Attachment B4 2007 CATI Questionnaire

ATTACHMENT B4
N-SSATS 2007 CATI QUESTIONNAIRE

Attachment B4 (N-SSATS CATI Questionnaire)
FORM APPROVED OMB NO.: 0930-XXXX
APPROVAL EXPIRES: XX/XX/XXXX
See OMB burden statement on last page
INTRODUCTION:

Hello, my name is [INTERVIEWER] and I am calling concerning the Federal Government’s annual
survey of substance abuse treatment providers called N-SSATS or the National Survey of
Substance Abuse Treatment Services. The N-SSATS survey is sponsored by SAMHSA, the
Substance Abuse and Mental Health Services Administration.

1. INTERVIEWER: IS A CONTACT NAME OR A FACILITY DIRECTOR’S NAME LISTED?
YES

ASK:

NO

ASK:

May I speak with [CONTACT NAME OR FACILITY DIRECTOR] regarding (his/her) 2007 N-SSATS
questionnaire?
I would like to speak to your facility director regarding this facility’s 2007 N-SSATS questionnaire.
Could you give me his or her name?

TO CHANGE DIRECTOR’S NAME: ENTER <2> ON MENU SCREEN, RECORD NAME + ENTER <7> TO RETURN TO MENU SCREEN
TO CHANGE CONTACT PERSON: ENTER <1> ON MENU SCREEN, RECORD NAME + ENTER <7> TO RETURN TO MENU SCREEN

• SPEAKING WITH FACILITY DIRECTOR/APPROPRIATE PERSON

GO TO #2 BELOW

• SPEAKING WITH FACILITY DIRECTOR/APPROPRIATE PERSON

GO TO #2 BELOW

• CONNECTED TO FACILITY DIRECTOR /APPROPRIATE PERSON

REREAD INTRODUCTION AND GO TO #2 BELOW

• FACILITY DIRECTOR/CONTACT HAS DIFFERENT NUMBER

ENTER <3> ON MENU SCREEN AND CALL

• FACILITY DIRECTOR NOT AVAILABLE
ENTER <4> ON MENU SCREEN
AND FOLLOW INSTRUCTIONS
(INTERIM STATUS AND EXIT)

• ANSWERING MACHINE
• REFUSES

2. Recently you were mailed a letter from Dr. Javaid Kaiser at SAMHSA along with a letter from your State or
Federal Agency Substance Abuse Director. Both letters requested the participation of your facility in the
2007 N-SSATS. We are calling at this time to complete the survey. Is this a good time?
IF RESPONDENT REQUESTS LETTERS BE RESENT, COMPLETE CATI PROBLEM SHEET AND GIVE IT TO
YOUR SUPERVISOR.

IMPORTANT. READ:

YES

I will be asking you questions about [fill FACILITY NAME] at

[fill LOCATION ADDRESS].
TO CHANGE FACILITY NAME OR ADDRESS:

ENTER <2> ON MENU SCREEN,
RECORD NAME + ENTER <7> TO
RETURN TO MENU SCREEN

TO CONTINUE WITH INTERVIEW

ENTER ON MENU SCREEN

NO
• SCHEDULE CALLBACK AT CONVENIENT TIME
• COMPLETING ON THE WEB
•
•
•
•
•
•

NO LONGER PROVIDES SUBSTANCE ABUSE TREATMENT
NEVER PROVIDED SUBSTANCE ABUSE SERVICES
DUPLICATE FACILITY
MERGED WITH ANOTHER FACILITY
FACILITY CLOSED/NO LONGER EXISTS
SATELLITE FACILITY

• REPORTED ELSEWHERE
• DISPLAY NETWORK SCREEN

ENTER <4> ON MENU SCREEN

ENTER <5> ON MENU SCREEN
(FINAL STATUS AND EXIT)

ENTER <6> ON MENU SCREEN
ENTER <7> ON MENU SCREEN

1

NATIONAL SURVEY OF SUBSTANCE ABUSE TREATMENT SERVICES
>a<

NATIONAL SURVEY OF SUBSTANCE ABUSE TREATMENT SERVICES

>a1<

Which of the following substance abuse services are
offered by this facility [fill UFA@NAM1] [fill UFA@NAM2]
at [fill LOC@UAD1] [fill LOC@UAD2]?
Please answer “Yes” or “No” for each.
@1 Intake, assessment, or referral,
@2 Detoxification,
@3 Substance abuse treatment (services that focus on initiating
and maintaining an individual’s recovery from substance abuse
and on averting relapse)
@4 Any other substance abuse services (SPECIFY AND END WITH //)
(1) YES

[@1]
[@2]
[@3]
[@4]

>1a<

(0) NO

(d) DON’T KNOW

(r) REFUSED

<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>

You reported that this facility at this location does not offer
detoxification or substance abuse treatment.
Is that correct?
<1> YES, THIS IS CORRECT
<0> NO, THIS IS NOT CORRECT. RETURN TO A1 FOR CORRECTION
DON’T KNOW
REFUSED
@

[@]

>a1x<

Could I speak with someone else who may be familiar with the
day-to-day operation of this facility?
(1) ENTER CONTACT PERSON’S NAME
(d) DON’T KNOW
(r) REFUSED
@an1

[@]

2

>a1y<

Could I speak with [fill CPER]?
<1> YES [goto are5]
<2> NOT AVAILABLE - INTERVIEWER: Thank you, I will callback.
<3> CONNECTED TO ANSWERING MACHINE [goto are4_2]
@

[@]

>are4_2<

INTERVIEWER:

READ ANSWERING MACHINE MESSAGE THEN PRESS ENTER
TO INTERIM STATUS

@
[@]

>are5<

Hello, my name is _________ and I am calling on behalf of the
federal government’s annual survey of facilities that provide
substance abuse services. The survey is called the National Survey
of Substance Abuse Treatment Services or N-SSATS for short. I have
a few questions I’d like to ask you.
PROBE:

This survey is sponsored by SAMHSA, the Substance Abuse
And Mental Health Services Administration.

<1> CONTINUE
<2> NOT A CONVENIENT TIME
@
[@]

>a2a<

Does this facility detoxify clients from . . .
@1
@2
@3
@4

Alcohol
Opiates
Cocaine
Other (SPECIFY AND END WITH //)

(1) YES
[@1]
[@2]
[@3]
[@4]

>a2b<

(0) NO

(d) DON’T KNOW

(r) REFUSED

<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>

Does this facility routinely use medications during detoxification?
<1> YES
<0> NO
DON’T KNOW
REFUSED
@ [goto a4]

[@]

3

>a4<

What is the primary focus of this facility at this location?
INTERVIEWER:

CODE ONE ONLY

<1> Substance abuse treatment services
<2> Mental health services
<3> Mix of mental health and substance abuse
treatment services (neither is primary)
<4> General health care
<5> Other (SPECIFY AND END WITH //)
DON’T KNOW
REFUSED
@
[@]

>a5<

Is this facility operated by . . .
INTERVIEWER:
<1>
<2>
<3>
<4>
<5>
<6>

CODE ONE ONLY

a private for-profit organization, [goto a6]
a private non-profit organization, [goto a6]
state government, [goto a8]
local, county, or community government, [goto a8]
tribal government, or [goto a8]
federal government? [goto a5a]

DON’T KNOW
REFUSED
@
[@]

>a5a<

Which federal government agency?
INTERVIEWER:
<1>
<2>
<3>
<4>

CODE ONE ONLY

the Department of Veterans Affairs,
Department of Defense,
Indian Health Service, or
some other federal government agency? (SPECIFY AND END WITH //)

DON’T KNOW
REFUSED
@ [goto a8]
[@]

>a6<

Is this facility a solo practice, meaning, an office with a single
practitioner or therapist?
<1> YES
<0> NO
DON’T KNOW
REFUSED
@

4

[@]

5

>a7<

Is this facility affiliated with a religious organization?
<1> YES
<0> NO
DON’T KNOW
REFUSED
@

[@]

>a8<

Is this facility a jail, prison, or other organization that
provides treatment exclusively for incarcerated persons or juvenile
detainees?
<1> YES [goto a45]
<0> NO
DON’T KNOW
REFUSED
@

[@]

>a8a<

Just to confirm, this facility provides substance abuse treatment
services only to incarcerated persons or juvenile detainees.
Is that correct?
<1> YES, THAT IS CORRECT [goto uloc6]
<0> NO, THAT IS NOT CORRECT
@

[@]

>a9<

Is this facility located in, or operated by, a hospital?
<1> YES [goto a9a]
<0> NO [goto a10]
DON’T KNOW[goto a10]
REFUSED[goto a10]
@

[@]

>a9a<

What type of hospital?
INTERVIEWER:

CODE ONE ONLY

<1> a general hospital (including VA hospital),
<2> psychiatric hospital, or
<3> some other specialty hospital, for example,
alcoholism or maternity, etc.? (SPECIFY AND END WITH //)
DON’T KNOW
REFUSED
@

6

[@]

7

>a10<

What telephone number or numbers should a potential client call to
schedule an intake appointment?
INTERVIEWER:

IF R TELLS YOU THE INTAKE NUMBER IS THE SAME AS THE
NUMBER YOU CALLED, YOU MUST CONFIRM THAT NUMBER. IT
IS FILLED AT THE END OF RESPONSE NUMBER 3 FOR THIS
PURPOSE. YOU CANNOT ASSUME R KNOWS WHICH NUMBER YOU
CALLED TO REACH HIM.

(1) TO RECORD INTAKE TELEPHONE NUMBER(S)
(2) DOES NOT APPLY (SPECIFY AND END WITH //)
(3) SAME NUMBER YOU JUST CALLED [fill AREA][fill PRFX:0]-[fill SUFX:0]
(4) SAME NUMBER YOU JUST CALLED PLUS ANOTHER NUMBER
(d) DON’T KNOW
(r) REFUSED
@an
ENTER
ENTER
ENTER
ENTER

NUMERIC PHONE NUMBER
EXTENSION (OPTIONAL)
NUMERIC PHONE NUMBER
EXTENSION (OPTIONAL)

(OPTIONAL): @phn
@ext
(OPTIONAL): @phn2
@ext2

OR
ENTER
ENTER
ENTER
ENTER

>V10<

ALPHA PHONE NUMBER (OPTIONAL): @ac3 @phn3
EXTENSION (OPTIONAL) @ext3
ALPHA PHONE NUMBER (OPTIONAL): @ac4 @phn4
EXTENSION (OPTIONAL) @ext4

I’ve recorded
[fill a10@ac]
as the area code for the intake number.
Is that correct?
<1> YES
<0> NO, MAKE NECESSARY CHANGE
DON’T KNOW
REFUSED
@

[@]

>V10b<

I’ve recorded
[fill a10@ac2]
as the area code for the second intake number.
Is that correct?
<1> YES
<0> NO, MAKE NECESSARY CHANGE
DON’T KNOW
REFUSED

8

@
[@]

9

>V10c<

I’ve recorded
[fill a10@ac3]
as the area code for [if a10@phn eq <>]the first[else]the
next[endif] intake number.
Is that correct?
<1> YES
<0> NO, MAKE NECESSARY CHANGE
DON’T KNOW
REFUSED
@

[@]

>V10d<

I’ve recorded
[fill a10@ac4]
as the area code for the next intake number.
Is that correct?
<1> YES [goto ta10_t2]
<0> NO, MAKE NECESSARY CHANGE
DON’T KNOW [goto ta10_t2]
REFUSED [goto ta10_t2]
@

[@]

>a11<

Does this facility operate a hotline that responds to substance
abuse problems? DO NOT consider 911 or the local police number a
hotline for the purpose of this survey.
PROBE:

A hotline is a telephone service that provides
information, referral, or immediate counseling,
frequently in a crisis situation.

