NCI/Office of Communications and Public Liaison |
APPENDIX 1C |
SMOKING CESSATION INTAKE FORM (SCIF) with SCREEN SHOTS |
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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
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
Cigars, cigarillos, or little cigars
A pipe
Chewing tobacco, snuff, or dip
Any other type of tobacco
Last time smoked a cigarette, even a puff :
dd/mm/yyyy
Don’t know
Refused
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.)
Everyday
Some days
Number of days smoked in the last 30 days: ___
Don’t know
Refused
Not asked
Not at all
Don’t know
Refused
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 Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Smoking Cessation Intake Form (SCIF Screen Shots |
Subject | SMOKING CESSATION INTAKE FORM (SCIF) with SCREEN SHOTS |
Author | Burstyn, Ilene (NIH/NCI) [E] |
File Modified | 0000-00-00 |
File Created | 2022-01-12 |