Intake Data for Web Clients

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/XXXX

Intake Data for Web Services Clients

Public reporting burden of this collection of information is estimated to average 15 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: OMB 0920-XXXX

Contact Information File
Consented	Y/N (Interviewer coded after obtaining informed consent)
User ID
Mode of Cessation Service	(Quitline vs. Web-based)
Date of Registration	(dd/mm/yyyy): _ _/_ _/_ _ ___
Last name	What is your full name?
First name	What is your full name?
Mailing Address	What is your mailing address?
City by zip	What is your mailing address?
State by zip	(filled in by zip)
Zip	What is your zip code?
County by zip	(filled in by zip)
Primary phone	What is your main phone number?
Secondary phone	Do you have a second phone number we can use?
Cell phone	Do you have a cell phone number?
Best time to call caller back	What is the best time to call you?
Email address	Do you have an email address?

Quitline Utilization Data File
Variable	Possible Data Values
User ID
Date of Registration	(dd/mm/yyyy): _ _/_ _/_ _ ___
Mode of Cessation Service	 Quitline  Web
State
Total Log-Ins	Number of times the user logged in to web account
Date of each log-in [1, 2, …..n]	(dd/mm/yyyy): _ _/_ _/_ _ ___
Length of visits [1,2,….n]	(hh:mm:ss)
Intake Survey Data – Minimum Dataset Items (MDS)
Variable		Survey Item	Possible Data Values
Purpose_Web		I am…	 Looking for help for myself  A researcher/health professional seeking info for a client/study
Referral source_Web		How did you hear about QuitNet?	 Website  TV;  Radio  other  Newspaper/magazine  My doctor/dentist  Friend/family  Friend/family  Drugstore  Brochure  Billboard
Current Tobacco Use_Web		What form or forms of tobacco do you/did you use? A) Cigarettes, B) Cigars, C) Pipes (bowls), D) Chewing tobacco or snuff (pouches), E) Other tobacco products (e.g. Bidis) F) none of the above	 Cigarettes  Cigars  Pipes (bowls)  Chewing tobacco, snuff, (pouches)  Other tobacco products (e.g. bidis)  None of the above
Smoke Status_Web		Are you currently a smoker?	 Yes, I currently smoke;  No, I quit within the last 6 months;  No, I quit more than 7 months ago;  No, I have never smoked
Intention to quit_Web		Are you seriously thinking of quitting smoking? A) Yes, within the next 30 days B) Yes, within the next 6 months C) No, not thinking of quitting
Time to first cigarette_Web		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
Intenstiy-Cigs_Web		On an average day, how many cigarettes do you (or did you) smoke?
Recent Quit Attempts_Web		In the last year, how many times have you quit smoking for at least 24 hours?
Past Quit Methods_Web		If you made a 24-hour quit attempt in the past year, what kind of treatment was used?	 No treatment - quit on my own;  Nicotine Patch;  Nicotine Gum;  Nicotine Inhaler;  Nicotine Spray;  Nicotine Lozenge;  Zyban/Wellbutrin/bupropion  Chantix/Varenicline  Face to face counseling  Telephone counseling  Acupuncture  hypnosis  other
Zip code		What is your zip code?	_ _ _ _ _
DOB		Date of birth	_ _ _ _
Gender		male/female	 Male  Female
		Are you currently pregnant? y/n	 Yes  NO
Education		What is the highest level of education that you have achieved?	 8th grade of less;  Some high school;  Finished HS/GED;  Some college;  College graduate;  Post-college
Ethnicity		Are you of Hispanic or Latino origin?	 NO (Not of Hispanic or Latino origin)  YES(of Hispanic or Latino origin)  DON’T KNOW  REFUSED
Race		What is your race? Which one or more of these groups would you say best describes you? (select one or more)	 White  Black or African American  Asian  Native Hawaiian or other Pacific Islander  American Indian or Alaska Native  SOME OTHER RACE (SPECIFY ___________)  DON’T KNOW  REFUSED