PROBE IF NECESSARY: If this facility is part of a group of
facilities that operates a central hotline to respond to
substance abuse problems, you should code “yes.”
<1> YES [goto a11a]
<0> NO [goto a12]
DON’T KNOW [goto a12]
REFUSED [goto a12]
@
[@]

10

>a11a<

What is this facility’s hotline telephone number or numbers?
INTERVIEWER:

IF AN ALPHA NUMBER IS REPORTED, RECORD IN THE
ALPHANUMERIC FIELD. ENTER ALL APPROPRIATE SPACES,
DASHES ETC.

(1) TO RECORD PHONE NUMBERS
(d) DON’T KNOW
(r) REFUSED
@an
[@]

>Va11a<

I’ve recorded
[fill a11a@ac]
as the area code(s) for the hotline.
Is that correct?
<1> YES
<0> NO, MAKE NECESSARY CHANGE
DON’T KNOW
REFUSED
@

[@]

>Va11a2<

I’ve recorded
[fill a11a@ac2]
as the area code for the second hotline.
Is that correct?
<1> YES
<0> NO, MAKE NECESSARY CHANGE
DON’T KNOW
REFUSED
@

[@]

>Va11a3<

I’ve recorded
[fill a11a@ac3]
as the area code for [if a11a@phn gt <>]the next[else] the
first[endif] hotline.
Is that correct?
<1> YES
<0> NO, MAKE NECESSARY CHANGE
DON’T KNOW
REFUSED
@

[@]

11

12

>Va11a4<

I’ve recorded
[fill a11a@ac4]
as the area code for the next hotline.
Is that correct?
<1> YES [goto a12_1]
<0> NO, MAKE NECESSARY CHANGE
DON’T KNOW [goto a12_1]
REFUSED [goto a12_1]
@

[@]

>a12_1<

Which of the following services are provided by this facility at
this location?
Which of the following Assessment and Pre-Treatment Services are
provided by this facility?
INTERVIEWER:

CODE ALL THAT APPLY

@1
@2
@3
@4

Screening for substance abuse
Screening for mental health disorders
Comprehensive substance abuse assessment or diagnosis
Comprehensive mental health assessment or diagnosis,
(for example, psychological or psychiatric evaluation
and testing)
@5 Outreach to persons in the community that may need treatment
@6 Interim services for clients when immediate admission
is not possible
(d) DON’T KNOW
(r) REFUSED
@
[@]

>a12_2<

Which of the following Pharmacotherapies are provided by this
facility at this location?
INTERVIEWER:
@7
@8
@9
@10
@11
@12
@13
@14

CODE ALL THAT APPLY

Antabuse
Naltrexone
Campral
Buprenorphine, with brand name Subutex
Buprenorphine, with brand name Suboxone
Methadone
Nicotine replacement
Medications for psychiatric disorders

(d) DON’T KNOW
(r) REFUSED
@
[@]

13

14

>a12_3<

Which of the following Testing services are provided by this
facility at this location? (Include tests performed at this
location, even if specimen is sent to an outside source for
chemical analysis.)
INTERVIEWER:
@15
@16
@17
@18
@19
@20
@21

CODE ALL THAT APPLY

Breathalyzer or other blood alcohol testing
Drug or alcohol urine screening
Screening for Hepatitis B
Screening for Hepatitis C
HIV testing
STD testing
TB screening

(d) DON’T KNOW
(r) REFUSED
@
[@]

>a12_4<

Which of the following Transitional Services are provided by this
facility at this location?
INTERVIEWER:

CODE ALL THAT APPLY

@22 Discharge planning
@23 Aftercare/continuing care
(d) DON’T KNOW
(r) REFUSED
@
[@]

15

>a12_5<

Which of the following Ancillary Services are provided by this
facility at this location?
INTERVIEWER:
@24
@25
@26
@27
@28
@29
@30
@31
@32
@33
@34
@35
@36
@37
@38
@39
@40

CODE ALL THAT APPLY

Case management services
Social skills development
Mentoring or peer support
Child care for clients’ children
Assistance with obtaining social services (for example,
Medicaid, WIC, SSI, SSDI)
Employment counseling or training for clients
Assistance in locating housing for clients
Domestic violence—family or partner violence services
(physical, sexual, and emotional abuse)
Early intervention for HIV
HIV or AIDS education, counseling, or support
Health education other than HIV/AIDS
Substance abuse education
Transportation assistance to treatment
Mental health services
Acupuncture
Residential beds for client’s children
Self-help groups (for example, AA, NA, Smart Recovery)

(d) DON’T KNOW
(r) REFUSED
@
[@]

>a13<

As part of substance abuse treatment, does this facility employ
individual counseling?
<1> YES [goto a13a]
<0> NO
DON’T KNOW
REFUSED
@

[@]

>a13a<

What percent of substance abuse clients receive individual
counseling?
INTERVIEWER:

ENTER A NUMBER.

@ num

[@] <

(d) DON’T KNOW
(r) REFUSED
@
> <0>

16

IF NONE, ENTER “0”

>a14<

As part of substance abuse treatment, does this facility employ
group counseling (with peers)?
<1> YES [goto a14a]
<0> NO
DON’T KNOW
REFUSED
@

[@]

>a14a<

What percent of substance abuse clients receive group counseling?
INTERVIEWER:

ENTER A NUMBER.

@ num

[@] <

(d) DON’T KNOW
(r) REFUSED
@
> <0>

17

IF NONE, ENTER “0”

>a15<

As part of substance abuse treatment, does this facility employ
family counseling?
<1> YES [goto a15a]
<0> NO
DON’T KNOW
REFUSED
@

[@]

>a15a<

What percent of substance abuse clients receive family counseling?
INTERVIEWER:

ENTER A NUMBER.

IF NONE, ENTER “0”

@ num

[@] <

>a16<

(d) DON’T KNOW
(r) REFUSED
@
> <0>

As part of substance abuse treatment, does this facility employ
marital/couples counseling?
<1> YES [goto a16a]
<0> NO
DON’T KNOW
REFUSED
@

[@]

>a16a<

What percent of substance abuse clients receive marital/couples
counseling?
INTERVIEWER:

ENTER A NUMBER.

@ num

[@] <

(d) DON’T KNOW
(r) REFUSED
@
> <0>

18

IF NONE, ENTER “0”

>a17<

Are any of the following practices part of this facility’s standard
operating procedures?
Please answer “Yes” or “No” for each.
(1) YES

(0) NO

(d) DON’T KNOW

(r) REFUSED

@1
@2
@3
@4
@5
@6
@7

[@1]
[@2]
[@3]
[@4]
[@5]
[@6]
[@7]

Required continuing education for staff
Periodic drug testing of clients
Regularly scheduled case review with a supervisor
Case review by an appointed quality review committee
Outcome follow-up after discharge
Periodic utilization review
Periodic client satisfaction surveys conducted
by the facility
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>

>a18<

Listed below are a variety of clinical/therapeutic approaches used
by substance abuse treatment facilities. For each, please mark the
box that best describes how often the practice is used at this
facility.
INTERVIEWER:
(1) NEVER
@1
@2
@3
@4
@5
@6
@7
@8
@9
@10

[@1]
[@2]
[@3]
[@4]
[@5]
[@6]
[@7]
[@8]

<1-4>
<1-4>
<1-4>
<1-4>
<1-4>
<1-4>
<1-4>
<1-4>

CODE ONE FREQUENCY FOR EACH

(2) RARELY

(3) SOMETIMES

(4) OFTEN

Substance abuse counseling
12-step approach
Brief intervention
Cognitive - behavioral therapy
Contingency management
Motivational interviewing
Trauma-related counseling
Anger management
Relapse prevention
Other treatment approach (SPECIFY AND END WITH //)

(d) DON’T KNOW
(r) REFUSED

19

>a19<

Does this facility operate a methadone maintenance or
detoxification program at this location?
<1> YES [goto a19a]
<0> NO [goto a20]
DON’T KNOW [goto a20]
REFUSED [goto a20]
@

[@]

>a19a<

Is the methadone program at this location a maintenance program, a
detoxification program, or both?
INTERVIEWER:

CODE ONE ONLY

<1> MAINTENANCE PROGRAM
<2> DETOXIFICATION PROGRAM
<3> BOTH
DON’T KNOW
REFUSED
@
[@]

>a19b<

Are ALL of the substance abuse clients at this facility currently
in the methadone program?
<1> YES
<0> NO
DON’T KNOW
REFUSED
@

[@]

>a20<

Does this facility offer a special program for DUI/DWI or other
drunk driver offenders at this location?
PROBE IF NECESSARY: You should answer “yes” if this facility
serves only DUI/DWI clients or if this facility has a special
DUI/DWI program.
<1> YES [goto a20a]
<0> NO [goto a21]
DON’T KNOW [goto a21]
REFUSED [goto a21]
@

[@]

20

>a20a<

Does this facility serve only DUI/DWI clients?
<1> YES
<0> NO
DON’T KNOW
REFUSED
@

[@]

>a21<

Does this facility provide substance abuse treatment services in
sign language (for example, American Sign Language, Signed English,
or Cued Speech) for the hearing impaired at this location?
READ IF NECESSARY: You should answer “yes” if either a staff
counselor or an on-call interpreter provides this service.
<1> YES
<0> NO
DON’T KNOW
REFUSED
@

[@]

>a22<

Does this facility provide substance abuse treatment services in a
language other than English at this location?
READ IF NECESSARY: You should answer “yes” if either a staff
counselor or an on-call interpreter provides this service.
<1> YES [goto a22a]
<0> NO [goto a23]
DON’T KNOW [goto a23]
REFUSED [goto a23]
@

[@]

>a22a<

At this facility, who provides substance abuse treatment services
in a language other than English?
INTERVIEWER:

CODE ONE ONLY

<1> A staff counselor who speaks a language
other than English, [goto a22b]
<2> An on-call interpreter (in person or by phone)
brought in when needed, or [goto a23]
<3> BOTH staff counselor and on-call
interpreter? [goto a22b]
DON’T KNOW [goto a23]
REFUSED [goto a23]
@
[@]

