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pdfAPPENDIX A
CLIENT INTERVIEW MATERIALS
PRR Study Locator............................................................................................................A1
PRR 24 and 36 Month Interview.......................................................................................A2
Interview Show Cards.......................................................................................................A3
FORM APPROVED
OMB No. 0930-0248
Expires 10/31/06
See burden statement on baseline and follow-up questionairres
DATE __________________
INTERVIEWER ID# ______________
STUDY ID# ____________
PRR STUDY LOCATOR FORM
On this form we collect information that will help us reach you when it’s time for your follow-up
interview. The information you give us will be kept in a separate place from your answers on the
interview. It will be used only to locate you for your follow-up, and it will not be given to anyone else.
We will not tell any contact anything except that you have been asked to take part in a health study.
1. Please tell me your full name:
_______________________________________________________ (________________________)
First
Middle
Last
2. Date of Birth: ________/________/________
(Maiden)
3. SS#: ________-______-_________
4.
Other names or nicknames: __________________________________________________________
5.
Where were you born? _____________________________________________________________
(City, State)
6.
How long have you lived in the Cleveland/Cuyahoga County area? __________________________
7.
Driver’s License #: _________________________________ State: _________________________
8.
Do you have car? (If yes) License #: __________________________________________________
9.
Military #: _______________________________________________________________________
10. Residence address: _________________________________________________________________
(Street address)
(Apt. # or P.O. Box #)
_________________________________________________________________
(City)
(Zip)
11. How long have you lived there? ______________________________________________________
12. Do you plan to move anytime soon? ___________________________________________________
Do you know where to? _____________________________________________________________
13. Home Phone: (_______) ______________________________
14. Who else lives there?
Full Name: ___________________________________________________ ___________________
(First, Middle, Last)
(Relationship)
Full Name: ___________________________________________________ ___________________
(First, Middle, Last)
(Relationship)
1
15. Cell Phone: (_______) ________________________________
16. Pager: (_______) ____________________________________
17. E-mail address: ______________________________________
18. Work phone? (_____) _____________________________________ ______________________
(Name of Company)
19. Other phone? (_____) _____________________________________ ______________________
(Whose phone is this?)
20. Do you have a message number? (_______) ________________________________
21. Who lives there?
Full Name: ___________________________________________________ ___________________
(First, Middle, Last)
(Relationship)
Full Name: ___________________________________________________ ___________________
(First, Middle, Last)
(Relationship)
22. Address: _______________________________________________________________
(Street address)
(Apt. # or P.O. Box
_______________________________________
(City)
(Zip)
23. Best mailing address: _______________________________________________________________
(Street address)
(Apt. # or P.O. Box
_______________________________________
(City)
24. Phone: (_____) ______________________
(Zip)
25. Who lives there?
Full Name: ___________________________________________________ ___________________
(First, Middle, Last)
(Relationship)
Full Name: ___________________________________________________ ___________________
(First, Middle, Last)
(Relationship)
26. Best Contacts: Do you have friends or relatives who usually know how to reach you if you should
move or leave the program?
(1) Full Name: ______________________________________________________________________
(First, Middle, Last)
Address: ________________________________________________________________________
Phone? (_____) _____________________________________ Relationship: _________________
2
Best Contacts: Do you have friends or relatives who usually know how to reach you if you should
move or leave the program?
(2) Full Name: ______________________________________________________________________
(First, Middle, Last)
Address: ________________________________________________________________________
Phone? (_____) _____________________________________ Relationship: _________________
(3) Full Name: ______________________________________________________________________
(First, Middle, Last)
Address: ________________________________________________________________________
Phone? (_____) _____________________________________ Relationship: _________________
Now I’d like to ask you about your family. If you don’t know their addresses, just the towns would help.
(Complete entire family; use extra space if necessary. Don’t forget brothers, sisters, spouse, ex-spouse, girlfriend, boyfriend,
baby’s father/mother, grandparents, cousins, aunts, uncles, foster parents, God parents, and adult children. Include cell phone and
pager numbers.)
27. Mother: _________________________________________________________________________
(Full Name: First, Middle, Last)
__________________________________________________________________________
(Address)
Phone: (_____) __________________ DOB: __________________ In touch? ________________
28. Father: __________________________________________________________________________
(Full Name: First, Middle, Last)
__________________________________________________________________________
(Address)
Phone: (_____) __________________ DOB: __________________ In touch? ________________
29. Relative: _____________________________________________________ __________________
(Full Name: First, Middle, Last)
(Relationship)
__________________________________________________________________________
(Address)
Phone: (_____) __________________ DOB: __________________ In touch? ________________
3
30. Relative: _____________________________________________________ __________________
(Full Name: First, Middle, Last)
(Relationship)
__________________________________________________________________________
(Address)
Phone: (_____) __________________ DOB: __________________ In touch? ________________
31. Relative: _____________________________________________________ __________________
(Full Name: First, Middle, Last)
(Relationship)
__________________________________________________________________________
(Address)
Phone: (_____) __________________ DOB: __________________ In touch? ________________
32. Relative: _____________________________________________________ __________________
(Full Name: First, Middle, Last)
(Relationship)
__________________________________________________________________________
(Address)
Phone: (_____) __________________ DOB: __________________ In touch? ________________
33. Relative: _____________________________________________________ __________________
(Full Name: First, Middle, Last)
(Relationship)
__________________________________________________________________________
(Address)
Phone: (_____) __________________ DOB: __________________ In touch? ________________
34. Relative: _____________________________________________________ __________________
(Full Name: First, Middle, Last)
(Relationship)
__________________________________________________________________________
(Address)
Phone: (_____) __________________ DOB: __________________ In touch? ________________
35. Relative: _____________________________________________________ __________________
(Full Name: First, Middle, Last)
(Relationship)
__________________________________________________________________________
(Address)
Phone: (_____) __________________ DOB: __________________ In touch? ________________
4
36. Is there a case worker, doctor, community clinic, religious institution or other contact that you see
regularly?
Name: ___________________________________________________________________________
Address: _________________________________________________________________________
Phone? (_____) ___________________________ Agency: _______________________________
37. Do you receive money or foodstamps regularly from an agency?
_______ Yes _______ No
(If yes) Agency ___________________________________________________________________
When is it paid?___________________________________________________________________
Where is the check sent? ____________________________________________________________
Where do you cash the check? _______________________________________________________
Case worker: __________________________________________ File #: ___________________
Who is your Representative Payee? ___________________________________________________
Address: _________________________________________________________________________
Phone? (_____) ___________________________ Agency: _______________________________
38. Is there any place you go regularly to hang out or to meet with friends?
Place:___________________________________________________________________________
Address or Intersection:____________________________________________________________
Phone: (_____) _________________________
Phone: (_____) _________________________
Times you might be there: __________________________________________________________
________________________________________________________________________________
39. Are you on probation, parole, or have an active court case?
_______ Yes _______ No
(If yes) Agency ___________________________________________________________________
I.D. Number (Department of Probation/Corrections, Case Number): _________________________
Probation/Parole Officer Name ______________________________________________________
Phone: (_____) __________________
5
40. INTERVIEWER: IF R IS INCARCERATED, RECORD EXPECTED RELEASE OR TRANSFER
DATE AND TRANSFER DESTINATION.
