals are client referrals to the quitline from health professionals, other intermediaries or services (including Web sites) that trigger a proactive call to the client initiated by the quitline.

• Fax referral system

• Community organization networks

• Online advertising (paid)

• Web referrals (links from Web sites, not paid ads)

• Central call center (“triage”) separate from the quitline

• Other. Please describe:

9. How many referrals did the quitline receive during [TIME PERIOD FILL] from the following?

a. FAX referrals	b. Other referrals (e.g., web referrals, “click to call,” online ads, etc.)	c. Total referrals (C=A+B)
N=	N=	N=

10. How many TOBACCO USERS who called or were referred to the quitline received the services listed below during [TIME PERIOD FILL]?

Note: Report only on those who received service for the first time, not those who requested service. For the purposes of this question, we define “received” service as anyone who received quitline self-help materials and/or began at least one counseling call with the quitline and/or received medications through the quitline. Number of minutes of counseling should be cumulative for each tobacco user. DO NOT include time spent conducting intake or other non-counseling time. [If your quitline’s intake process takes 10 minutes on average, subtract 10 minutes from the total number of minutes to calculate the number of counseling minutes for each tobacco user.

a.* Self-help materials with no counseling	b. Minimal Counseling (began first session but less than 3 minutes)	c. Low-intensity counseling (3-10 minutes)	d.* Higher-intensity counseling (>10 minutes)
N=	N=	N=	N=

*Note: a-d are mutually exclusive categories.

e. Number of tobacco users who were provided Medications (NRT or other FDA-approved medications for tobacco cessation) through the quitline

N=

f. Total tobacco users provided Minimal, low-intensity, or higher-intensity counseling OR medications OR both counseling and medications [Do NOT include those who received only self-help materials here.] (Note: This is the number that will be used to calculate treatment reach using the NAQC standard calculation.)

***If your quitline cannot report on the numbers of tobacco users receiving minimal, low-intensity, and higher-intensity counseling, include the number of tobacco users who began the first counseling session and/or received medications here.

N=

11. Please list your quitline’s population(s) with disproportionate burden of tobacco use and provide the number of tobacco users in the target population who called or were referred to the quitline received the services listed below for the first time in [TIME PERIOD FILL]?

Note: Report only on those who received service for the first time, not those who requested service. For the purposes of this question, we define “received” service as anyone who received quitline self-help materials and/or began at least one counseling call with the quitline and/or received medications through the quitline. Number of minutes of counseling should be cumulative for each tobacco user. DO NOT include time spent conducting intake or other non-counseling time. [If your quitline’s intake process takes 10 minutes on average, subtract 10 minutes from the total number of minutes to calculate the number of counseling minutes for each tobacco user.

Population(s) with disproportionate burden of tobacco use ____________________

a.* Self-help materials with no counseling	b. Minimal Counseling (began first session but less than 3 minutes)	c. Low-intensity counseling (3-10 minutes)	d.* Higher-intensity counseling (>10 minutes)
N=	N=	N=	N=

*Note: a-d are mutually exclusive categories.

e. Number of tobacco users who were provided Medications (NRT or other FDA-approved medications for tobacco cessation) through the quitline

N=

f. Total tobacco users provided Minimal, low-intensity, or higher-intensity counseling OR medications OR both counseling and medications [Do NOT include those who received only self-help materials here.] (Note: This is the number that will be used to calculate treatment reach using the NAQC standard calculation.)

***If your quitline cannot report on the numbers of tobacco users receiving minimal, low-intensity, and higher-intensity counseling, include the number of tobacco users who began the first counseling session and/or received medications here.

N=

12. Does your quitline use a translation service (e.g., AT&T) when providing counselling?

• Yes

• No

13. Does your quitline use counsellors who provide quitline services in languages other than English?

• Yes

• No (skip to Q15)

14. If yes, in which of the following languages does your quitline offer counselling, not translated through a third party? Select all that apply.

• English

• Spanish

• French

• Cantonese

• Mandarin

• Korean

• Vietnamese

• Russian

• Greek

• Amharic (Ethiopian)

• Punjabi

• Deaf and Hard of Hearing (TTY)

• Deaf and Hard of Hearing with video relay

• Other (please specify):_________

15. Many quitlines have eligibility criteria for receiving services based on state of residence, age, insurance status, being a member of a special population or readiness to quit. Are there eligibility criteria for receiving proactive counselling through your quitline?