21

22

>a22b<

In what other languages do staff counselors provide substance abuse
treatment at this facility?
INTERVIEWER:
@1
@2
@3
@4
@5
@6
@7
@8
@9
@10
@11
@12
@13
@14
@15
@17
@18

CODE ALL THAT APPLY

Hopi
Lakota
Navajo
Yupik
Any other American Indian or Alaska Native
language (SPECIFY AND END WITH //)
Arabic
Chinese
Creole
French
German
Hmong
Korean
Polish
Portuguese
Russian
Vietnamese
Any other language (SPECIFY AND END WITH //)

(d) DON’T KNOW
(r) REFUSED
@
[@]

>a23<

Which of the following types of clients are accepted into treatment
at this facility, at this location?
Please answer “Yes” or “No” for each.
(1) YES

[@1]
[@2]
[@3]
[@4]
[@5]
[@6]
[@7]
[@8]
[@9]

(0) NO

(d) DON’T KNOW

(r) REFUSED

@1 Adolescents
@2 Clients with co-occurring mental and substance abuse
disorders
@3 Criminal justice clients (other than DUI/DWI clients)
@4 Persons with HIV or AIDS
@5 Gays or lesbians
@6 Seniors or older adults
@7 Adult women
@8 Pregnant or postpartum women
@9 Adult men
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>

23

>a23a<

For which of the clients coded “yes” in question a20 does this
facility offer a program or group designed exclusively for that
type of client?
INTERVIEWER:

CODE ALL THAT APPLY

<1> Adolescents
<2> Clients with co-occurring mental and substance abuse
disorders
<3> Criminal justice clients (other than DUI/DWI clients)
<4> Persons with HIV or AIDS
<5> Gays or lesbians
<6> Seniors or older adults
<7> Adult women
<8> Pregnant or postpartum women
<9> Adult men
<10> Specially designed programs or groups for any other
types of clients (SPECIFY AND END WITH //)
DON’T KNOW
REFUSED
@
[@]

>a24<

Does this facility offer either of the following HOSPITAL INPATIENT
substance abuse services at this location?
Please answer “Yes” or “No” for each.
(1) YES

(0) NO

(d) DON’T KNOW

(r) REFUSED

@1 Hospital inpatient detoxification
(Similar to ASAM Levels IV-D and III.7-D, medically managed
or monitored inpatient detoxification)
@2 Hospital inpatient treatment
(Similar to ASAM Levels IV and III.7, medically managed
or monitored intensive inpatient treatment)
[@1] <0,1,d,r>
[@2] <0,1,d,r>

24

INTERVIEWER NOTE:

>a25<

ASAM is the American Society of Addiction Medicine

Does this facility offer any of the following RESIDENTIAL
(non-hospital) substance abuse services at this location, that is,
the location listed on the front cover?
Please answer “Yes” or “No” for each.
(1) YES

(0) NO

(d) DON’T KNOW

(r) REFUSED

@1 Residential detoxification
(Similar to ASAM Level III.2-D, clinically managed
residential detoxification or social detoxification)
@2 Residential short-term treatment
(Similar to ASAM Level III.5, clinically managed
high-intensity residential treatment; typically
30 days or less)
@3 Residential long-term treatment
(Similar to ASAM Levels III.3 and III.1, clinically managed
medium- or low-intensity residential treatment; typically
more than 30 days)
[@1] <0,1,d,r>
[@2] <0,1,d,r>
[@3] <0,1,d,r>

>a26<

Does this facility offer any of the following OUTPATIENT substance
abuse services at this location?
Please answer “Yes” or “No” for each.
(1) YES

(0) NO

(d) DON’T KNOW

(r) REFUSED

@1 Outpatient detoxification
(Similar to ASAM Levels I-D and II-D, ambulatory detoxification)
@2 Outpatient methadone or buprenorphine maintenance
(Opioid maintenance therapy)
@3 Outpatient day treatment or partial hospitalization
(Similar to ASAM Level II.5, 20 or more hours per week)
@4 Intensive outpatient treatment
(Similar to ASAM Level II.1, 9 or more hours per week)

[@1]
[@2]
[@3]
[@4]
[@5]

@5 Regular outpatient treatment
(Similar to ASAM Level I, outpatient treatment; non-intensive)
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>

25

>Va26a1<

So, this facility does not offer hospital inpatient, residential,
or outpatient substance abuse services. Is that correct?
<1> YES, THAT IS CORRECT [goto Va26a2]
<0> NO, THAT IS NOT CORRECT - (THIS WILL RETURN TO a24)
DON’T KNOW [goto Va26a2]
REFUSED [goto Va26a2]
@

[@]

>Va26a2<

What type of substance abuse treatment does this facility offer?
(1) TO RECORD VERBATIM AND END WITH //
(2) DOES NOT OFFER SUBSTANCE ABUSE TREATMENT SERVICES
(d) DON’T KNOW
(r) REFUSED
@

[@]

>a27<

Does this facility use a sliding fee scale?
READ IF NECESSARY: A sliding fee scale adjusts the fee for service
based on income and other factors.
<1> YES [goto a27a]
<0> NO [goto a28]
DON’T KNOW [goto a28]
REFUSED [goto a28]
@

[@]

26

>a27a<

Do you want the availability of a sliding fee scale published in
SAMHSA’s National Directory and online Treatment Facility Locator?
(Alternate Wording: If this facility becomes eligible to be
included in the Directory and Locator, do you want the availability
of a sliding fee scale published in SAMHSA’s National Directory and
online Treatment Facility Locator?)
READ IF NECESSARY: The Directory is an annual publication listing
substance abuse treatment facilities in the United States and the
services they offer. The Locator is an online version of the
Directory that also includes a mapping feature so clients can find
facilities easily.
READ IF NECESSARY: The Directory and Locator will explain that
sliding fee scales are based on income and other factors.
<1> YES
<0> NO
DON’T KNOW
REFUSED
@

[@]

>a28<

Does this facility offer treatment at no charge to clients who
cannot afford to pay?
READ IF NECESSARY: “Treatment at no charge” means there are no
out-of-pocket expenses, or just token out-of-pocket expenses, for
clients who cannot afford to pay for treatment.
<1> YES [goto a28a]
<0> NO [goto a29]
DON’T KNOW [goto a29]
REFUSED [goto a29]
@

[@]

27

>a28a<

Do you want the availability of free care for eligible clients
published in SAMHSA’s National Directory and online Treatment
Facility Locator?
Alternate Wording: If this facility becomes eligible to be
included in the Directory and Locator, do you want the availability
free care for eligible clients published in SAMHSA’s National
Directory and online Treatment Facility Locator?)
READ IF NECESSARY: The Directory is an annual publication listing
substance abuse treatment facilities in the United States and the
services they offer. The Locator is an online version of the
Directory that also includes a mapping feature so clients can find
facilities easily.
READ IF NECESSARY: The Directory and Locator will explain that
potential clients should call the facility for information on
eligibility.
<1> YES
<0> NO
DON’T KNOW
REFUSED
@

[@]

>a29<

Does this facility receive any funding or grants from the Federal
government, or state, county or local governments, to support its
substance abuse treatment programs? Do not include Medicare,
Medicaid, or federal military insurance. These forms of client
payments will be included in the next question.
<1> YES
<0> NO
DON’T KNOW
REFUSED
@

[@]

28

>a30<

Which of the following types of client payments or insurance are
accepted by this facility for substance abuse treatment?
(1) YES

[@1]
[@2]
[@3]
[@4]
[@5]
[@6]
[@7]
[@8]
[@9]

>a31<

(0) NO

(d) DON’T KNOW

(r) REFUSED

@1 No payment accepted (free treatment for ALL clients)
@2 Cash or self-payment
@3 Medicare
READ IF NECESSARY: Medicare is the federal health insurance
program for people age 65 and older and people with
disabilities.
@4 Medicaid
READ IF NECESSARY: Medicaid is a joint federal and state
program that helps with medical costs for some people with
low incomes and limited resources. Medicaid programs vary
from state to state.
@5 A state-financed health insurance plan other than Medicaid,
READ IF NECESSARY: for example, State Children’s Health
Insurance Program (SCHIP) or high risk insurance pools)
@6 Federal military insurance such as TRICARE or Champ-VA
@7 Private health insurance
@8 Access To Recovery (ATR) vouchers
(to be answered by facilities in the following states only:
CA, CT, FL, ID, IL, LA, MO, NJ, NM, TN, TX, WA, WI, WY)
@9 Other (SPECIFY AND END WITH //)
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>

Does this facility have agreements or contracts with managed care
organizations for providing substance abuse treatment services?
READ IF NECESSARY: Managed care organizations have agreements with
certain health care providers who give services to plan members,
usually at discounted rates. Examples include managed behavioral
healthcare organizations (MBHOs), health maintenance organizations
(HMOs), and preferred provider organizations (PPOs).
<1> YES
<0> NO
DON’T KNOW
REFUSED
@

[@]

29

SECTION B:

CLIENT COUNT INFORMATION

IMPORTANT: Questions in Section B ask about two different time
periods, that is, the single day of March 30, 2007, and the
12-month period ending on March 31, 2007. Please pay special
attention to the period specified in each question.
READ IF NECESSARY: If this is a mental health facility, include in
your client counts all clients receiving substance abuse treatment,
even if substance abuse is their secondary diagnosis.
INTERVIEWER:
@
[@][nodata]

>a32<

HIT ENTER TO CONTINUE

Questions a33 through a38 ask about the number of clients in
treatment at this facility at specified times.
Please code the option below that best describes how client counts
will be reported in these questions.
INTERVIEWER:

CODE ONE ONLY

<1> Questions a33 through a38 will include client counts for
this facility alone [goto a33]
<2> Questions a33 through a38 will include client counts for
this facility combined with other facilities [goto a33]
<3> Client counts for this facility will be reported by
another facility [goto a41]
DON’T KNOW
REFUSED
@
[@]

HOSPITAL INPATIENT
>a33<

On March 30, 2007, did any patients receive HOSPITAL INPATIENT
substance abuse services at this facility?
<1> YES [goto a33a]
<0> NO [goto a34]
DON’T KNOW [goto a34]
REFUSED [goto a34]
@

[@]

30

>Va33<

Two responses I recorded appear to be inconsistent. I recorded
that this facility offers hospital inpatient substance abuse
services but did not have any clients receiving these services on
March 30, 2007.
Is that correct?
<1> YES, THAT IS CORRECT [goto a34]
<2> NO, FACILITY DOES NOT OFFER INPATIENT SERVICES [goto a24]
(CHANGE a25 AND THEN CHECK FORWARD)
<3> NO, FACILITY DID HAVE INPATIENTS ON MARCH 30 [goto a33]
DON’T KNOW [goto a34]
REFUSED [goto a34]
@

[@]

>Va33q<

Two responses I recorded appear to be inconsistent. I recorded
that this facility does not offer hospital inpatient substance
abuse services but did have clients receiving these services on
March 30, 2007. Is that correct?
<1> YES, THAT IS CORRECT [goto a33a]
<2> NO, FACILITY DOES OFFER INPATIENT SERVICES [goto a24]
(CHANGE a25 AND THEN CHECK FORWARD)
<3> NO, FACILITY DID NOT HAVE INPATIENTS ON [goto a33]
MARCH 30 (CHANGE a33)
DON’T KNOW [goto a33a]
REFUSED [goto a33a]
@

[@]

>a33a<

On March 30, 2007, how many patients received the following
HOSPITAL INPATIENT substance abuse services at this facility?
COUNT a patient in one service only, even if the patient received
both services. DO NOT count family members, friends, or other
non-treatment clients.
INTERVIEWER:

ENTER A NUMBER.