Release/transfer date: ______/______/______
Destination: ______________________________________________________________________
Comments: _______________________________________________________________________
________________________________________________________________________
41. INTERVIEWER: PLEASE NOTE
APPROXIMATE HEIGHT: ____’____” HAIR COLOR: _________ EYE COLOR _________
42. ETHNICITY
___ Hispanic (Central American)
___ Hispanic (Cuban)
___ Hispanic (Dominican)
___ Hispanic (Mexican)
___ Hispanic (Puerto Rican)
___ Hispanic (South American)
___ Hispanic (Other)
Specify________________________
___ Black or African American
___ Asian
___ American Indian
___ Native Hawaiian or other Pacific Islander
___ Alaska Native
___ White
___ Other
Specify______________________________
42. INTERVIEWER: PLEASE NOTE ANY PERMANENT IDENTIFYING PHYSICAL
CHARACTERISTICS, SUCH AS SCARS OR TATTOOS.
6
Project Rehabilitation and Restitution
Twenty-Four (24) & Thirty-Six (36) Month
FOLLOW-UP INTERVIEW
CLIENT ID #
_____ _____ _____ _____ _____
INTERVIEW WAVE
BASELINE
INTERVIEWER ID (Circle one)
1
INTERVIEW MONTH
_______ _______
INTERVIEW DAY
_______ _______
INTERVIEW YEAR
_______ _______
BEGIN TIME
____ ____:____ ____ am/pm
2
3
4
5
i
ii
TABLE OF CONTENTS
Part A: Living Arrangements/Relationships/Family Situation...................................1
Part B: Drug and Alcohol Use....................................................................................7
Part C: Criminal Behavior in the Last 12 Months......................................................12
Part D: Education and Training..................................................................................15
Part E: Employment/Financial Support .....................................................................16
Part F: Friendships.....................................................................................................19
Part G: Leisure Time Activities..................................................................................20
Part H: Psychological Status ......................................................................................21
Part I: Abuse .............................................................................................................23
Part J: Health Status ..................................................................................................24
Part K: View of Self/Expectations for the Future ......................................................29
Part L: WURS-25 ........................................................................................................32
Part M: Circumstances, Motivation, and Readiness....................................................33
Part N: Quality of Life .................................................................................................34
Part O: Indiana Job Satisfaction Scale.........................................................................38
Part P: Lifestyle Criminality Screening Form .............................................................40
Part Q: Risk Assessment Battery.................................................................................42
Part R: Motivation for Sealing Records ......................................................................47
Part S: Client Service Utilization and Satisfaction…………………………………...52
Part T: Interviewer Impressions ..............................................................................68
iii
iv
PART A: LIVING ARRANGEMENTS/RELATIONSHIPS/FAMILY SITUATION
I’d like to start by asking you some questions about your living situation.
[Display Show Card # 1]
A1.Where are you currently living?
1 = One family house, duplex or condominium
2 = Apartment or other multiple family building
3 = Mobile home/Trailer
4 = Hotel room, rooming house or boarding house
5 = Hospital or medical institution
6 = Jail, prison or other controlled environment
7 = Residential treatment program
8 = Group residence or halfway house
9 = Homeless shelter
10 = Street, abandoned building, or no regular place
11 = Other (specify)_________________________
12 = Satellite house
A2.Would you move if you could?
0= No
1= Yes 2= Not sure
[Display Show Card #1]
A3.Where were you living most of the time during the past 12 months?
1 = One family house, duplex or condominium
2 = Apartment or other multiple family building
3 = Mobile home/Trailer
4 = Hotel room, rooming house or boarding house
5 = Hospital or medical institution
6 = Jail, prison or other controlled environment
7 = Residential treatment program
8 = Group residence or halfway house
9 = Homeless shelter
10 = Street, abandoned building, or no regular place
11 = Other (specify)_________________________
12 = Satellite house
A4.
In how many different places have you lived during the past 12 months?
PLACE = "01"]
[SAME
1
A5. What places in your neighborhood are important to you now?
[Display Show Card #2] CIRCLE YES IF ITEM IS MENTIONED, NO IF IT IS NOT.
THEN FOR EACH ITEM MENTIONED IN COLUMN (1), ASK:
Is this [PLACE] associated with drugs or violence?
[CODE COLUMN (2) TO REFLECT:]
0= no associations with illegal activities
1= drug associated
2= violence associated
3= drug AND violence associated
1
2
A5A1.
No Important Place
Yes No
A5A2.
0
1
2
3
A5B1.
Freeway
Yes No
A5B2.
0
1
2
3
A5C1.
Church
Yes No
A5C2.
0
1
2
3
A5D1.
Abandoned house/building
Yes No
A5D2.
0
1
2
3
A5E1.
Trolley/Bus
Yes No
A5E2.
0
1
2
3
A5F1.
Deli/corner store
Yes No
A5F2.
0
1
2
3
A5G1.
Discount department store
Yes No
A5G2.
0
1
2
3
A5H1.
Shopping mall or market
Yes No
A5H2.
0
1
2
3
A5I1.
Street/corner/parking lot
Yes No
A5I2.
0
1
2
3
A5J1.
School
Yes No
A5J2.
0
1
2
3
A5K1.
Liquor Store
Yes No
A5K2.
0
1
2
3
A5L1.
Projects
Yes No
A5L2.
0
1
2
3
A5M1. Recreation center/park/gym
Yes No
A5M2. 0
1
2
3
A5N1.
Police station
Yes No
A5N2.
0
1
2
3
A5O1.
Restaurant or bar
Yes No
A5O2.
0
1
2
3
A5P1.
Dope house/crack house
Yes No
A5P2.
0
1
2
3
A5Q1.
Other commercial area
Yes No
A5Q2.
0
1
2
3
A5R1.
Other transit area
Yes No
A5R2.
0
1
2
3
A5S1.
Other community area
Yes No
A5S2.
0
1
2
3
A5T1.
Other place (specify)
Yes No
A5T2.
0
1
2
3
2
[Display Show Card #3 AND ASK]
A6-7.
With whom did you live the most during (TIME PERIOD):
01
02
03
04
05
06
07
A8-9.
Both Parents
Father Mainly
Mother Mainly
Spouse (and children)
Children Only
Parent & Children
Other Relative
08
09
10
11
12
13
14
15
Member of the Opposite Sex (mate)
Member of the Same Sex (mate)
Other Friends
Fellow jail/prison inmates
Other Institution-Hospital residents
Other Treatment Program residents
Alone
Other (specify)
A6.
The past 12 months? ............................................_______________________
A7.
The past 3 months? .............................................._______________________
Were you living with someone in a sexual relationship – a spouse or significant other – during
(TIME PERIOD):
0 = No
1 = Yes, with (legal) spouse
5 = Incarcerated; with no “significant other”
2 = Yes, with significant other
7 = Incarcerated; has “significant other”
A8. The past 12 months?
[IF "NO" SKIP TO A18]
[IF “YES” Ask]
A9. The past 3 months?
A10. How long have (had) you been living together in this relationship (excluding prison time)?
[RECORD VERBATIM AND CODE IN MONTHS_________]
A11. How many different people did you live with in a sexual relationship during
the past 12 months?
.
