Form 3 SCIF with screen shots

NCI/Office of Communications and Public Liaison

APPENDIX 1C

SMOKING CESSATION INTAKE FORM (SCIF) with SCREEN SHOTS

Public Burden Statement

Background

Dependency – Summary

Motivation

CIG

QuitVet

Service

• Subject of Interaction

• Subject 1

• No Value

• Hospital/Clinic/Physician/Second Opinion

• General Cancer Site Information

• Treatment/Side Effects

• Hospice/Palliative Care/Home Care/Supplies

• Financial Assistance

• Monetary/Personal Property Donations

• Publication Request

• Other Inquiry

• Screening Mammogram

• Diagnostic Mammogram

• Pap Test

• PSA Test

• Screening Colonoscopy

• Screening Spiral CT for Lung

• Screening MRI for Breast

• Diagnostic MRI for Breast

• Other Diagnostic Test

• Other Screening Test

• CT-General Information Only

• CT-General Information and Search

• CT-CCR Clinical Trials

• CT-Results and Outcomes

• Support Groups/Counseling Services

• Emotional Wellness

• Other Psychosocial Issue

• Suicidal Client

• HPV

• Heredity/Genetics/Family History

• Environmental Risk Factors

• Diet and Nutrition for Prevention

• Exercise/Obesity for Prevention/Risk

• Hormone Use and Cancer Risk

• HIV/AIDS

• EMF – Cell Phones

• EMF – Other

• Other Risk Factors

• CAM General Information

• CAM – Biologically Based Products

• CAM-Mind Body/Spirituality/Energy Med

• CAM-Manual Therapies

• CAM-Whole Systems

• Medical Marijuana

• Body/Tissue/Hair Donations

• Genetic Services

• Report/Statistics

• Proton Beam Radiation (txt/side effects)

• NCI Programs & Initiatives

• Employment at NCI

• NCI Budget

• NCI Funding Opportunities

• Scientific Materials for Researchers

• NCI & ARRA

• Cancer.gov Comments or Questions

• Problems with CT Search

• NCI Logo Request

• Artwork Request

• NCI Other

• Cigarettes

• Cigars, Cigarillos or Little Cigars

• Pipes

• Chewing Tobacco, Snuff, or Dip

• Other Tobacco

• Secondhand Smoke

• Marijuana (recreational use)

• Cessation Counseling/Information

• Subject 2 Same as 1

• Subject 3 Same as 1

• Subject 4 Same as 1

• Subject 5 Same as 1

• Cancer Site 1

• Aids-related cancers

• ALL

• AML

• Anal

• Biliary tract

• Bladder

• Brain

• Breast

• Carcinoma of unknown primary

• Cervical

• CLL

• CML

• Colorectal

• Endometrial/Uterine

• Esophageal

• Eye

• Gastrointestinal carcinoid tumor/GIST

• Head and neck

• Hodgkin lymphoma

• Myeloma/Plasma cell neoplasm

• Non-Hodgkin lymphoma

• Ovarian

• Pancreas

• Prostate

• Renal (kidney) and renal pelvis

• Skin cancer (nonmelanoma)

• Small intestine

• Soft tissue

• Stomach/Gastric

• Thyroid

• Break off

• Other – Central nervous system

• Other – Digestive

• Other – Endocrine system

• Other – Hematologic system

• Other – Leukemia

• Other – Lymphoma

• Other – Musculoskeletal and connective tissue

• Other – Reproductive, female

• Other – Reproductive, mal

• Other – Respiratory

• Other – Urinary organs

• Other cancers

• Childhood cancers

• Not applicable/No specific site mentioned

• Special Codes

• Special Code

• No Value

• CTCA Calls

• Affordable Care Act (ACA)

• In the news

• Cancer Bulletin Ending

• Recalcitrant Cancer Research Act

• UCSF Study Call

• Special Code 2 (same as 1)

• Referrals Given

• Referral 1

• No Value

• CIS information service

• Smoking Quitline

• Public Inquiries

• POS

• NCI Doc/Program

• NCI Designated Cancer Center

• NCI CCR/Clinical Center

• NCCCP

• CDC-BCCEDP

• CDC-BCCEDP – Missouri

• Genetics Services

• Other Healthcare Facility

• National or Community Org/Other Gov. Program

• International Referral

• Other

• None

• Break Off

• Referral 2 (same as 1)

• Referral 3 (same as 1)

• Referral 4 (same as 1)

• Referral 5 (same as 1)

• Referral 6 (same as 1)