Note: Counselling here refers to a caller-centered, person-tailored, in-depth, motivational interaction that occurs between cessation specialist/counsellor/coach and caller.

• Yes

• No, there are no restrictions on receiving proactive counselling – skip to Q17

16. The eligibility criteria include: Select all that apply.

• Resident of state

• Age: (please specify required age for services): years of age ______

• No insurance

• Underinsured

• Medicaid

• Medicare insured

• Private insured or private insurance holders

• Length of time quit: (please specify the eligibility criteria):__________

• Readiness to quit: (please provide your quitline’s definition of readiness to quit):_______

• Special population: (please specify which populations):________

• Other (please specify):_________

17. Do the different levels of quitline proactive counselling services you provide (e.g., single session counselling vs. multi-session counselling) have different eligibility criteria?

Note: Many quitlines have different levels of criteria for different types of services which may be based in-part on budgetary pressures. This question is designed to address this issue. Please reply fully so we can understand the different types of eligibility for the different levels of service.

• Yes: (please fill-in as many blanks as needed)

Number of sessions________ Eligibility Criteria _________

Number of sessions________ Eligibility Criteria _________

Number of sessions________ Eligibility Criteria _________

• No

18. If your quitline addressed eligibility criteria for proactive counselling in other ways not reported in Questions 16-17, please specify: ____________________________________________________________

Quitlines address quitting medications in a variety of ways. Questions 19-53 pertain to how your quitline provided medications.

19. Did your quitline provide free quitting medications (i.e., quitting aids) to clients?

• Yes

• No – skip to Q49

20. Did your quitline provide free nicotine replacement patches to clients?

• Yes

• No (skip to Q24)

21. What criteria made a caller eligible to receive free nicotine replacement patches from the quitline? Select all that apply.

• Resident of state

• Age: (please specify required age for free nicotine replacement patches): _____ years of age

• Uninsured

• Underinsured

• Medicaid

• Medicare insured

• Private insured (or private insurance holders)

• Enrolment in counselling

• Special population (please specify which populations):______________

• Medical conditions

• Readiness to quit

• Limited supply – orders filled on first come / first served basis

• Geographic area (please specify ____________)

• Research study criteria

• Other (please specify): _________

22. How many weeks of free nicotine replacement patches per quit attempt did your quitline provide to clients? Please fill-in as many blanks as needed.

Note: if your quitline provides varying amounts of free nicotine replacement patches depending on eligibility criteria, please specify your eligibility criteria.

Number of weeks of patches per quit attempt______ Eligibility Criteria _________

Number of weeks of patches per quit attempt ______ Eligibility Criteria_________

Number of weeks of patches per quit attempt ______ Eligibility Criteria_________

23. Was there a limit to the number of times a caller could receive free nicotine replacement patches in one year?

• Yes (please specify ________)

• No

24. Did your quitline provide nicotine replacement gum to clients?

• Yes

• No (skip to Q28)

25. What criteria made a caller eligible to receive free nicotine replacement gum from the quitline? Select all that apply.

• Resident of state

• Age: (please specify required age for free nicotine replacement gum): _____ years of age

• Uninsured

• Underinsured

• Medicaid

• Medicare insured

• Private insured (or private insurance holders)

• Enrolment in counselling

• Special population (please specify which populations):______________

• Medical conditions

• Readiness to quit

• Limited supply – orders filled on first come / first served basis

• Geographic area (specify zip code(s) ____________)

• Research study criteria

• Other (please specify): _________

26. How many weeks of free nicotine replacement gum per quit attempt did your quitline provide to clients?

Please fill-in as many blanks as needed.

Note: if your quitline provides varying amounts of free nicotine replacement gum depending on eligibility criteria, please specify your eligibility criteria.