A12-13. During (TIME PERIOD), did your spouse/partner get drunk 2 or more times per month?
A12. The past 12 months?
A13. The past 3 months?
(0) No
(0) No
(1) Yes
(1) Yes
A14-15. During (TIME PERIOD), did your spouse/partner use drugs?
(0) No
A14. The past 12 months?
A15. The past 3 months ?
(0) No
(1) Yes
(1) Yes
3
[IF "YES," TO A14, ASK A16]
[IF “YES,” TO A15, ASK A17]
A16-17. Did you and your partner use drugs together during (TIME PERIOD) ?
(0) No
A16. The past 12 months?
A17. The past 3 months?
(0) No
(1) Yes
(1) Yes
[Display Show Card 4]
A18-22. During the past 12 months, how often were you in contact with (PERSON)?
0 = Not at all
1 = Once or twice
2 = A few times
4 = About once a week
5 = Almost daily
6 = Daily
A23.
3 = About once a month
-9 = N/A-Has no parents/siblings/etc.
A18. Parents (or parent figures)?
(______)
A19. Brothers/sisters?
(______)
A20. Significant other (spouse or girlfriend)?
(______)
A21. Friends?
(______)
A22. Other significant person (Specify)
(______)
How many children do you have?
(___/___)
[IF NONE, CODE "00" AND SKIP TO A32]
A24 – A31a. Starting with the youngest, how old are your children?
A24 – A31b. Does this [child] live with you?
[Display Show Card 4]
A24 – A31c. During the past 12 months, how often have you been in contact with [child]?
0 = Not at all 1 = Once or twice 2 = A few times
4 = About once a week
5 = Almost daily
Ages
(Youngest at top)
A24a
A25a
A26a
A27a
A28a
A29a
A30a
A31a
_______
_______
_______
_______
_______
_______
_______
_______
3 = About once a month
6 = Daily
Does Child live
with Respondent
A24b
A25b
A26b
A27b
A28b
A29b
A30b
A31b
(0) No
(0) No
(0) No
(0) No
(0) No
(0) No
(0) No
(0) No
(1) Yes
(1) Yes
(1) Yes
(1) Yes
(1) Yes
(1) Yes
(1) Yes
(1) Yes
Frequency
Contact
A24c _________
A25c _________
A26c _________
A27c _________
A28c _________
A29c _________
A30c _________
A31c _________
4
Now we are going to discuss the help and encouragement you may have received from your FAMILY OR
FRIENDS with your treatment and recovery effort
[Display Show Card 5]
A32-38. In the past 12 months, how much encouragement have you received from your:
0= None
1= Low
2= Moderate
3= High
A32. Spouse/sexual partner?
A33. Siblings (brother or sister)?
A34. Children (18 or older)?
A35. Children (18 or younger)?
A36. Parents (mother or father)?
A37. Other close relatives?
A38. Friends?
6= Too young to be aware
(______)
(______)
(______)
(______)
(______)
(______)
(______)
[Display Show Card 6]
A39. In the past 12 months, when you were on the streets (i.e., out of prison), how often did you get money,
food, shelter or other help from your family or relatives?
0 = Never
1 = Rarely
2 = Sometimes 3 = Often
4 = Almost always
5 = Always
(________)
A40-41. Were you unhappy or dissatisfied with your situation at home (where you were living) in
(TIME PERIOD)?
A42.
A40.
The past 12 months?
(0) No
A41.
The past 3 months?
(0) No
(1) Yes
(1) Yes
Have you had serious problems getting along with the people you have lived with in the past 12
months? This includes physical fights, angry outbursts, threatening language or gestures. [CODE
"N/A" IF LIVES ALONE AND SKIP TO A52]
(0) No
(1) Yes
[IF "YES," ASK]
A43. With whom (circle all that apply)?
01
02
03
04
05
06
07
Both Parents
Father Mainly
Mother Mainly
Spouse (and children)
Children Only
Parent & Children
Other Relative
08
09
10
11
12
13
14
15
[Display Show Card 7]
Member of the Opposite Sex (mate)
Member of the Same Sex (mate)
Other Friends
Fellow jail/prison inmates
Other Institution-Hospital residents
Other Treatment Program residents
Alone
Other (specify)
5
A44.
Have you had serious problems getting along with the people you have lived with in the past 3
months? This includes physical fights, angry outbursts, threatening language or gestures.
(0) No
(1) Yes
[IF "YES," ASK]
A45. With whom? (circle all that apply)
01
02
03
04
05
06
07
Both Parents
Father Mainly
Mother Mainly
Spouse (and children)
Children Only
Parent & Children
Other Relative
08
09
10
11
12
13
14
15
[Display Show Card 7]
Member of the Opposite Sex (mate)
Member of the Same Sex (mate)
Other Friends
Fellow jail/prison inmates
Other Institution-Hospital residents
Other Treatment Program residents
Alone
Other (specify)
A46 – A51. [Display Show Card 8]
Thinking about the people you've lived with for most of the past 12 months,
use this card and tell me how often you: [If respondent lived in different households for equal
lengths of time, use the most recent experience.]
0 = Never 1 = Rarely 2 = Sometimes 3 = Often
4 = Almost always
5 = Always
A46.
Got along together?
(______)
A47.
Really enjoyed being together?
(______)
A48.
Got drunk together?
(______)
A49.
Used other drugs together?
(______)
A50.
Had serious talks about each other's interests and needs?
(______)
A51.
Helped each other with problems?
(______)
A52 – A57. [Display Show Card 9] Think back to the past month. How would you rate your relationship
with your [PERSON] during this time?
1 = Couldn't be worse
2 = Pretty bad
3 = Okay
4 = Pretty good 5 = Couldn't be better
A52. Mother/mother figure
(________)
A53. Father/father figure
(________)
A54. Brother(s)
(________)
A55. Sister(s)
(________)
A56. Significant other (spouse/partner)
(________)
6
A57. Children
(________)
PART B: DRUG AND ALCOHOL USE
This next section is on drug and alcohol use.
Think back to the past month.
B1. What was your primary drug during the past month?
(Circle only one response but Do Not Read Responses Aloud)?
A) Alcohol
G) Heroin
M) Other Amphetamines S) Ketamine/Special
K/Vitamin K
B) Inhalants
H) Heroin and Cocaine
together
N) Minor Tranquilizers
T) Rohypnol (Roofies)
C) Marijuana and hashish I) Prescribed Methadone
O) Barbiturates
U) GHB/Grievous Bodily
Harm/Liquid Ecstasy
D) Hallucinogens
J) Street Methadone
P) Other sedatives/
hypnotics
V) More than one
substance at a time
E) Crack/freebase
K) Other Opiates
Q) PCP
W) Other (specify)
F) Cocaine
L) Methamphetamines or R) Ecstasy/MDMA
speed
Now I'd like to talk about your drug or alcohol use in the past 12 months.
B2.
During the past 12 months, has your drug or alcohol use decreased or stopped?
(0) No
(1) Yes
[IF NO, SKIP TO B6. IF “YES,” ASK]
B3-5. Why do you think you have cut down or stopped your use of alcohol and/or drugs?
