Form 3 SCIF with screen shots

Collection of Customer Service, Demographic and Smoking/Tobacco Use Information from NCI's Contact Center, Cancer Information Service (CIS) Clients (NCI)

Appendix 1C SCIF with Screen Shots_2021

Smoking Cessation "Intake" Questions

OMB: 0925-0208

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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

    • G-COVID-19

    • G-General Cancer Questions

    • G-Symptoms

    • G-Cancer Statistics/Epidemiological Stats

    • G-Prognosis

    • G-Research Donations

    • G-General Donations

    • G-Suicidal Client

    • G-Other Inquiries

    • CP-Risk Factors

    • CP-Genetics

    • CP-Prevention

    • Tests

    • TX-General Treatment

    • TX Surgery

    • TX-Radiation Therapy

    • TX-Chemotherapy

    • TX-Immunotherapy

    • TX-Targeted Therapy

    • TX-Hormone Therapy

    • TX-Stem Cell Transplant

    • TX-Complementary and Alternative Medicine

    • CAM-Medical Marijuana

    • CAM-Biological Based Products

    • CAM-Manual Therapies

    • CAM-Whole Systems

    • CAM-Mind Body/Spiritual/Energy Med.

    • CAM-High Does Vitamin C

    • Side Effects

    • CT-General Information Only

    • CT-General Information & Search

    • CT-CCR Clinical Trials

    • CT-Results and Outcomes

    • Coping

    • MC-Finding Health Care Services

    • MC-Managing Costs and Medical Information

    • MC-Palliative/Hospice Care

    • Publication Requests

    • SM-Cigarettes

    • SM-Cigars, Cigarillos or Little Cigars

    • SM-Pipes

    • SM-Chewing Tobacco

    • SM-Other Tobacco

    • SM-Marijuana (recreational use)

    • SM-Cessation Counseling/Information

    • SM-E-cigs

    • SM-NRT (nicotine replacement therapy)

    • NCI-About NCI

    • NCI-Key Initiatives

    • NCI-Budget

    • NCI-Problems with a CT Search

    • NCI-Permissions Requests

    • NCI-Other

    • NCI-Risk Tools

    • NCI-QuitSTART and other apps

    • SEER Cancer Statistics

    • SEER Datasets and Software

    • SEER Manuals

    • SEER Registries/Training etc.

    • SEER-other

    • FB-Advertising (products/services)

    • FB-Fundraising

    • FB-Other Languages

    • FB-CAM Cures

  • 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

  • COVID-19

  • NCCAPS (NCI COVID study)

  • CTCA Calls

  • VA Smoking Chat

  • TMIST

  • All of Us Research Program Dr. Rosenberg Affordable Care Act (ACA)

  • In the News (anything people saw on TV e.g. Angelina Jolie, etc.)

  • Vice President’s Cancer Initiative

  • First in Human

  • CT Feedback (PIQ only)

  • Cancer Research Initiative Mailbox

  • Genomics Podcast

  • VA Lung Screening

  • Pediatric Petitions/Funding

  • FDA Referral (quit smoking)

  • Exceptional Responders

  • MATCH

  • Ped MATCH

  • Emperor of All Maladies

  • VM Callback

  • FB Live Event

  • Hurricane

  • DART

  • Every Try Counts

  • Cell Phone Risk

  • E2112

  • PIQ Custom Phone Response

  • PIQ Referred by DOC

  • PIO Referred by Center for Global

  • Health

  • PIQ Incarcerated Client

  • 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)

  • Follow-up Actions

  • Action 1

  • No Value

  • None

  • Sent information by mail

  • Emailed information

  • Social Media post

  • Warm transfer org/agency

  • Scheduled call back

  • Other

  • Action 2 (same as 1)

  • Clinical Trials

  • N/A

  • Client Initiated

  • IS Initiated



  • 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 (1st 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?


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleSmoking Cessation Intake Form (SCIF Screen Shots
SubjectSMOKING CESSATION INTAKE FORM (SCIF) with SCREEN SHOTS
AuthorBurstyn, Ilene (NIH/NCI) [E]
File Modified0000-00-00
File Created2022-01-12

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