IF NONE, ENTER “0”

@1 Hospital inpatient detoxification
(Similar to ASAM Levels IV-D and III.7-D, medically managed
or monitored inpatient detoxification)
@2 Hospital inpatient treatment
(Similar to ASAM Levels IV and III.7, medically managed or
monitored intensive inpatient treatment)
@ NUMBER HOSPITAL INPATIENT TOTAL BOX

[@1] <
[@2] <

(d) DON’T KNOW
(r) REFUSED
@
>
>

31

32

>Va33ax<

Two responses I recorded may be inconsistent. I just recorded that
[fill a30a@1] patients were receiving hospital inpatient
detoxification on March 30. However, earlier I recorded that this
facility does not offer hospital inpatient detoxification. Have I
recorded something incorrectly?
<1> DID NOT HAVE HOSPITAL INPATIENT DETOXIFICATION CLIENTS
ON 3/30/07 [goto a33a]
<2> DOES OFFER HOSPITAL INPATIENT DETOXIFICATION –
CHANGE a24 [goto a24]
<3> CORRECT AS RECORDED [goto va33a2_ck]
DON’T KNOW [goto va33a2_ck]
REFUSED [goto va33a2_ck]
@

[@]

>Va33ax2<

Two responses I recorded may be inconsistent. I just recorded that
zero patients were receiving hospital inpatient detoxification on
March 30. However, earlier I recorded that this facility offers
hospital inpatient detoxification. Have I recorded something
incorrectly?
<1> DID HAVE HOSPITAL INPATIENT DETOXIFICATION CLIENTS
ON 3/30/07 [goto a33a]
<2> DOES NOT OFFER HOSPITAL INPATIENT DETOXIFICATION –
CHANGE a24_1 [goto a24@1]
<3> CORRECT AS RECORDED [goto va33a2_ck]
DON’T KNOW [goto va33a2_ck]
REFUSED [goto va33a2_ck]
@

[@]

>Va33bx<

Two responses I recorded may be inconsistent. I just recorded that
[fill a33a@2] patients were receiving hospital inpatient substance
abuse treatment on March 30. However, earlier I recorded that this
facility does not offer hospital inpatient substance abuse
treatment. Have I recorded something incorrectly?
<1> DID NOT HAVE HOSPITAL INPATIENT SUBSTANCE ABUSE CLIENTS
ON 3/30/07 [goto a33]
<2> DOES OFFER HOSPITAL INPATIENT SUBSTANCE ABUSE TREATMENT –
CHANGE a24 [goto a24]
<3> CORRECT AS RECORDED [goto va33a2b_ck]
DON’T KNOW [goto va33a2b_ck]
REFUSED [goto va33a2b_ck]
@

[@]

33

>Va33bx2<

Two responses I recorded may be inconsistent. I just recorded that
zero patients were receiving inpatient substance abuse treatment on
March 30. However, earlier I recorded that this facility offers
inpatient substance abuse treatment. Have I recorded something
incorrectly?
<1> DID HAVE HOSPITAL INPATIENT TREATMENT CLIENTS ON
3/30/07 [goto a33a@2]
<2> DOES NOT OFFER HOSPITAL INPATIENT TREATMENT –
CHANGE a24_2 [goto a24@2]
<3> CORRECT AS RECORDED [goto va33a2b_ck]
DON’T KNOW [goto va33a2b_ck]
REFUSED [goto va33a2b_ck]
@

[@]

>Va33a1<

Your response to this question is unusually large compared to most
other facilities. I have recorded that [fill tafill_] had
[fill a33a@tot] hospital inpatient substance abuse treatment
clients on March 30, 2007. Is that correct?
<1> YES, THAT IS CORRECT [goto a33b]
<2> NO, CHANGE THE NUMBER OF CLIENTS IN a33a [goto a33a]
@

[@]

>Va33a2<

Two responses I recorded are inconsistent. A moment ago, I
recorded that on March 30, 2007, some clients were receiving
hospital inpatient substance abuse services at [fill tafill_].
However, I’ve just recorded that zero clients were receiving
substance abuse treatment or detoxification. Have I recorded
something incorrectly?
<1> YES CHANGE a33 OR a33a [goto a33]
<0> NO [goto Va33a3]
DON’T KNOW [goto a33d]
REFUSED [goto a33d]
@

[@]

>Va33a3<

What type of hospital inpatient substance abuse services were
clients receiving at [fill tafill_] on March 30, 2007?
INTERVIEWER:

BACKCODE TO a33a (1 AND 2) WHEN APPROPRIATE

<1> TO RECORD VERBATIM AND END WITH // [specify] [goto a33d]
DON’T KNOW [goto a34]
REFUSED [goto a34]
@
[@]

34

>a33b<

How many of the patient from the HOSPITAL INPATIENTS TOTAL BOX were
under the age of 18?
INTERVIEWER:

ENTER A NUMBER.

IF NONE, ENTER “0”

@ NUMBER UNDER AGE 18
(d) DON’T KNOW
(r) REFUSED
@
[@]

>Va33b<

Two responses I recorded are inconsistent. I just recorded that
[fill a33b] hospital inpatients were under the age of 18.
However, earlier I recorded that [fill tafill_] had a total of
[fill a33a@tot] hospital inpatients on March 30. Have I recorded
something incorrectly?
<1> CHANGE THE NUMBER OF INPATIENTS IN a33a [goto a33a]
<2> CHANGE THE NUMBER UNDER AGE 18 IN a33b [goto a33b]
DON’T KNOW [goto a33c]
REFUSED [goto a33c]
@

[@]

>a33c_1<

How many of the patients from the HOSPITAL INPATIENT TOTAL BOX
received methadone or buprenorphine dispensed by this facility?
Include patients who received these drugs for detoxification or
maintenance purposes.
INTERVIEWER:

ENTER A NUMBER.

IF NONE, ENTER “0”

@1 METHADONE

>Va33c<

Two responses I recorded are inconsistent. I just recorded that
[fill a33c@tot] hospital inpatients received either methadone or
buprenorphine on March 30. However, earlier I recorded that
[fill tafill_] had a total of [fill a33a@tot] hospital inpatients
on March 30. Have I recorded something incorrectly?
<1> CHANGE THE NUMBER OF INPATIENTS IN a33a [goto a33a]
<2> CHANGE THE NUMBER RECEIVING METHADONE IN a33c [goto a33c]
(CURRENTLY RECORDED AS [fill a33c@1])
<3> CHANGE THE NUMBER RECEIVING BUPRENORPHHINE
IN a33c] [goto a33c@2]
(CURRENTLY RECORDED AS [fill a33c@2])
DON’T KNOW [goto a33d]
REFUSED [goto a33d]
@

[@]

35

>Va33c1<

Two responses I recorded may be inconsistent. I just recorded that
[fill a33c@tot] patients were receiving methadone or buprenorphine
dispensed at this facility. However, earlier I recorded that this
facility does not operate a methadone maintenance or detoxification
program at this facility.
Have I recorded something incorrectly?
<1> DID NOT HAVE METH/BUPRENORPHHINE CLIENTS –
CHANGE a33c [goto a33c]
<2> DOES OPERATE A METHADONE MAINTENANCE OR DETOXIFICATION PROGRAM
AT THIS FACILITY
CHANGE a19 [goto a19]
<3> CORRECT AS REPORTED
DON’T KNOW
REFUSED
@

[@]

>a33c_2<

How many of the patients from the HOSPITAL INPATIENT TOTAL BOX
received methadone or buprenorphine dispensed by this facility?
Include patients who received these drugs for detoxification or
maintenance purposes.
INTERVIEWER:

ENTER A NUMBER.

IF NONE, ENTER “0”

@2 BUPRENORPHINE
[@1] <
[@2] <

>a33d<

> <0>
> <0>

On March 30, 2007, how many hospital inpatient beds at this
facility were specifically designated for substance abuse
treatment?
ENTER (1) TO ENTER NUMBER
@an
NUMBER OF BEDS:
@

(0) NONE

(d) DON’T KNOW

(r) REFUSED

@num

[@]

>Va33az2<

Your response to this question is unusually large compared to
the [fill a33a@tot] patients who received inpatient services
on March 30. I recorded [fill tafill_] had [fill a32d@num]
beds designated for hospital inpatient substance abuse treatment
clients on March 30, 2007. Is that correct?
<1> YES, THAT IS CORRECT [goto a34]
<2> NO, CHANGE THE NUMBER OF BEDS IN a33d [goto a33d]
<3> NO, CHANGE THE NUMBER OF CLIENTS IN a33a
(CURRENTLY LISTED AS [fill a33a@tot]) [goto a33a]
DON’T KNOW

36

 REFUSED
@ [goto a33]
[@]

37

RESIDENTIAL (NON-HOSPITAL)
>a34<

On March 30, 2007, did any clients receive RESIDENTIAL
(non-hospital) substance abuse services at this facility?
<1> YES [goto a34a]
<0> NO [goto a35]
DON’T KNOW [goto a35]
REFUSED [goto a35]
@

[@]

>Va34q<

Two responses I recorded appear to be inconsistent. I recorded
that this facility does not offer residential non-hospital
substance abuse services but did have clients receiving these
services on March 30, 2007.
Is that correct?
<1> YES, THAT IS CORRECT [goto a34a]
<2> NO, FACILITY DOES OFFER RESIDENTIAL SERVICES [goto a25]
(CHANGE a25 THEN CHECK FORWARD)
<3> NO, FACILITY DID NOT HAVE RESIDENTIAL CLIENTS
ON [goto a34]
MARCH 30 (CHANGE a34 THEN CHECK FORWARD)
DON’T KNOW [goto a34a]
REFUSED [goto a34a]
@

[@]

>Va34q2<

Two responses I recorded appear to be inconsistent. I recorded
that this facility offers residential non-hospital substance abuse
services but did not have clients receiving these services on
March 30, 2007.
Is that correct?
<1> YES, THAT IS CORRECT [goto a35]
<2> NO, FACILITY DOES NOT OFFER RESIDENTIAL
SERVICES [goto a25]
(CHANGE a25 THEN CHECK FORWARD)
<3> NO, FACILITY DID HAVE RESIDENTIAL CLIENTS ON [goto a34]
MARCH 30 (CHANGE a34 THEN CHECK FORWARD)
DON’T KNOW [goto a35]
REFUSED [goto a35]
@

[@]

38

>a34a<

On March 30, 2007, how many clients received the following
RESIDENTIAL substance abuse services at this facility?
COUNT a client in one service only, even if the client received
multiple services. DO NOT count family members, friends, or other
non-treatment clients.
INTERVIEWER:

ENTER A NUMBER.