Reason #1____________________________________________________________________
____________________________________________________________________________
Reason #2____________________________________________________________________
____________________________________________________________________________
Reason #3 ________________________________________________________________________________
__________________________________________________________________________________________
7
[Display Show Card 10]
B6 (A – W). Look at this card and tell me which of the substances listed you have used during the past 12 months
PLACE A CHECK MARK NEXT TO EACH SUBSTANCE MENTIONED ON DRUG USAGE CHART
ON NEXT PAGE; BOLDED SUBSTANCE ARE CONSIDERED INJECTABLE, FOR EACH OF
THESE MENTIONED, PLACE A CHECK MARK NEXT TO SUBSTANCE ON PAGE 10 (B7)
IF NO DRUG OR ALCOHOL USAGE DURING THE PAST YEAR, ASK:
B6A. You've indicated that you haven't used any alcohol or drugs
during the past 12 months. Is this correct?
(0) No
(1) Yes
[IF "YES," SKIP TO C1]
[FOR EACH SUBSTANCE CHECKED, Display Show CARD 11 and ASK]
B6 (A – W). Now, how often have you used (substance) during (TIME PERIOD)
1. The past 12 months?
2. The past 3 months?
[RECORD IN DRUG USAGE CHART AS FOLLOWS:]
00 = Never
01 = Several times a year (less than once a month)
02 = About once a month
03 = About once every two weeks
04 = About once a week
05 = Several times a week
06 = Every day
07 = More than once every day
8
DRUG USAGE CHART
USE SCALE ON P. 8
Code Type of
No. Drug
Year prior
How Often
How Often
3 months prior
__A Alcohol—any use .......................................................... 1. ____/____ 2. ____/____
__B Alcohol—to intoxication................................................ 1. ____/____ 2. ____/____
__C Inhalants (glue, gas, paint, toluene, liquid paper) ......... 1. ____/____ 2. ____/____
__D Marijuana/Hashish ........................................................ 1. ____/____ 2. ____/____
__E Hallucinogens (LSD, DMT, Peyote) .............................. 1. ____/____ 2. ____/____
__F Crack/Freebase............................................................. 1. ____/____ 2. ____/____
__G Cocaine (by itself) ....................................................... 1. ____/____ 2. ____/____
__H Heroin (by itself).......................................................... 1. ____/____ 2. ____/____
__I
Heroin and Cocaine (used together) ......................... 1. ____/____ 2. ____/____
__J
Prescribed Methadone .................................................. 1. ____/____ 2. ____/____
__K Street Methadone (non-prescription) .......................... 1. ____/____ 2. ____/____
__L Other Opiates (Codeine, Morphine, Demerol) .......... 1. ____/____ 2. ____/____
__M Methamphetamine/Speed/Ice/Crank.......................... 1. ____/____ 2. ____/____
__N Other Amphetamines (Uppers/Diet Pills) .................. 1. ____/____ 2. ____/____
__O Minor tranquilizers (Librium, Valium, etc.) ..................... 1. ____/____ 2. ____/____
__P Barbiturates (downs) .................................................. 1. ____/____ 2. ____/____
__Q Other Sedatives/Hypnotics (Quaaludes, etc.) ............... 1. ____/____ 2. ____/____
__R PCP............................................................................... 1. ____/____ 2. ____/____
__S Ecstasy (MDMA) ........................................................... 1.____/____ 2.____/____
__T Ketamine/Special K/Vitamin K ...................................... 1.____/____ 2.____/____
__U Rohypnol (Roofies) ....................................................... 1.____/____ 2.____/____
__V GHB/Grievous Bodily Harm/Liquid Ecstasy .................. 1.____/____ 2.____/____
__W More than one drug at a time (excluding alcohol)……..1.____/____ 2.____/____
__X Other (Specify drug).................................................... 1. ____/____ 2. ____/____
9
For each drug the respondent reported using in the past 12 months, ASK:
B7. Did you inject [drug] in the past 12 months?
[IF “NO” SKIP TO NEXT APPLICABLE DRUG]
Now, how often have you injected [drug] during (TIME PERIOD)
1. The past 12 months? [IF “NO” SKIP TO NEXT DRUG]
2. The past 3 months?
How Often
Year Prior
Inject Year prior
__A (0) No (1) Yes
__B (0) No (1) Yes
__C (0) No (1) Yes
__D (0) No (1) Yes
__E (0) No (1) Yes
__F (0) No (1) Yes
__G (0) No (1) Yes
__H (0) No (1) Yes
B8.
B9.
How Often
3 months prior
Cocaine (by itself)………………………………1. _____/_____ 2. _____/_____
Heroin (by itself)………………………………..1. _____/_____ 2. _____/_____
Heroin and cocaine together…………………….1. _____/_____ 2. _____/_____
Other opiates (codeine, morphine, demerol)….…1. _____/_____ 2. _____/_____
Methamphetamines/speed/ice……………….…..1. _____/_____ 2. _____/_____
Other amphetamines………………………….…1. _____/_____ 2. _____/_____
Barbiturates……………………………………...1. _____/_____ 2. _____/_____
Other drug………………………………….……1. _____/_____ 2. _____/_____
What would you consider to have been your:
a.
Primary (“preferred”) drug during the past 12 months?
__________
b.
Secondary drug during the past 12 months?
__________
What would you consider to have been your:
a.
Primary (“preferred”) drug during the past 3 months?
__________
b.
Secondary drug during the past 3 months?
__________
[CODE B8 & B9 FROM LIST BELOW; IF NO SECONDARY DRUG, CODE "N/A"]
______________________________________________________________________
G) Heroin
M) Other Amphetamines S) Ketamine/Special
A) Alcohol
K/Vitamin K
B) Inhalants
H) Heroin and Cocaine
together
N) Minor Tranquilizers
T) Rohypnol (Roofies)
C) Marijuana and hashish I) Prescribed Methadone
O) Barbiturates
U) GHB/Grievous Bodily
Harm/Liquid Ecstasy
D) Hallucinogens
J) Street Methadone
P) Other sedatives/
hypnotics
V) More than one
substance at a time
E) Crack/freebase
K) Other Opiates
Q) PCP
W) Other (specify)
F) Cocaine
L) Methamphetamines or R) Ecstasy/MDMA
speed
10
B10. During [TIME PERIOD], how did you usually get your drugs? [READ RESPONSE OPTIONS]
a.
The past 12 months?
b.
The past 3 months?
(_____/_____)
(_____/_____)
01 = You stole them
02 = You were a runner, look-out, etc.
03 = You traded sex for drugs
04 = Your friends gave them to you
05 = You bought them
06 = You dealt drugs to support your habit
07 = You received them free due to your gang rank
08 = Other (specify)
[Display Show Card 12 FOR B11-25]
B11-14. How often, in the past 12 months, you have used drugs/alcohol because:
0= Never
1= Rarely 2= Sometimes 3= Often
4= Almost Always
5= Always
B11.
You felt bored?.................................................................................(________)
B12.
You felt lonely? ................................................................................(________)
B13.
You felt sad? ....................................................................................(________)
B14.
You felt angry?.................................................................................(________)
B15-20. How often, in the past 12 months, did you use drugs or alcohol to help you:
B15.
Increase energy or alertness? ............................................................(________)
B16.
Find excitement? ..............................................................................(________)
B17.
To feel comfortable around people?.................................................(________)
B18.