Number of weeks of gum per quit attempt ______ Eligibility Criteria _________

Number of weeks of gum per quit attempt ______ Eligibility Criteria _________

Number of weeks of gum per quit attempt ______ Eligibility Criteria _________

27. Was there a limit to the number of times a caller could receive free nicotine replacement gum in one year?

• Yes

• No

28. Did your quitline provide free Lozenges to clients?

• Yes

• No (skip to Q32)

29. What criteria made a caller eligible to receive free Lozenges from the quitline? Select all that apply.

• Resident of state

• Age: (please specify required age for free Lozenges): _____ years of age

• Uninsured

• Underinsured

• Medicaid

• Medicare insured

• Private insured (or private insurance holders)

• Enrolment in counselling

• Special population (please specify which populations):______________

• Medical conditions

• Readiness to quit

• Limited supply – orders filled on first come / first served basis

• Geographic area (specify zip code(s) ____________)

• Research study criteria

• Other (please specify): _________

30. How many weeks of free Lozenges per quit attempt did your quitline provide to clients? Please fill-in as many blanks as needed.

Note: if your quitline provides varying amounts of free Lozenges depending on eligibility criteria, please specify your eligibility criteria.

Number of weeks of Lozenges per quit attempt ______ Eligibility Criteria _________

Number of weeks of Lozenges per quit attempt ______ Eligibility Criteria _________

Number of weeks of Lozenges per quit attempt ______ Eligibility Criteria _________

31. Was there a limit to the number of times a caller could receive free Lozenges in one year?

• Yes

• No

32. Did your quitline provide free Zyban® (Bupropion) to clients?

• Yes

• No (skip to Q36)

33. What criteria made a caller eligible to receive free Zyban® (Bupropion) from the quitline? Select all that apply.

• Resident of state

• Age: (please specify required age for free Zyban® (Bupropion)): _____ years of age

• Uninsured

• Underinsured

• Medicaid

• Medicare insured

• Private insured (or private insurance holders)

• Enrolment in counselling

• Special population (please specify which populations):______________

• Medical conditions

• Readiness to quit

• Limited supply – orders filled on first come / first served basis

• Geographic area (specify zip code(s) ____________)

• Research study criteria

• Other (please specify): _________

34. How many weeks of free Zyban® (Bupropion) per quit attempt did your quitline provide to clients? Please fill-in as many blanks as needed.

Note: if your quitline provides varying amounts of free Zyban® (Bupropion) depending on eligibility criteria, please specify your eligibility criteria.

Number of weeks of Zyban per quit attempt ______ Eligibility Criteria _________

Number of weeks of Zyban per quit attempt ______ Eligibility Criteria _________

Number of weeks of Zyban per quit attempt ______ Eligibility Criteria _________

35. Was there a limit to the number of times a caller could receive free Zyban® (Bupropion) in one year?

• Yes

• No

36. Did your quitline provide free Chantix® (Varenicline) to clients?

• Yes

• No (skip to Q40)

37. What criteria made a caller eligible to receive free Chantix® (Varenicline)from the quitline? Select all that apply.

• Resident of state

• Age: (please specify required age for free Chantix® (Varenicline)): _____ years of age

• Uninsured

• Underinsured

• Medicaid

• Medicare insured

• Private insured (or private insurance holders)

• Enrolment in counselling

• Special population (please specify which populations):______________

• Medical conditions

• Readiness to quit

• Limited supply – orders filled on first come / first served basis

• Geographic area (specify zip code(s) ____________)

• Research study criteria

• Other (please specify): _________

38. How many weeks of free Chantix® (Varenicline) per quit attempt did your quitline provide to clients? Please fill-in as many blanks as needed.

Note: if your quitline provides varying amounts of free Chantix® (Varenicline) depending on eligibility criteria, please specify your eligibility criteria.

Number of weeks of Chantix per quit attempt ______ Eligibility Criteria _________

Number of weeks of Chantix per quit attempt ______ Eligibility Criteria _________

Number of weeks of Chantix per quit attempt ______ Eligibility Criteria _________

39. Was there a limit to the number of times a caller could receive free Chantix® (Varenicline) in one year?

• Yes

• No

40. Did your quitline provide free nicotine nasal spray to clients?

• Yes

• No (skip to Q44)

41. What criteria made a caller eligible to receive free nicotine nasal spray from the quitline? Select all that apply.

• Resident of state

• Age: (please specify required age for free nicotine nasal spray): _____ years of age

• Uninsured

• Underinsured

• Medicaid

• Medicare insured

• Private insured (or private insurance holders)

• Enrolment in counselling

• Special population (please specify which populations):______________

• Medical conditions

• Readiness to quit

• Limited supply – orders filled on first come / first served basis

• Geographic area (specify zip code(s) ____________)

• Research study criteria

• Other (please specify): _________

42. How many weeks of free nicotine nasal spray per quit attempt did your quitline provide to clients? Please fill-in as many blanks as needed.