IF NONE, ENTER “0”

@1 Residential detoxification
(Similar to ASAM Level III.2-D, clinically managed
residential detoxification or social detoxification)
@2 Residential short-term treatment
(Similar to ASAM Level III.5, clinically managed
high-intensity residential treatment; typically 30 days
or less)
@3 Residential long-term treatment
(Similar to ASAM Levels III.3 and III.1, clinically managed
medium- or low-intensity residential treatment; typically
more than 30 days)
@num RESIDENTIAL TOTAL

[@1] <
[@2] <
[@3] <

>Va34act<

(d) DON’T KNOW
(r) REFUSED
@
> <0>
> <0>
> <0>

The number of clients receiving residential services is the same
number I recorded earlier for hospital inpatients. Are you
counting the same clients in both categories?
<1> YES - CHANGE HOSPITAL INPATIENTS [goto a33a]
<2> YES - CHANGE RESIDENTIAL CLIENTS [goto a34a]
<0> NO - NOT COUNTED TWICE
@

[@]

>Va34ax<

Two responses I recorded may be inconsistent. I just recorded that
[fill a34a@1] clients were receiving residential detoxification on
March 30, 2007. However, earlier I recorded that this facility
does not offer residential detoxification. Have I recorded
something incorrectly?
<1> DID NOT HAVE RESIDENTIAL DETOXIFICATION CLIENTS
ON 3/30/07 [goto a34a]
<2> DOES OFFER RESIDENTIAL DETOXIFICATION - CHANGE a25 [goto a25]
<3> CORRECT AS RECORDED [goto va34a4_ck]
DON’T KNOW [goto va34a4_ck]
REFUSED [goto va34a4_ck]
@

[@]

39

40

>Va34ax2<

Two responses I recorded may be inconsistent. I just recorded that
zero clients were receiving residential detoxification on March 30.
However, earlier I recorded that this facility offers residential
detoxification. Have I recorded something incorrectly?
<1> DID HAVE RESIDENTIAL DETOXIFICATION CLIENTS
ON 3/30/07 [goto a34a]
<2> DOES NOT OFFER RESIDENTIAL DETOXIFICATION –
CHANGE a25_1 [goto a25@1]
<3> CORRECT AS RECORDED
DON’T KNOW
REFUSED
@ [goto va34a4_ck]

[@]

>Va34a4<

Two responses I recorded may be inconsistent. I just recorded that
[fill a34a@2] clients were receiving residential short-term
treatment. However, earlier I recorded that this facility does not
offer residential short-term treatment. Have I recorded something
incorrectly?
<1> DID NOT HAVE RESIDENTIAL SHORT-TERM CLIENTS
ON 3/30/07 [goto a34a]
<2> DOES OFFER RESIDENTIAL SHORT-TERM TREATMENT –
CHANGE a25 [goto a25@2]
<3> CORRECT AS RECORDED
DON’T KNOW
REFUSED
@ [goto va34az_ck]

[@]

>Va34a42<

Two responses I recorded may be inconsistent. I just recorded that
zero clients were receiving residential short-term treatment on
March 30. However, earlier I recorded that this facility offers
residential short-term treatment. Have I recorded something
incorrectly?
<1> DID HAVE RESIDENTIAL SHORT-TERM TREATMENT CLIENTS
ON 3/30/07 [goto a34a]
<2> DOES NOT OFFER RESIDENTIAL SHORT-TERM TREATMENT –
CHANGE a25_2 [goto a25@2]
<3> CORRECT AS RECORDED
DON’T KNOW
REFUSED
@

[@]

41

>Va34az<

Two responses I recorded may be inconsistent. I just recorded that
[fill a34a@3] patients were receiving residential long-term
treatment. However, earlier I recorded that this facility does not
offer residential long-term treatment. Have I recorded something
incorrectly?
<1> DID NOT HAVE RESIDENTIAL LONG-TERM CLIENTS
ON 3/30/07 [goto a34a]
<2> DOES OFFER RESIDENTIAL LONG-TERM TREATMENT –
CHANGE a25 [goto a25@3]
<3> CORRECT AS RECORDED
DON’T KNOW
REFUSED
@ [goto Va31a1_ck]

[@]

>Va34az3<

Two responses I recorded may be inconsistent. I just recorded that
zero clients were receiving residential long-term treatment on
March 30. However, earlier I recorded that this facility offers
residential long-term treatment. Have I recorded something
incorrectly?
<1> DID HAVE RESIDENTIAL LONG-TERM TREATMENT CLIENTS
ON 3/30/07 [goto a34a@1]
<2> DOES NOT OFFER RESIDENTIAL LONG-TERM TREATMENT –
CHANGE a25_3 [goto a25@3]
<3> CORRECT AS RECORDED
DON’T KNOW
REFUSED
@

[@]

>Va34a1<

Your response to this question is unusually large compared to most
other facilities. I recorded [fill tafill_] had [fill a34a@tot]
residential substance abuse treatment clients on March 30, 2007.
Is that correct?
<1> YES, THAT IS CORRECT [goto a34b]
<0> NO, CHANGE THE NUMBER OF CLIENTS IN a34a [goto a34a]
DON’T KNOW
REFUSED
@ [goto a34b]

[@]

42

>Va34a2<

Two responses I recorded are inconsistent. A moment ago, I
recorded that on March 30, 2007, some clients were receiving
residential non-hospital substance abuse treatment or
detoxification at [fill tafill_]. However, I have just recorded
that zero clients were receiving these types of care. Have I
recorded something incorrectly?
<1> YES (CHANGE a34 or a34a) [goto a34]
<0> NO
DON’T KNOW [goto a34b]
REFUSED [goto a34b]
@

[@]

>Va34a3<

What type of residential non-hospital substance abuse treatment or
detoxification were clients receiving at [fill tafill_] on
March 30, 2007?
INTERVIEWER:

BACKCODE TO a34a (1, 2 AND 3) WHEN APPROPRIATE

<1> TO RECORD VERBATIM (END WITH //)[specify] [goto a34b]
DON’T KNOW [goto a34b]
REFUSED [goto a34b]
@
[@]

>a34b<

How many of the clients from the RESIDENTIAL TOTAL BOX were under
the age of 18?
INTERVIEWER:

ENTER A NUMBER.

IF NONE, ENTER “0”

@ NUMBER UNDER AGE 18
(d) DON’T KNOW
(r) REFUSED
@
[@]

>Va34b<

Two responses I recorded are inconsistent. I just recorded that
[fill a34b] residential clients were under the age of 18.
However, earlier I recorded that [fill tafill_] had a total of
[fill a34a@tot] residential clients on March 30. Have I recorded
something incorrectly?
<1> CHANGE THE NUMBER OF RESIDENTIAL CLIENTS IN a34a [goto a34a]
<2> CHANGE THE NUMBER UNDER AGE 18 IN a34b [goto a34b]
DON’T KNOW [goto a34c]
REFUSED [goto a34c]
@

[@]

43

>a34c_1<

How many of the clients from the RESIDENTIAL TOTAL BOX received
methadone or buprenorphine dispensed by this facility? Include
clients who received these drugs for detoxification or maintenance
purposes.
INTERVIEWER:

ENTER A NUMBER.

IF NONE, ENTER “0”

@1 METHADONE

>a34c_21<

How many of the clients from the RESIDENTIAL TOTAL BOX received
methadone or buprenorphine dispensed by this facility? Include
clients who received these drugs for detoxification or maintenance
purposes.
INTERVIEWER:

ENTER A NUMBER.

IF NONE, ENTER “0”

@2 BUPRENORPHINE
[@1] <1-20000> <0>
[@2] <1-20000> <0>

>Va34c<

Two responses I recorded are inconsistent. I just recorded that
[fill a34c@tot] residential clients received either methadone or
buprenorphine on March 30. However, earlier I recorded that
[fill tafill_] had a total of [fill a34a@tot] residential clients
on March 30.
Have I recorded something incorrectly?
<1> CHANGE THE NUMBER OF RESIDENTIAL CLIENTS IN a34a [goto a34a]
<2> CHANGE THE NUMBER RECEIVING METHADONE IN a34c_1 [goto a34c]
CURRENTLY RECORDED AS [fill a34c@1]
<3> CHANGE THE NUMBER RECEIVING BUPRENORPHINE
IN a34c_2 [goto a34c@2] CURRENTLY RECORDED AS [fill a34c@2]
DON’T KNOW [goto a34d]
REFUSED [goto a34d]
@

[@]

44

>Va34c1<

Two responses I recorded may be inconsistent. I just recorded that
[fill a34c@tot] clients were receiving methadone or buprenorphine
dispensed at this facility. However, earlier I recorded that this
facility does not a operate methadone maintenance or detoxification
program at this facility.
Have I recorded something incorrectly?
<1> DID NOT HAVE METH/BUPRENORPHINE CLIENTS –
CHANGE a34c [goto a34c]
<2> DOES OPERATE A METHADONE MAINTENANCE OR
DETOXIFICATION PROGRAM – CHANGE a19 [goto a19]
<3> CORRECT AS REPORTED, NO CHANGE NEEDED
DON’T KNOW
REFUSED
@

[@]

>a34d<

On March 30, 2007, how many residential beds at this facility were
specifically designated for substance abuse treatment?
ENTER (1) TO ENTER NUMBER
@an
NUMBER OF BEDS:

(0) NONE

(d) DON’T KNOW

(r) REFUSED

@num

(d) DON’T KNOW
(r) REFUSED
@
[@]

>Va34az2<

Your response to this question is unusually large compared to the
[fill a34a@tot] clients who received residential services on
March 30. I recorded [fill tafill_] had [fill a34d@num] beds
designated for residential substance abuse treatment clients on
March 30, 2007. Is that correct?
<1> YES, THAT IS CORRECT [goto a35]
<2> NO, CHANGE THE NUMBER OF BEDS IN a34d [goto a34d]
<3> NO, CHANGE THE NUMBER OF CLIENTS IN a34a [goto a34a]
CURRENTLY LISTED AS [fill a34a@tot]
DON’T KNOW
REFUSED
@ [goto a35]

[@]

45

OUTPATIENT
>a35<

During the month of March 2007, did any clients receive OUTPATIENT
substance abuse services at this facility?
<1> YES [goto a35a]
<0> NO [goto a36]
DON’T KNOW [goto a36]
REFUSED [goto a36]
@

[@]

>Va35q<

Two responses I recorded appear to be inconsistent. I recorded
that this facility does not offer outpatient substance abuse
services but did have clients who received outpatient substance
abuse services during the month of March. Is that correct?
<1> YES, THAT IS CORRECT [goto a35a]
<2> NO, FACILITY DOES OFFER OUTPATIENT SERVICES [goto a26]
(CHANGE a26 THEN CHECK FORWARD)
<3> NO, FACILITY DID NOT HAVE OUTPATIENT
CLIENTS DURING [goto a35] THAT TIME
(CHANGE a35 THEN CHECK FORWARD)
DON’T KNOW
REFUSED
@ [goto a35a]

[@]

46

>a35a<

As of March 30, 2007, how many active clients were enrolled in each
of the following OUTPATIENT substance abuse services at this
facility? An active outpatient client is someone who was seen at
this facility for a substance abuse treatment or detoxification at
least once during the month of March 2007 and was still enrolled in
treatment on March 30, 2007.
COUNT a client in one service only, even if the client received
multiple services. DO NOT count family members, friends, or other
non-treatment clients.
INTERVIEWER:

ENTER A NUMBER.