Have fun and party with friends? .....................................................(________)
B19.
Forget or escape problems? ..............................................................(________)
B20.
Relax from pressures or stress? ........................................................(________)
B21-25. How often, in the past 12 months, was your drug or alcohol use caused by:
B26.
B21.
Just being in certain places or situations that made
you want them?.................................................................................(________)
B22.
Pressures from others to use them? ..................................................(________)
B23.
Having problems you can't solve? ....................................................(________)
B24.
Drugs/alcohol being so easy to get? .................................................(________)
B25.
Your need to feel high? ....................................................................(________)
Do you want to stop using?
0= No
1= Yes
2= Not sure ...................(________)
11
PART C: CRIMINAL BEHAVIOR IN THE LAST 12 MONTHS
The next questions are about your involvement in illegal activities during the past 12 months,
including things for which you may or may not have been caught. Remember that it’s important for
you to respond honestly, and that what you tell me is private and confidential.
C1.
How much time did you spend in jail/prison during the past 12 months? [Code in days]
RECORD VERBATIM
C2.
How many different times have you been in jail or prison during (TIME PERIOD)?
a.
The past 12 months?
(_____/_____)
[IF “NO TIME IN JAIL OR PRISON IN PAST 12 MONTHS, SKIP TO C3]
b.
The past 3 months?
(_____/_____)
C3-21. a) Were you involved in (ILLEGAL ACTIVITY) during the past 12 months?
[IF NO, ENTER “0” UNDER COLUMN A AND SKIP TO NEXT CRIMINAL ACTIVITY]
[IF "YES," ASK THE FOLLOWING AND RECORD RESPONSES ON CHART]
b) How many times were you involved in this activity during the past 12 months?
c) How many times were you arrested for this activity during the past 12 months?
d) Were you involved in (ILLEGAL ACTIVITY) during the past 3 months?
[IF NO, ENTER “0” UNDER COLUMN D AND SKIP TO NEXT CRIMINAL ACTIVITY]
IF "YES," ASK:
e) How many times were you involved in this activity during the
past 3 months?
IF “0” DURING PAST 3 MONTHS, SKIP TO NEXT ACTIVITY
f) How many times were you arrested for this activity during the
past 3 months?
[IF NO ILLEGAL ACTIVITIES IN CHART, SKIP TO C24]
12
C. ARREST/ILLEGAL ACTIVITY CHART
Past 12 months
Criminal Number
Activity of times
Arrests
Most recent 3 months
Criminal Number
Activity Of times
Arrests
3.
Drinking alcohol (DWI, DUI, public consumption or
intoxication)?......................................................................... a. ____ b. ____ c. ____ d. ____ e. ____ f. ____
4.
Use/possession of illegal drugs (or paraphernalia)? .............. a. ____ b. ____ c. ____ d. ____ e. ____ f. ____
5.
Sale, distribution, or manufacturing of any drugs (not
counting use or possession)?
6.
Forgery or fraud (writing bad checks, running con games)... a. ____ b. ____ c. ____ d. ____ e. ____ f. ____
7.
Forgery of drug prescriptions?............................................... a. ____ b. ____ c. ____ d. ____ e. ____ f. ____
8.
Fencing (buying/receiving stolen property)? ......................... a. ____ b. ____ c. ____ d. ____ e. ____ f. ____
9.
Illegal gambling, running numbers, or bookmaking?............ a. ____ b. ____ c. ____ d. ____ e. ____ f. ____
a. ____ b. ____ c. ____ d. ____ e. ____ f. ____
10. Prostitution or pimping?........................................................ a. ____ b. ____ c. ____ d. ____ e. ____ f. ____
11. Burglary or auto theft?........................................................... a. ____ b. ____ c. ____ d. ____ e. ____ f. ____
12. Other theft (larceny, shoplifting)? ......................................... a. ____ b. ____ c. ____ d. ____ e. ____ f. ____
13. Robbery (armed robbery, mugging)?..................................... a. ____ b. ____ c. ____ d. ____ e. ____ f. ____
14. Rape? ..................................................................................... a. ____ b. ____ c. ____ d. ____ e. ____ f. ____
15. Murder? ................................................................................. a. ____ b. ____ c. ____ d. ____ e. ____ f. ____
16. Violence against other persons (aggravated assault,
kidnapping, threatening with a weapon, arson, etc.)?
a. ____ b. ____ c. ____ d. ____ e. ____ f. ____
17. Weapons offenses? ................................................................ a. ____ b. ____ c. ____ d. ____ e. ____ f. ____
18. Vandalism? ............................................................................ a. ____ b. ____ c. ____ d. ____ e. ____ f. ____
19. Vagrancy, loitering? .............................................................. a. ____ b. ____ c. ____ d. ____ e. ____ f. ____
20. Trafficking people across the border?……………………… a. ____ b. ____ c. ____ d. ____ e. ____ f. ____
21. Other Illegal Activity? (Specify) ______________________ a. ____ b. ____ c. ____ d. ____ e. ____ f. ____
13
C22.
Which statement best describes why you engaged in illegal activity during the past year?
I engaged in illegal activity
1 = For drugs or for money to get drugs
2 = For the excitement
3 = To get money for food or shelter
4 = For nice clothes, a stereo, cars or other things
5 = Because I wanted to be accepted by my friends
6 = Other (specify)______________________________________________
[SHOW CARD 13 AND SAY]
C23. How much of your income or source of support usually came from some kind of illegal activity during
[TIME PERIOD]
0 = None
1= Very little 2 = About 1/4 3 = About 1/2
4 = About 3/4
5 = Almost all
6 = All of it -9 = Incarcerated
a.
The past 12 months?................. ......................................................______
b.
The past 3 months? ........................................................................ ______
C24. Did you have any parole violations during the last 12 months?
[IF NO, SKIP TO PART D.]
C25.
How many?
C26.
How many days did you serve on the violation(s)? [TOTAL]
0= No time served
1= 01-30
2= 31-60
3= 61-90
(0) No (1) Yes
4= 91-120
5=121-180
6=181-270
7=271-365
14
PART D: EDUCATION AND TRAINING
Now I'd like to ask you some questions about any educational or training experiences you may have
had since paroling.
D1.
During the past 12 months, were you enrolled in a school or vocational training program?
(0) No
(1) Yes
[IF "NO," CODE "0" AND SKIP TO PART E]
D2.
How many weeks were you actually enrolled in training/classes during the past 12 months?
[Number of mo. X 4= weeks]
[IF MORE THAN ONE TRAINING CLASS USE WORKSHEET BELOW TO DETERMINE TOTAL
NUMBER OF WEEKS ENROLLED IN TRAINING PROGRAMS]
TRAINING CLASS WORKSHEET
NAME OF CLASS OR PROGRAM
NO. OF WEEKS
TOTAL (ENTER ABOVE)
D3.
Did you complete any training or receive any certificates, degrees, diplomas, etc. during the past 12
months?
(0) No
(1) Yes
Specify Degrees:
15
PART E: EMPLOYMENT/FINANCIAL SUPPORT
I'd like to ask you a few questions about any employment you've had and other means of
support during the past year.
E1. Did you hold a job during:
a. The past 12 months?
(0) No (1) Yes
[IF “NO,” SKIP E2 and ASK E2a & E2B]
b. The past 3 months?