• Follow-up Actions

• Action 1

• No Value

• Sent information by mail

• Emailed information

• Social Media post

• Warm transfer POS

• Warm transfer org/agency

• Scheduled call back

• Other

• Action 2 (same as 1)

• Action 3 (same as 1)

• Action 4 (same as 1)

• Action 5 (same as 1)

• Clinical Trials

• Yes

• No

• Background Screen

• Cigarettes per Day

• Age

• Gender

• Male

• Female

• Substance Use Disorder

• Yes

• No

• Mental Health Disorder

• Yes

• No

Dependency Screen:

• Age when starting smoking cigarettes

• First cigarette of the day after awakening

• In life, number of quit attempts for 1 day or longer

• Duration (beyond a day) of successful quitting

• In past year, number of quit attempts

  • First call to the quit line in the past 12 months?

• Longest time quit

• Types of tobacco have you used in the past 30 days

  1. Cigarettes

     • Menthol cigarettes?

       • Yes, I usually smoke menthol cigarettes

       • No, I usually smoke other types of cigarettes (non-menthol)

       • Don’t know

       • Refused

       • Not asked

  2. Cigars, cigarillos, or little cigars

  3. A pipe

  4. Chewing tobacco, snuff, or dip

  5. Any other type of tobacco

• Last time smoked a cigarette, even a puff :

  1. dd/mm/yyyy

  2. Don’t know

  3. Refused

  4. Not asked

• Avg. Number of cigarettes smoked each day ___

• Currently smoke cigarettes every day, some days, or not at all? (Note: “currently” refers to right now, today.)

  1. Everyday

  2. Some days

     • Number of days smoked in the last 30 days: ___

       • Don’t know

       • Refused

       • Not asked

  3. Not at all

  4. Don’t know

  5. Refused

  6. Not asked

• Age?

• Sex?

• If female, are you pregnant right now?

• Symptoms experienced after quitting

  • Feeling irritable, angry, agitated

  • Mood swings, depressed, down, or blue

  • Nervous, anxious, jumpy

  • Cravings

  • Trouble sleeping, nightmares, dreams

  • Has not tried to quit before (1^st quit attempt)

  • Weight gain

  • Increased appetite or hunger

  • Tired, fatigued

  • Feeling ill, sick, nausea, general malaise

  • Headache

  • Chest pain, shortness of breath

  • Stress

  • Unable to concentrate

  • Dizzy, lightheaded

  • Shakes

  • Other (please explain)

• Triggers

• Did not ask triggers

• After meals

• Alcohol

• Other substance abuse

• Anxiety

• Coffee

• Driving

• Fatigue

• Driving

• Phone calls

• Sadness

• Stress

• Watching TV

• Work breaks

• Nightmares

• Intrusive thoughts

• Other (please explain)

• Past medication to quit

• Did not ask

• Used in past

• Bupropion hydrochloride (e.g.Zyban, Wellbutrin)

• Chantrix

• Herbal

• Inhalers

• Lozenges

• Nasal sprays

• Patches

• Policrilex gums

• 2 NRT combinations

• Bup+NRT combination

• Other

• Future Meds

• Did not ask

• Not interested

• Bupropion hydrochloride

• Chantrix

• Herbal

• Inhalers

• Lozenges

• Nasal sprays

• Patches

• Policrilex gums

• 2 NRT combinations

• Bup+NRT combination

• Other

• Comorbidity

• Substance Abuse

• Other

Motivation Screen Questions:

• Most important reason for wanting to quit

• Restrictions placed on smokers in restaurants, at work, and other public places

• Family or friends

• To feel more in control of your life

• To improve your health

• To save money

• To improve your health

• Because your doctor told you to

• Because of your children (grandkids)

• For a healthy pregnancy

• Just tired of smoking

• Professionalism, Role model

• Religious reasons

• Extracurricular activities (e.g. basketball, jogging, dancing, volleyball, etc.)

• Age

• Concern about cancer prompted by death of family member or public figure

• Dirty/bad habit

• Other (please explain)

• Did not ask

• Secondary Reason?

  • See examples from last question

  • No other reason

  • Did not ask

• Others in the household currently using tobacco products (one or more)

• Other Users?

• Child?

• Friend?

• Parent?

• Partner?

• Household Tobacco Products Used

• Chewing

• Cigarettes

• Cigars

• Pipes

• Snuff

• Quitting

• Quitting next 30 days?

• Quit date

• Confidence in Quitting

• No value

• Somewhat confident

• Confident

• Neutral

• Not confident at all

• Call Backs?

• Interested in call back?

• Agree to terms of service?