IF NONE, ENTER “0”

@1 Outpatient detoxification
(Similar to ASAM Levels I-D and II-D, ambulatory
detoxification)
@2 Outpatient methadone or buprenorphine maintenance
(Opioid maintenance therapy)
@3 Outpatient day treatment or partial hospitalization
(Similar to ASAM Level II.5, 20 or more hours per week)
@4 Intensive outpatient treatment
(Similar to ASAM Level II.1, 9 or more hours per week)
@5 Regular outpatient treatment
(Similar to ASAM Level I, outpatient treatment;
non-intensive)
@ num OUTPATIENT TOTAL

[@1]
[@2]
[@3]
[@4]
[@5]

<
<
<
<
<

>
>
>
>
>

(d) DON’T KNOW
(r) REFUSED
@

47

>Va35a<

The number of outpatient methadone/buprenorphine maintenance
clients is the same number as the number of regular outpatient
clients. Are you counting the same clients in both categories?
<1> YES, CORRECT THE NUMBER OF METHADONE/BUPRENORPHINE
MAINTENANCE CLIENTS IN a34a2
<2> YES, CORRECT THE NUMBER OF REGULAR OUTPATIENT CLIENTS IN a35a5
<3> NO, CORRECT AS RECORDED
DON’T KNOW
REFUSED
@

[@]

>Va35am<

Two responses I recorded may be inconsistent. I just recorded that
[fill a35a@1] clients were receiving outpatient detoxification as
of March 30, 2007. However, earlier I recorded that this facility
does not offer outpatient detoxification. Have I recorded
something incorrectly?
<1> DID NOT HAVE OUTPATIENT DETOXIFICATION CLIENTS
AS OF 3/30/07 [goto a35a]
<2> DOES OFFER OUTPATIENT DETOXIFICATION - CHANGE a26 [goto a26]
<3> CORRECT AS RECORDED [goto va35a2_ck]
DON’T KNOW [goto va35a2_ck]
REFUSED [goto va35a2_ck]
@

[@]

>Va35am2<

Two responses I recorded may be inconsistent. I just recorded that
zero clients were receiving outpatient detoxification as of
March 30, 2007. However, earlier I recorded that this facility
offers outpatient detoxification. Have I recorded something
incorrectly?
<1> DID HAVE OUTPATIENT DETOXIFICATION CLIENTS
AS OF 3/30/07 [goto a35a]
<2> DOES NOT OFFER OUTPATIENT DETOXIFICATION TREATMENT –
CHANGE a26 [goto a26@1]
<3> CORRECT AS RECORDED [goto va35a2_ck]
DON’T KNOW [goto va35a2_ck]
REFUSED [goto va35a2_ck]
@

[@]

48

>Va35an<

Two responses I recorded may be inconsistent. I just recorded
that [fill a35a@2] clients were receiving outpatient
methadone/buprenorphine maintenance as of March 30, 2007. However,
earlier I recorded that this facility does not offer outpatient
methadone/buprenorphine maintenance.
Have I recorded something incorrectly?
<1> DID NOT HAVE OUTPATIENT METHADONE/BUPRENORPHINE CLIENTS
AS OF 3/30/07 [goto a35a]
<2> DOES OFFER OUTPATIENT METHADONE/BUPRENORPHINE MAINTENANCE –
CHANGE a26 [goto a26@2]
<3> CORRECT AS RECORDED [goto va35a3_ck]
DON’T KNOW [goto va35a3_ck]
REFUSED [goto va35a3_ck]
@

[@]

>Va35an2<

Two responses I recorded may be inconsistent. I just recorded that
zero clients were receiving outpatient methadone/buprenorphine
maintenance, as of March 30, 2007. However, earlier I recorded
that this facility offers outpatient methadone/buprenorphine
maintenance.
Have I recorded something incorrectly?
<1> DID HAVE OUTPATIENT METHADONE MAINTENANCE/BUPRENORPHINE
CLIENTS AS OF 3/30/07 [goto a35a]
<2> DOES NOT OFFER OUTPATIENT METHADONE/BUPRENORPHINE
MAINTENANCE – CHANGE a25 [goto a26@2]
<3> CORRECT AS RECORDED [goto va35a3_ck]
DON’T KNOW [goto va35a3_ck]
REFUSED [goto va35a3_ck]
@

[@]

>Va35ao<

Two responses I recorded may be inconsistent. I just recorded that
[fill a35a@3] clients were receiving outpatient day treatment or
partial hospitalization as of March 30, 2007. However, earlier I
recorded that this facility does not offer outpatient day treatment
or partial hospitalization.
Have I recorded something incorrectly?
<1> DID NOT HAVE OUTPATIENT DAY TREATMENT OR PARTIAL
HOSPITALIZATION [goto a35a] CLIENTS AS OF 3/30/07 - CHANGE a35a
<2> DOES OFFER OUTPATIENT DAY TREATMENT OR PARTIAL HOSP –
CHANGE a26 [goto a26@3]
<3> CORRECT AS RECORDED [goto va35a4_ck]
DON’T KNOW [goto va35a4_ck]
REFUSED [goto va35a4_ck]
@

[@]

49

50

>Va35ao2<

Two responses I recorded may be inconsistent. I just recorded that
zero clients were receiving outpatient day treatment or partial
hospitalization as of March 30, 2007. However, earlier I recorded
that this facility offers outpatient day treatment or partial
hospitalization.
Have I recorded something incorrectly?
<1> DID HAVE OUTPATIENT DAY TREATMENT OR PARTIAL HOSPITALIZATION
CLIENTS AS OF 3/30/07 - CHANGE a35a [goto a35a]
<2> DOES NOT OFFER OUTPATIENT DAY TREATMENT OR PARTIAL
HOSP - CHANGE a26 [goto a26@3]
<3> CORRECT AS RECORDED [goto va35a4_ck]
DON’T KNOW [goto va35a4_ck]
REFUSED [goto va35a4_ck]
@

[@]

>Va35aq<

Two responses I recorded may be inconsistent. I just recorded that
[fill a35a@4] clients were receiving intensive outpatient treatment
as of March 30, 2007. However, earlier I recorded that this
facility does not offer intensive outpatient treatment.
Have I recorded something incorrectly?
<1> DID NOT HAVE INTENSIVE OUTPATIENT TREATMENT [goto a35a]
CLIENTS AS OF 3/30/07 - CHANGE a35a
<2> DOES OFFER INTENSIVE OUTPATIENT TREATMENT –
CHANGE a25 [goto a26@4]
<3> CORRECT AS RECORDED [goto va35a5_ck]
DON’T KNOW [goto va35a5_ck]
REFUSED [goto va35a5_ck]
@

[@]

>Va35aq2<

Two responses I recorded may be inconsistent. I just recorded that
zero clients were receiving intensive outpatient treatment as of
March 30, 2007. However, earlier I recorded that this facility
offers intensive outpatient treatment.
Have I recorded something incorrectly?
<1> DID HAVE INTENSIVE OUTPATIENT TREATMENT
CLIENTS AS OF 3/30/07 - CHANGE a35a[goto a35a]
<2> DOES NOT OFFER INTENSIVE OUTPATIENT TREATMENT –
CHANGE a26_4 [goto a26@4]
<3> CORRECT AS RECORDED [goto va35a5_ck]
DON’T KNOW [goto va35a5_ck]
REFUSED [goto va35a5_ck]
@

[@]

51

52

>Va35ar<

Two responses I recorded may be inconsistent. I just recorded that
[fill a35a@5] clients were receiving regular outpatient treatment
as of March 30, 2007. However, earlier I recorded that this
facility does not offer regular outpatient treatment.
Have I recorded something incorrectly?
<1> DID NOT HAVE REGULAR OUTPATIENT TREATMENT CLIENTS
AS OF 3/30/07 [goto a35a]
<2> DOES OFFER REGULAR OUTPATIENT TREATMENT –
CHANGE a26 [goto a26@5]
<3> CORRECT AS RECORDED
DON’T KNOW
REFUSED
@ [goto va35a_skip]

[@]

>Va35ar2<

Two responses I recorded may be inconsistent. I just recorded that
zero clients were receiving regular outpatient treatment as of
March 30, 2007. However, earlier I recorded that this facility
offers regular outpatient treatment.
Have I recorded something incorrectly?
<1> DID HAVE REGULAR OUTPATIENT TREATMENT CLIENTS
AS OF 3/30/07 - CHANGE a35a [goto a35a]
<2> DOES NOT OFFER REGULAR OUTPATIENT TREATMENT –
CHANGE a26_5 [goto a26@5]
<3> CORRECT AS RECORDED [goto va35a_skip]
DON’T KNOW [goto va35a_skip]
REFUSED [goto va35a_skip]
@

[@]

>Va35a<

Your response to this question is unusually large compared to most
other facilities. I have recorded [if a32 eq <2>] that these
facilities have[else]this facility had[endif] [fill a35a@tot]
outpatient substance abuse treatment clients actively enrolled in
outpatient treatment on March 30, 2007.
Is that correct?
<1> YES, THAT IS CORRECT [goto a35b]
<2> NO, CHANGE THE NUMBER OF CLIENTS IN
a35a 1 THROUGH 5 [goto a35a]
DON’T KNOW
REFUSED
@ [goto a35b]

[@]

53

>Va35a1<

Two responses I recorded appear to be inconsistent. A moment ago I
recorded that as of March 30, 2007, some clients were enrolled in
an outpatient substance abuse program at [fill tafill_]. However,
I’ve just recorded that no clients were receiving outpatient
detoxification, outpatient methadone/buprenorphine maintenance, day
treatment or partial hospitalization, intensive outpatient
treatment, or regular outpatient treatment services on March 30,
2007.
Have I recorded something incorrectly?
<1> YES (CHANGE a35 OR a35a) [goto a35]
<2> NO, ALL CLIENTS WERE DISCHARGED BEFORE MARCH 30 [goto a35_tot]
<0> NO
DON’T KNOW [goto a35_tot]
REFUSED [goto a35_tot]
@

[@]

>Va35a2<

What type of outpatient substance abuse services were clients
receiving at [fill tafill_] on March 30, 2007?
INTERVIEWER:

BACKCODE TO a35a (a THROUGH e) WHEN APPROPRIATE

<1> TO RECORD VERBATIM (END WITH //)[specify]
DON’T KNOW
REFUSED
@
[@]

>a35b<

How many of the clients from the OUTPATIENT TOTAL BOX were under
the age of 18?
ENTER (1) TO ENTER NUMBER
@an
NUMBER OF BEDS:

(0) NONE

@num

(d) DON’T KNOW
(r) REFUSED
@
[@]

54

(d) DON’T KNOW

(r) REFUSED

>Va35b<

Two responses I recorded are inconsistent. I just recorded that
[fill a35b:,] outpatients were under the age of 18. However,
earlier I recorded that [fill tafill_] had a total of
[fill a35a@tot:,] outpatients on March 30.
Have I recorded something incorrectly?
<1> CHANGE THE NUMBER OF OUTPATIENTS IN a35a [goto a35a]
<2> CHANGE THE NUMBER UNDER AGE 18 IN a35b [goto a35b]
DON’T KNOW [goto a35c]
REFUSED [goto a35c]
@

[@]

>a35c_1<

How many of the clients from the OUTPATIENT TOTAL BOX received
methadone or buprenorphine dispensed by this facility?
Include clients who received these drugs for detoxification or
maintenance purposes.
INTERVIEWER:

ENTER A NUMBER.