(0) No
(1) Yes
[IF “NO” ASK E2b AND THEN CONTINUE but SKIP ALL “B” QUESTIONS REQUESTING
WORK INFORMATION DURING THE past 3 months]
E2. What was the reason you were not working during the [TIME PERIOD]?
a. The past 12 months?
______/______
b. The past 3 months?
______/______
1 = Not in labor force - housewife
2 = Not in labor force - student
3 = Not in labor force - disabled
4 = Not in labor force - retired
5 = Not in labor force - institutionalized: jail, hospital, etc.
6 = Not in labor force - (other, specify _____________________)
7 = Looked, but could not find a job
8 = Did not look for job
9 = Involved in drug related activities (selling, etc.)
10 = Involved in other illegal activities
[IF CLIENT HAS NOT WORKED IN THE LAST 12 MONTHS, SKIP TO E14]
E3.How many different jobs did you have during [TIME PERIOD]
a. The past 12 months?
_____/_____
b. The past 3 months?
_____/_____
E4.How many hours did you typically work per week at this/these jobs during [TIME PERIOD]?
a. The past 12 months?
b. The past 3 months?
_____/_____
_____/_____
16
E5.Which best describes this job/these jobs during [TIME PERIOD]?
a. The past 12 months?
_____/_____
_____/_____
b. The past 3 months?
1 = Odd jobs (occasional or irregular)
2 = Part-time (under 35 hours per week)
3 = Full-time (35 hours or more per week)
E6. [Display Show Card #14] What kind of job did you have during [TIME PERIOD]?
a. The past 12 months?
b. The past 3 months?
_____/_____
_____/_____
E7. What was your weekly take home pay ($) during [TIME PERIOD]?
a. The past 12 months?
b. The past 3 months?
_____/_____
_____/_____
E8. During [TIME PERIOD], about how many days did you lose from work because of drug or alcohol use?
a. The past 12 months?
b. The past 3 months?
_____/_____
_____/_____
E9. How many days were you employed during [TIME PERIOD]?
a. The past 12 months?
b. The past 3 months?
_____/_____
_____/_____
E10. Did you quit a job during the past 12 months?
(0) No (1) Yes
[IF “NO” SKIP TO E12; IF “YES” ASK]
E11 Why did you quit?
[RECORD VERBATIM]_________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
E12. What is the longest time you've worked for the same employer in the past 12 months?
[Record response verbatim – code in weeks]
17
E13. During the past 12 months, did you receive any help or encouragement from your co-workers or employer
to remain drug or alcohol-free?
(0) No
(1) Yes
(7) Co-workers/employer didn't know drug use history
We want to know whether you’ve received any income during the past year, from what source, and
how much you’ve received.
E14-22. Did you receive any income from [READ EACH CATEGORY] during the [TIME PERIOD]?
a) The past 12 months?
[IF “NO” SKIP TO NEXT ITEM]
[IF “YES” ASK]
b) The past 3 months?
c) How much income did you receive from [ITEM] during the past 12 months?
Sources of Financial Support
Past
year
Most recent
3 months
Amount
In the
last 12
months
CODE: (0) No (1) Yes
E14. Your mate/spouse................................................ a. (___) b. (___)
c. (___/___/___/___/___)
E15. Your family (e.g. parents, parent figures) ........... a. (___) b. (___)
c. (___/___/___/___/___)
E16. Your friends......................................................... a. (___) b.(___)
c. (___/___/___/___/___)
E17. TANF or public assistance (food stamps,
housing assistance, AFDC, Medicaid)................ a. (___) b. (___)
c. (___/___/___/___/___)
E18. Prostitution or pimping........................................ a. (___) b. (___)
c. (___/___/___/___/___)
E19. Drug-related activities ......................................... a. (___) b. (___)
c. (___/___/___/___/___)
E20. Illegal activities (other than
prostitution/drugs)............................................ a. (___) b. (___)
c. (___/___/___/___/___)
E21. Any other (Specify) _______________________a. (___) b. (___)
c. (___/___/___/___/___)
E22.
Did you have any financial or money troubles because of your alcohol
or drug use in the past 12 months?
0 = No 1 = YES, very Minor 2 = Minor 3 = Serious 4 = Very serious
-9 = Didn’t Use
18
PART F: FRIENDSHIPS
This next series of questions concerns your friends and acquaintances.
[Display Show Card #15 for F1 thru F6]
Look at this card and use it to tell me what the majority of the people you were hanging out with in the
community during the past year were usually like.
0 = Never 1 = Rarely 2 = About 1/4 of the time
3 = About half the time
4 = About 3/4 of the time
5 = Almost always
6 = Always
-9 = N/A (No friends)
Please tell me, in the past year, how often did the people you were hanging out with:
F1.
Work a regular job?………………………...........................................................…………………(___)
F2.
Get high from too much alcohol?…………..........................................................…………………(___)
F3.
Use street drugs?……………………….. .............................................................…………………(___)
F4.
Trade, sell or deal drugs?…………………...........................................................…………………(___)
F5.
Hang out with a gang?……………………...........................................................…………………(___)
F6.
Do other things which are against the law? ..........................................................…………………(___)
[Display Show CARD #16 for F7 thru F10)
1 = None of them
2 = One/a few
-9 = N/A (No friends)
3 = About ½
4 = Most
5 = All of them
F7.
How many of them have ever gone to jail or prison?............................................…………………(___)
F8.
[IF “NONE OF THEM” SKIP TO F9]
How many of them have spent time in jail or prison in the past year?…….(___)
F9.
How many of them have ever gone for treatment for drugs or alcohol abuse? ......……………………..(___)
[IF “NONE OF THEM” SKIP TO NEXT SECTION]
F10. How many of them have gone for drug/alcohol treatment in the past year?.(___)
19
PART G: LEISURE TIME ACTIVITIES
Now I’m going to ask you about your leisure time activities. Please use Show Card #17 and tell me
how much time of your free time you spent on each activity in the past 12 months.
0 = None of my free time 1 = Very little of my free time 2 = About 25% of my free time
3 = About 50% of my free time
4 = About 75% of my free time
5 = Almost all of my free time
6 = All of my free time
G1.Watching TV (or going to movies)? ..........................................................................(___)
G2.Playing games for fun (cards, dominoes, pool)? .......................................................(___)
[DO NOT INCLUDE GAMBLING]
G3.Doing physical exercise? ..........................................................................................(___)
G4.Doing hobbies?
..................................................................................................(___)
G5.Reading/writing, drawing, listening to or playing music? ........................................(___)
G6.Religious activities (private or social) ......................................................................(___)
G7.Family time
..................................................................................................(___)
G8.Other Activity (specify) _______________________________ ..............................(___)
20
PART H: PSYCHOLOGICAL STATUS
Now I'd like to know how you were feeling emotionally in the past 12 months.
H1-12. During (TIME PERIOD), did you have a significant period THAT WAS NOT DRUG OR ALCOHOLRELATED when you:
a. The past 12 months?
[IF “NO” SKIP TO NEXT ITEM]
b. The past 3 months?
Past
Year
CODES:
Most recent
3 months?
(0) No
1.
Got into trouble because of your friends?
a. (___)
b. (___)
2.