Note: if your quitline provides varying amounts of free nicotine nasal spray depending on eligibility criteria, please specify your eligibility criteria.

Number of weeks of nasal spray per quit attempt ______ Eligibility Criteria _________

Number of weeks of nasal spray per quit attempt ______ Eligibility Criteria _________

Number of weeks of nasal spray per quit attempt ______ Eligibility Criteria _________

43. Was there a limit to the number of times a caller could receive free nicotine nasal spray in one year?

• Yes (please specify ________)

• No

44. Did your quitline provide free nicotine inhaler to clients?

• Yes

• No (skip to Q48)

45. What criteria made a caller eligible to receive free nicotine inhaler from the quitline? Select all that apply.

• Resident of state

• Age: (please specify required age for free nicotine inhaler): _____ years of age

• Uninsured

• Underinsured

• Medicaid

• Medicare insured

• Private insured (or private insurance holders)

• Enrolment in counselling

• Special population (please specify which populations):______________

• Medical conditions

• Readiness to quit

• Limited supply – orders filled on first come / first served basis

• Geographic area (specify zip code(s) ____________)

• Research study criteria

• Other (please specify): _________

46. How many weeks of free nicotine inhaler per quit attempt did your quitline provide to clients? Please fill-in as many blanks as needed.

Note: if your quitline provides varying amounts of free nicotine inhaler depending on eligibility criteria, please specify your eligibility critieria.

Number of weeks of inhaler per quit attempt ______ Eligibility Criteria _________

Number of weeks of inhaler per quit attempt ______ Eligibility Criteria _________

Number of weeks of inhaler per quit attempt ______ Eligibility Criteria _________

47. Was there a limit to the number of times a caller could receive free nicotine inhaler in one year?

• Yes (please specify ________)

• No

48. Did your quitline provide other free quitting medications to clients?

• Yes (please specify _____)

• No

49. Besides offering free medications (as reported in Questions 19-48), did your quitline provide discounted quitting medications?

• Yes

• No (skip to Q51)

50. What discounted quitting medications did you provide? Select all that apply.

• Nicotine replacement patch

• Nicotine replacement gum

• Lozenge

• Zyban® (Bupropion)

• Chantix® (Varenicline)

• Nasal spray

• Inhaler

• Other (please specify _____________)

51. Did your quitline provide voucher/coupon or certificate to redeem quitting medications?

• Yes

• No (skip to Q53)

52. What quitting medications did you provide voucher/coupon or certificate for? Select all that apply.

• Nicotine replacement patch

• Nicotine replacement gum

• Lozenge

• Zyban® (Bupropion)

• Chantix® (Varenicline)

• Nasal spray

• Inhaler

• Other (please specify _____________)

53. If your quitline addressed quitting medications in other ways not reported in Questions 19-52, please specify: ____________________________________________________________

Questions 54-58 ask about how your quitline conducts 7-Month Follow-up Surveys. These questions will be asked only once during [TIME FILL].

54. Does your quitline obtain consent for the 7-Month Follow-up survey at intake?

• Yes

• No

55. Does your quitline send out a pre-notification or advance letter to increase participation in the 7-Month Follow-up Survey?

• Yes

• No

56. Does your quitline use incentives to increase participation in the 7-Month Follow-up Survey?

• Yes

• No

57. What is the minimum number of attempts your quitline makes to reach an eligible quitline caller for follow-up evaluation before closing out the contact?

Quitline makes at least ________________ number of attempts

58. Does your quitline use a mix-mode to conduct the 7-Month Follow-up Survey?

Note: mixed-mode survey asks the same questions and offers the same response choices using two or more survey modes, such as Internet, telephone, interactive voice response or mail.

• Yes

• No