IF NONE, ENTER “0”

@1 METHADONE

>a35c_2<

How many of the clients from the OUTPATIENT TOTAL BOX received
methadone or buprenorphine dispensed by this facility?
Include clients who received these drugs for detoxification or
maintenance purposes.
INTERVIEWER:

ENTER A NUMBER.

IF NONE, ENTER “0”

@2 BUPRENORPHINE
[@1] <1-20000> <0>
[@2] <1-20000> <0>

>Va35c1<

Two responses I recorded may be inconsistent. I just recorded that
[fill a34c@tot] patients were receiving methadone or buprenorphine
dispensed at this facility. However, earlier I recorded that this
facility does not operate a methadone maintenance or detoxification
program at this location.
Have I recorded something incorrectly?
<1> DID NOT HAVE METH/BUPE CLIENTS - CHANGE a35c [goto a35c]
<2> DOES OPERATE A METHADONE MAINTENANCE OR DETOXIFICATION
PROGRAM – CHANGE a19 [goto a19]
<3> CORRECT AS REPORTED; NO CHANGE
DON’T KNOW
REFUSED
@ [goto Va35c2_ck]

[@]

55

56

>Va35c<

Two responses I recorded are inconsistent. I just recorded that
[fill a35c@tot] outpatients received either methadone or
buprenorphine on March 30. However, earlier I recorded that
[fill tafill_] had a total of [fill a35a@tot] outpatients on
March 30.
Have I recorded something incorrectly?
<1> CHANGE THE NUMBER OF OUTPATIENTS IN a35a [goto a35a]
<2> CHANGE THE NUMBER RECEIVING METHADONE IN a35c_1 [goto a35c]
(CURRENTLY RECORDED AS [fill a35c@1])
<3> CHANGE THE NUMBER RECEIVING BUPRENORPHINE
IN a35c_2 [goto a35c@2]
(CURRENTLY RECORDED AS [fill a35c@2])
DON’T KNOW [goto a35_tot]
REFUSED [goto a35_tot]
@

[@]

>Va35c2<

Two responses I recorded may be inconsistent. Earlier I recorded
that [fill a35a@2] outpatients were in a methadone/buprenorphine
maintenance program as of March 30, 2007 and I’ve just recorded
that only [fill a35c@tot] clients were receiving methadone or
buprenorphine as of March 30, 2007. Is that correct?
<1> YES, THAT IS CORRECT [goto va35c2a_ck]
<2> NO, CHANGE THE [fill a35a@2] METH/BUP CLIENTS
IN a35a [goto a35a@2]
<3> NO, CHANGE THE [fill a35c@tot] CLIENTS RECEIVING
METH/BUP IN a35c [goto a35c]
DON’T KNOW [goto va35c2a_ck]
REFUSED [goto va35c2a_ck]
@

[@]

>Va35c3<

Two responses I recorded may be inconsistent. Earlier I recorded
that this facility operates a methadone maintenance or
detoxification program, and I’ve just recorded that no clients were
receiving methadone or buprenorphine on March 30, 2007. Is that
correct?
<1> YES, THAT IS CORRECT
<2> NO, DID NOT OPERATE A METHADONE MAINTENANCE OR DETOXIFICATION
PROGRAM (CHANGE a19) [goto a19]
<3> NO, THAT IS NOT CORRECT. CLIENTS WERE RECEIVING
METHADONE [goto a33c]
OR BUPRENORPHINE (CHANGE INPATIENTS a33c)
(CHANGE RESIDENTIAL CLIENTS a34c)
(CHANGE OUTPATIENTS a35c)
DON’T KNOW
REFUSED
@

[@]

57

58

>a35d<

Without adding to the staff or space available in March 2007, what
is the maximum number of clients who could have been enrolled in
outpatient substance abuse treatment on March 30, 2007? This is
generally referred to as outpatient capacity.
<

> OUTPATIENT CAPACITY ON MARCH 30, 2007

DON’T KNOW
REFUSED
@
[@]

>Va35d<

Is it correct that [if a32 ne <2>]this facility[else]these
facilities[endif] could have accommodated an enrollment of
[fill a35d_tot] outpatient substance abuse clients on March 30,
2007?
<1> YES [goto a36]
<2> NO, CHANGE NUMBER OF OUTPATIENTS ENROLLED ON MARCH 30
([fill a35a@tot]) [goto a35a]
<3> NO, CHANGE OUTPATIENT CAPACITY [goto a35d]
DON’T KNOW
REFUSED
@

[@]

>Va35d2<

Earlier I recorded that you had [fill a35a@tot] active outpatient
clients as of March 30, 2007. However, you just reported that the
total outpatient capacity for [if a32 ne <2>]this facility these
facilities on March 30 was only [fill a35d].
Have I recorded something incorrectly?
<1> CHANGE OUTPATIENT CAPACITY IN a35d [goto a35d]
<2> CORRECT AS RECORDED
DON’T KNOW
REFUSED
@

[@]

59

>a36<

Some clients are treated for both alcohol and drug abuse, while
others are treated for only alcohol or only drug abuse.
Approximately what percent of the substance abuse treatment
clients enrolled at this facility on March 30, 2007, including
hospital inpatient, residential, and/or outpatient, were being
treated for . . .
INTERVIEWER:

THIS SHOULD TOTAL 100 PERCENT.
RECONCILE

INTERVIEWER:

ENTER A NUMBER.

IF NOT, PLEASE

IF NONE, ENTER “0”

@ num
@1 BOTH alcohol AND drug abuse
@2 ONLY alcohol abuse
@3 ONLY drug abuse

[@1] <
[@2] <
[@3] <

(d)
(r)
@
> <0>
> <0>
> <0>

DON’T KNOW
REFUSED

>a36_check] clients were receiving substance
abuse services on March 30. This should total 100 percent. I
have:
[fill a36@1] % were receiving services for abuse of both alcohol
and drugs
[fill a36@2] % were receiving services for alcohol abuse only
[fill a36@3] % were receiving services for drug abuse only.
What have I recorded incorrectly?
ENTER <1> TO REVIEW THE NUMBERS
@ [goto a36]
[@]

>a37<

Approximately what percent of the substance abuse treatment clients
enrolled at this facility on March 30, 2007, had a diagnosed
co-occurring substance abuse and mental health disorder?
INTERVIEWER:

ENTER A PERCENT.

<
> PERCENT OF CLIENTS
@
[@1] <0-100%>
[@2] <0-100%>
[@3] <0-100%>

60

IF NONE, ENTER “0”

>a38<

In the 12 months beginning April 1, 2006, and ending March 31,
2007, how many ADMISSIONS for substance abuse treatment did this
facility have? Count every admission and re-admission in this
12-month period. If a person was admitted 3 times, count this as
3 admissions.
For outpatient clients, consider an admission to be the initiation
of a treatment program or course of treatment. Count admissions
into treatment, not individual treatment visits.
If data for this time period are not available, use the most recent
12-month period for which you have data.
If this is a mental health facility, count all admissions in which
clients received substance abuse treatment, even if substance abuse
was their secondary diagnosis.
PROBE IF NECESSARY: If data for this period are not available, use
the most recent 12-month period for which you have data.
PROBE IF NECESSARY: If this is a mental health facility, count all
admissions in which clients received substance abuse treatment,
even if substance abuse was their secondary diagnosis.
<1-20000> NUMBER OF SUBSTANCE ABUSE ADMISSIONS
IN 12-MONTH PERIOD
DON’T KNOW
REFUSED
@

[@]

>Va38a4<

Your response to this question is unusually large compared to most
other facilities. I have recorded [fill a38] substance abuse
treatment admissions in the period from April 1, 2006 to March 31,
2007. Is that correct?
<1> YES [goto a39]
<0> NO, CHANGE ADMISSIONS IN a38 [goto a38]
DON’T KNOW [goto a39]
REFUSED [goto a39]
@

[@]

61

>Va38a1<

I’ve just recorded a number [if a38 eq a34_tot]equal
to[else]smaller than[endif] [fill tafill_][if a32 eq
<2>]’[else]’s[endif] one-day client count for their 12-month
admissions, so I would like to verify that I have recorded these
numbers correctly.
I have the March 30, 2007 Hospital Inpatients as [fill a30a@tot]
I have the March 30 Residential clients as [fill a34a@tot]
I have the Outpatients still enrolled on March 30
as [fill a35a@tot]
For a 1-day total of [fill a36_tot] clients.
And, I have the 12-month admissions for [fill tafill_]
recorded as [fill a38].
Are these numbers correct?
<1>
<2>
<3>
<4>
<5>

YES
NO,
NO,
NO,
NO,

[goto Va38a3_ck]
CHANGE HOSPITAL INPATIENTS
CHANGE RESIDENTIAL CLIENTS
CHANGE OUTPATIENT CLIENTS
CHANGE ADMISSIONS

DON’T KNOW [goto Va38a3_ck]
REFUSED [goto Va38a3_ck]
@
[@]

>Va38a3<

Your response to this question is unusually large compared to most
other facilities. I would like to verify the client counts that I
recorded for [fill tafill_]:
I have the March 30, 2007 Hospital Inpatients as [fill a33a@tot]
I have the March 30 Residential clients as [fill a34a@tot]
I have the Outpatients still enrolled on March 30
as [fill a35a@tot]
For a 1-day total of [fill a36_tot] clients.
And, I have [fill tafill_][if a32 eq <2>]’[else]’s[endif] 12-month
admissions recorded as [fill a38].
Are these numbers correct?
<1>
<2>
<3>
<4>
<5>