Felt like no one really cared about you?
a. (___)
b. (___)
3.
Had serious problems with girlfriend/boyfriend?
a. (___)
b. (___)
4.
Had trouble making or keeping friends?
a. (___)
b. (___)
5.
Were taking prescribed medication for any
psychological or emotional problems?
a. (___)
b. (___)
6.
Experienced serious thoughts of suicide?
a. (___)
b. (___)
7.
Attempted suicide?
a. (___)
b. (___)
8.
Had trouble controlling violent behavior?
a. (___)
b. (___)
9.
Had trouble understanding, concentrating, or remembering? a. (___)
b. (___)
10.
Experienced hallucinations?
a. (___)
b. (___)
11.
Experienced serious anxiety or tension?
a. (___)
b. (___)
12.
Experienced serious depression?
a. (___)
b. (___)
(1) Yes
[Display Show Card # 18]
H13. Overall, how troubled or upset have you been during the past 30 days by any emotional or psychological
problems?
0 = Not at all 1 = Slightly 2 = Moderately 3 = Considerably 4 = Extremely
21
H14.
How many times during the past 12 months have you been treated for any
psychological or emotional problems in a hospital, or as a private patient?
(___/___)
[IF "NONE," CODE "00" THEN SKIP TO H19]
H15.
What kind of treatment did you receive – inpatient, outpatient, or both? ..
(_______)
1 = Inpatient
2 = Outpatient
3 = Both inpatient and outpatient
[IF “INPATIENT” ASK H16]
[IF “OUTPATIENT” ASK H17]
[IF “INPATIENT” & “OUTPATIENT” ASK H16 & H17]
H16-17. How many days during the past 12 months did you receive [treatment]?
H16. Inpatient treatment?
H17. Outpatient treatment?
H18. What type of professional did you see? (READ CHOICES ALOUD – CIRCLE ALL THAT APPLY)
1= Counselor
2= Case worker/social worker
3= Psychologist
4= Psychiatrist
6= Medical doctor
5= Other (Specify) _________________________________________
H19.
Are you taking, on a regular basis, any medication which has been prescribed
for you by a doctor for psychological or emotional problems?
(0) No
(1) Yes
[IF “NO” SKIP TO H20; IF "YES" ASK]
a. What medication are you taking for a psychological or emotional problems?
H20. Are you taking any other medication for a psychological or emotional problem?
[IF “NO” SKIP TO NEXT SECTION; IF “YES” ASK:]
a. What other medication are you taking for a psychological or emotional problem?
H21. Are you taking any other medication for a psychological or emotional problem?
[IF “YES” ASK:]
a. What other medication are you taking for a psychological or emotional problem?
22
PART I: ABUSE
The questions in this section deal with abuse. Most people who have experienced abuse find it
difficult to discuss, due to the unpleasant and often upsetting memories and feelings which are
"stirred up." Please do your best to answer these questions honestly. Do you have any questions
before we begin?
During the past 12 months:
I1.
Have you been touched or handled in a way that you didn't like? ..……………...(0) No (1) Yes
I2.
Have you been forced or pressured into having
sex when you did not want to? .......................................................……………...(0) No (1) Yes
I3.
Have you seriously considered calling the police or other authorities
because of the way members of your household were acting?. ......……………...(0) No (1) Yes
[READ EACH CATEGORY, BELOW. IF "NO," SKIP TO NEXT ITEM. IF "YES,"
ASK QUESTIONS A AND B]
I4-9.
During the past 12 months, were you [ABUSE]:
A.
0 = Never
B.
How many times did this happen in the past 12 months?
1 = Once
2 = Several times
3 = More than 5 times
-7 = Refused to answer
By whom was this done usually in the past 12 months? [CODE FROM LIST]
1 = Mother (step mother)
2 = Father (step father)
3 = Mother and Father
4 = Brother
5 = Sister
6 = Spouse/sexual partner
7 = Other (Specify) _____________
Abuse?
A. How Often
B. By Whom
I4.
Beaten or burned?
(0) No (1) Yes
(______)
(______)
I5.
Molested/fondled?
(0) No (1) Yes
(______)
(______)
I6.
Raped/sodomized?
(0) No (1) Yes
(______)
(______)
I7.
Locked in a room
or tied up?
(0) No (1) Yes
(______)
(______)
I8.
Intentionally
deprived of food?
(0) No (1) Yes
(______)
(______)
I9.
Other?
(0) No (1) Yes
(______)
(______)
(Specify) ___________________________________________________
23
PART J: HEALTH STATUS
This next section deals with your physical health during the last 12 months.
[Display Show Card #19]
J1.
How would you describe your health during the past 12 months?
1 = Excellent
J2.
2 = Good
3 = Fair
4 = Poor
How many times in the past 12 months were you admitted to a hospital
for medical problems which were not alcohol or drug related?
[IF ANY, ASK]
J3. How many days (total) did you stay in the hospital in the past 12 months?
J4.
How many times in the past 12 months did you visit a hospital emergency
room and receive services for reasons not related to drug or alcohol use?
J5.
(Other than when you were in the hospital) how many times in the past 12 months
have you gone to the doctor for health problems that had nothing to do with drug or alcohol use?
J6.
Are you currently taking any prescribed medication for a health or medical problem?
(0) No
(1) Yes
[IF “NO” SKIP TO J9; IF "YES," ASK]
a. What prescription medication are you currently taking?
J7.
Are you currently taking any other prescription medication?
(0) No
(1) Yes
[IF “NO” SKIP TO J9; IF “YES,” ASK]
a. What other prescription medication are you currently taking?
J8.
Are you currently taking any other prescription medication?
(0) No
(1) Yes
[IF “NO” SKIP TO J9; IF “YES,” ASK]
a. What other prescription medication are you currently taking?
24
J9.
Are you taking any non-prescription medications regularly?
(0) No
(1) Yes
[IF “NO” SKIP TO J12; IF "YES," ASK]
a. What non-prescription medication are you currently taking?
J10.
Are you taking any other non-prescription medications regularly?
(0) No
(1) Yes
[IF “NO” SKIP TO J12; IF "YES," ASK]
a. What other non-prescription medication are you currently taking?
J11.
Are you taking any other non-prescription medications regularly?
(0) No
(1) Yes
[IF “NO” SKIP TO J12; IF "YES," ASK]
a. What other non-prescription medication are you currently taking?
[ASK ALL]
J12.
Do you have any chronic medical problems that continue to interfere with your life?
(0) No
J13.
(1) Yes
To what extent are any physical health problems you have a result of your drug and alcohol use?
[READ RESPONSE OPTIONS]
0 = Not at all
1 = A little
2 = Some
3 = A lot
25
Now I'd like to know about any alcohol or drug-related treatment experiences you had in the past year.
J14. In the past 12 months, how many times were you treated for drinking problems or alcohol-related incidents?
J15. In the past 12 months, how many times were you treated for drug or other substance abuse- related
problems/incidents?
[IF J14 AND J15 = "00" SKIP TO J32; OTHERWISE ASK]
J16 – J28.
In the past 12 months, were you treated in a [TX TYPE]?