YES
NO,
NO,
NO,
NO,

[goto a39]
CHANGE HOSPITAL INPATIENTS
CHANGE RESIDENTIAL CLIENTS
CHANGE OUTPATIENT CLIENTS
CHANGE ADMISSIONS

DON’T KNOW [goto a39]
REFUSED [goto a39]
@ [goto a39]
[@]

62

>a38a<

How many of the 12-month treatment admissions included in question
37 were funded by ATR vouchers?
<

> NUMBER OF ADMISSIONS FUNDED BY ATR VOUCHERS
DON’T KNOW
REFUSED

@
[@]

>Va38a<

Two responses I recorded are inconsistent. I just recorded that
[fill a38a:,] 12-month treatment admissions included in question 38
were funded by ATR vouchers. However, earlier I recorded that
[fill tafill_] had a total of [fill a38a@tot:,] admissions in the
12 months beginning April 1, 2006, and ending March 31, 2007. Have
I recorded something incorrectly?
<1> CHANGE THE NUMBER OF ADMISSIONS IN a38 [goto a38]
<2> CHANGE THE NUMBER ADMISSIONS FUNDED BY ATR VOUCHERS
IN a38a [goto a38a]
DON’T KNOW [goto a39]
REFUSED [goto a39]
@

[@]

>a39<

How many facilities are included in the client counts reported in
questions a33 through a38?
<1> Only this facility [goto a40]
<2> This facility plus others [ENTER NUMBER OF FACILITIES
INCLUDED IN CLIENT COUNTS]
@ num THIS FACILITY
@ num PLUS ADDITIONAL FACILITIES
@ num TOTAL FACILITIES

[@] <
[@] <

(d) DON’T KNOW
(r) REFUSED
@
> <1-2>
> <1-2>

63

>a40<

For which of the numbers you just reported did you provide actual
client counts and for which did you provide your best estimate?
INTERVIEWER:

(1) ACTUAL
@1
@2
@3
@4

[@1]
[@2]
[@3]
[@4]

CODE “N/A” FOR ANY TYPE OF CARE NOT PROVIDED BY
THIS FACILITY ON MARCH 30, 2007.
(2) ESTIMATE

(-4) N/A

Hospital inpatient clients
Residential clients
Outpatient clients
12-month admissions

(d) DON’T KNOW
(r) REFUSED
@
<1,2,-4>
<1,2,-4>
<1,2,-4>
<1,2,-4>

SECTION C:
>a41<

GENERAL INFORMATION

Does this facility operate a halfway house or other transitional
housing for substance abuse clients at this location, that is,
[fill UFA@NAM1] [fill UFA@NAM2] located at
[fill LOC@UAD1] [fill LOC@UAD2]?
<1> YES
<0> NO
DON’T KNOW
REFUSED
@

[@]

>a42_1<

I have a few final, general questions about
[fill UFA@NAM1] [fill UFA@NAM2]
[fill LOC@UAD1] [fill LOC@UAD2].
Does this facility or program have licensing, certification, or
accreditation from any of the following organizations?
PROBE:

Only include facility-level licensing, accreditation, etc.,
related to the provision of substance abuse services.
Do not include general business licenses, fire marshal
approvals, personal-level credentials, or food service
licenses, etc.

INTERVIEWER:
(1) YES

CODE “YES,” “NO” OR “DON’T KNOW” FOR EACH

(0) NO

(d) DON’T KNOW

@1 State substance abuse agency
@2 State mental health department

64

(r) REFUSED

[@1] <0,1,d,r>
[@2] <0,1,d,r>

65

>a42_2<

READ STEM IF NECESSARY: Does this facility or program have
licensing, certification, or accreditation from any of the
following organizations . . .
PROBE:

Only include facility-level licensing, accreditation, etc.,
related to the provision of substance abuse services.
Do not include general business licenses, fire marshal
approvals, personal-level credentials, or food service
licenses, etc.

INTERVIEWER:
(1) YES

[@3]
[@4]
[@5]
[@6]

CODE “YES,” “NO” OR “DON’T KNOW” FOR EACH

(0) NO

(d) DON’T KNOW

(r) REFUSED

@3 State department of health
@4 Hospital licensing authority
@5 JCAHO or the Joint Commission on Accreditation of
Healthcare Organizations
@6 CARF or the Commission on Accreditation of
Rehabilitation Facilities
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>
<0,1,d,r>

>a42_3<

READ STEM IF NECESSARY: Does this facility or program have
licensing, certification, or accreditation from any of the
following organizations . . .
PROBE:

Only include facility-level licensing, accreditation, etc.,
related to the provision of substance abuse services.
Do not include general business licenses, fire marshal
approvals, personal-level credentials, or food service
licenses, etc.

INTERVIEWER:
(1) YES

CODE “YES,” “NO” OR “DON’T KNOW” FOR EACH

(0) NO

(d) DON’T KNOW

(r) REFUSED

@7 NCQA or National Committee for Quality Assurance
@8 COA or Council on Accreditation for Children &
Family Services
@9 Another state or local agency or other organization
(SPECIFY AND END WITH //)
[@7] <0,1,d,r>
[@8] <0,1,d,r>
[@9] <0> <1> [specify]

66

>a43<

Has this facility received a National Provider Identifier (NPI)?
<1> YES [goto a43a]
<0> NO [goto a44]
DON’T KNOW [goto a44]
REFUSED [goto a44]
@

[@]

>a43a<

What is the NPI for this facility?
@num NUMBER OF NPI
(d) DON’T KNOW
(r) REFUSED
@

[@]

>a44<

Does this facility have a website or webpage with information about
the facility’s substance abuse treatment programs?
<1> YES
<0> NO
DON’T KNOW
REFUSED
@

[@]

>a45<

If eligible, does this facility want to be listed in the National
Directory and online Treatment Facility Locator?
(Alternate wording: If this facility becomes eligible to be
included in the Directory and Locator, does this facility want to
be listed in SAMHSA’s National Directory and online Treatment
Facility Locator?)
READ IF NECESSARY: The Directory is an annual publication listing
substance abuse treatment facilities in the United States and the
services they offer. The Locator is an online version of the
Directory that also includes a mapping feature so clients can find
facilities easily.
<1> YES
<0> NO
DON’T KNOW
REFUSED
@

[@]

67

>a46<

Would you like to receive a free paper copy of the next National
Directory of Drug and Alcohol Abuse Treatment Programs when it is
published?
<1> YES
<0> NO
DON’T KNOW
REFUSED
@

[@]

>a47<

Who was primarily responsible for completing this form? This
information will only be used if we need to contact you about your
responses. It will not be published.

@an

(1) YES, NAME, & PHONE NUMBER ARE CORRECT
(0) NO, MAKE CORRECTIONS
(d) DON’T KNOW
(r) REFUSED
NAME:
TITLE:
PHONE: @phn
FAX NUMBER:
EMAIL ADDRESS:
@

Extension:

@ext

[@an]

68

>uloc<

[missing ]
I’d like to make a final verification of the name, address, and
phone number that will be listed in the National Directory [endif]
for this facility:
[fill UFA@NAM1]
[fill UFA@NAM2]
[FILL LOC@UAD1]
[FILL LOC@UAD2]
[FILL LOC@UCTY], [FILL LOC@UST] [FILL LOC@UZP5:0]-[FILL LOC@UZP4]
And the facility’s main telephone number is:
FPRF:0]-[fill FSUX:0] EXT: [fill FACN@PEXT]

([fill FARE]) [fill

(1) YES, FACILITY NAME, ADDRESS & PHONE NUMBER ARE CORRECT
(0) NO, MAKE CORRECTIONS
(d) DON’T KNOW
(r) REFUSED
FACILITY NAME:
FACILITY NAME (CONT):
ADDRESS 1:
ADDRESS 2:
CITY/STATE/ZIP:
FACILITY PHONE:

[@]
>other_1<

Extension:

[missing ][fill NFRi]

MPRID = [fill csid]

I’ve recorded [fill uloc@ac] as the area code.

Is that correct?

<1> YES [goto other2]
<0> NO, MAKE NECESSARY CHANGE
d> DON’T KNOW [goto other2]
REFUSED [goto other2]

>other2<

[fill NFRi]

MPRID = [fill csid]

Is there another substance abuse treatment facility in your
organization that is currently located at [fill LOC@UAD1] fill
LOC@UAD2] [fill LOC@UCTY], [fill LOC@UST] [fill LOC@UZP5:0]-[fill
LOC@UZP4:0]
<1> YES
<0> NO
<3> The location address has been edited but it is the same address

[@]
>uloc2<

[missing ][fill NFRi]

MPRID = [fill csid]

I would also like to verify this facility’s fax number.
records show: ([fill fac]) [fill fexc:0]-[fill fnum:0].
correct?

Our
Is that

<1> YES, FAX NUMBER IS CORRECT [goto uloc5]
<0> NO, FAX NUMBER IS NOT CORRECT, MAKE CHANGES [goto uloc4]

69

<2> NO LONGER HAVE FAX MACHINE [goto uloc5]
DON’T KNOW [goto uloc5]
REFUSED [goto uloc5]

70

>uloc3<

[missing ][fill NFRi]

MPRID = [fill csid]

Does this facility have a fax machine?
<1> YES
<0> NO [goto uloc5]
DON’T KNOW [goto uloc5]
REFUSED [goto uloc5]

[@]
>uloc4<

[fill NFRi]

MPRID = [fill csid]

What is your fax number:
ENTER FAX NUMBER:

[@]
>other_3<

[missing ][fill NFRi]

MPRID = [fill csid]

I’ve recorded [fill uloc4@ac] as the area code for the fax number.
Is that correct?
<1> YES [goto uloc5]
<0> NO, MAKE NECESSARY CHANGE
DON’T KNOW [goto uloc5]
REFUSED [goto uloc5]
[goto uloc4]

[@]
>uloc5<

[@]
>uloc1a2<

[fill NFRi]

MPRID = [fill csid]

INTERVIEWER:

ENTER RESPONDENT’S NAME.

[fill NFRi]

MPRID = [fill csid]

IF NOT KNOWN, ASK.

I may need to call you back regarding your new address. A note on
my computer indicates there may be duplicate information in our
database.
ENTER <1> TO CONTINUE
ENTER CALL BACK DATE AND TIME IN SUPERVISOR NOTES
<2> SUPERVISOR APPROVED

71

[@]
INTERVIEWER:ARE THERE ANY REASONS/PROBLEMS WITH THIS CASE THAT A
SUPERVISOR SHOULD REVIEW BEFORE IT IS FINAL STATUS?
<1> YES, SUPERVISOR REVIEW
<0> NO PROBLEMS, FINAL STATUS

[@]
>thnk<

Those are all the questions I have.
participation.

Thank you for your

Public burden for this collection of information is estimated to average 40 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. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden to SAMHSA Reports Clearance Officer;
Room 7-1044, 1 Choke Cherry Road, Rockville, MD 20857. 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. The
OMB number for this project is 0930-XXXX.

72