[READ EACH OPTION ALOUD and ENTER “0” IF NOT TREATED OR “1” IF TREATED]
[FOR EACH CHECKED, ASK]
a) How many different times did you receive treatment at (TX TYPE) in the past 12 months?
b) Was it your idea to go to (TX TYPE) or were you pressured, forced, or taken?
(1) Voluntary
(2) Involuntary
c) Altogether, how many days have you been treated in (TX TYPE) in the past 12 months?
DRUG/ALCOHOL TREATMENT CHART
No (0)
Yes (1)
Times
treated
Voluntary (1)/
Involuntary (2)
Total # of
days treated
J16. Therapeutic Community
or Residential Treatment Center?
_____
a. (___/___)
b. (___)
c. (___/___/___)
J17. Emergency room?
_____
a. (___/___)
b. (___)
c. (___/___/___)
J18. Private physician?
_____
a. (___/___)
b. (___)
c. (___/___/___)
J19. Hospital/Institution detox?
_____
a. (___/___)
b. (___)
c. (___/___/___)
J20. Short-term residential Tx program?
_____
a. (___/___)
b. (___)
c. (___/___/___)
J21. Non-residential day program?
_____
a. (___/___)
b. (___)
c. (___/___/___)
J22. Night care (work out, sleep in)?
_____
a. (___/___)
b. (___)
c. (___/___/___)
J23. Outpatient clinic?
(Drug/alc counseling only)
_____
a. (___/___)
b. (___)
c. (___/___/___)
J24. Individual psychotherapy?
_____
a. (___/___)
b. (___)
c. (___/___/___)
J25. Methadone maintenance?
_____
a. (___/___)
b. (___)
c. (___/___/___)
J26. Methadone detox?
_____
a. (___/___)
b. (___)
c. (___/___/___)
J27. Sober living?
_____
a. (___/___)
b. (___)
c. (___/___/___)
J28. Other treatment program (specify)
_____
a. (___/___)
b. (___)
c. (___/___/___)
26
J29.
What was your reason for entering treatment the last time?
a. Was there another reason why you entered treatment the last time?
(0) No
(1) Yes(0) No
___
(1) Yes(0) No
(1) Yes
J30.
[IF “NO” SKIP TO J31; IF “YES” ASK]
What was the other reason you entered treatment the last time?
[Display Show CARD #20]
J31. Overall, how helpful have these treatments been?
0 = Not at all helpful
1 = Somewhat helpful
2 = Quite helpful
3 = Extremely Helpful
J32. During the past 12 months, how many times did you try to quit using alcohol on your own?
[IF "NEVER," CODE "00." IF NO DRUG/ALCOHOL USE IN THE PAST YEAR, CODE "N/A"]
J33. During the past 12 months, how many times did you try to quit using drugs on your own?
[IF "NEVER," CODE "00." IF NO DRUG/ALCOHOL USE IN THE PAST YEAR, CODE "N/A"]
[IF BOTH J32 AND J33 = "00" OR "N/A," SKIP TO J37; OTHERWISE ASK]
J34. What was your reason for trying to quit drugs or alcohol?
(0) No
J35.
a. Did you have any other reason for trying to quit using drugs or alcohol?
(1) Yes
(0) No
(1) Yes(0) No ___
(1) Yes(0) No
(1) Yes
[IF “NO” SKIP TO J37]
What was your other reason for trying to quit using drugs or alcohol?
27
(0) No
J36.
a. Did you have any other reason for trying to quit using drugs or alcohol?
(1) Yes
(0) No
(1) Yes(0) No ___
(1) Yes(0) No
(1) Yes
[IF “NO” SKIP TO J37]
What was your other reason for trying to quit using drugs of alcohol?
J37. How many times have you attended self-help (12-Step) meetings [SPECIFY AA, NA, CA]
in (TIME PERIOD)?
00 = Never
01 = Once
02 = 2 to 5 times
05 = 21 to 30 times
03 = 6 to 10 times
06 = 31 to 50 times
04 = 11 to 20 times
07 = 51 to 99 times
08 = 100 to 500 times09 = More than 500 times
09 = more than 500 times
(______)
a. The past 12 months?
[IF “NEVER” SKIP TO J39; OTHERWISE ASK]
b. The past 3 months?
(______)
[Display Show Card #21]
J38. During [TIME PERIOD], how often did you find those meetings helpful?
0 = Never
1 = Rarely
2 = Sometimes
a. The past 12 months?
3 = Often
4 = Almost always
5 = Always
-9 = N/A
(______)
[ASK “B” IF RESPONDENT REPORTED ATTENDING MEETINGS IN 3-MONTH PERIOD]
b. The past 3 months?
(______)
[Display Show Card #22 AND SAY]
How much do you agree or disagree with each of the following statements:
1 = Strongly Disagree
2 = Disagree
3 = Not Sure
4 = Agree
5 = Strongly Agree
[IF NO DRUG/ALCOHOL USE IN THE PAST 12 MONTHS, CODE “N/A”]
J39.
In the past 30 days, I was extremely troubled by alcohol-related problems ..(_____)
J40.
In the past 30 days, I was extremely troubled by drug-related problems.......(_____)
J41.
At this time, treatment for alcohol problems is not important to me
(_____)
28
J42.
At this time, treatment for drug problems is not important to me
(_____)
29
PART K: VIEW OF SELF/EXPECTATIONS FOR THE FUTURE
The questions in this section deal with the way you view yourself now.
[Display Show Card #23 FOR K1 THROUGH K18]
K1-18. Use this card to tell me how you see yourself now. Are you...
0 =Not at all 1 =Somewhat 2 =Moderately
3 =Quite a bit 4 =Extremely
K1.
Optimistic about your future?
(_____)
K2.
Considerate and concerned about others?
(_____)
K3.
Respectful of rules and regulations?
(_____)
K4.
Respectful of authority figures?
(_____)
K5.
Not impulsive (you think before you act)?
(_____)
K6.
Responsible for own actions?
(_____)
K7.
In control of your life?
(_____)
K8.
In touch with your feelings?
(_____)
K9.
Trusting of others?
(_____)
K10.
Honest and trustworthy?
(_____)
K11.
Realistic (in your expectations)?
(_____)
K12.
Self-respectful (feel you are worth something)?
(_____)
K13.
Sexually confident?
(_____)
K14.
Self-reliant (able to support/take care of self)?
(_____)
K15.
Motivated (willing to work hard for what you want)? (_____)
K16.
Able to share your feelings with others?
(_____)
K17.
Self-assured (confident about yourself)?
(_____)
K18.
Open to suggestions?
(_____)
30
The following statements ask you about what is, or is not, important to you, what goals
you may have for yourself, and about your beliefs and opinions on different things.
[Display Show Card #24 FOR K19 THROUGH K32]
K19-K32.
How much do you agree or disagree with each of the following statements:
1 = Strongly disagree 2 = Disagree 3 = Not sure
4 = Agree
-9 = N/A (has no children, no friends, etc.)
5 = Strongly agree
It is important for me:
K19.
To have a good family life
(_____)
K20.
To have a good time with my friends
(_____)
K21.
To work hard and support myself
(_____)
K22.
To have lots of money, cars, and other possessions `
(_____)
K23.
To have drugs and/or alcohol whenever I want them
(_____)
K24.
(that) occasional/recreational use of marijuana is okay
(_____)
K25.
(that) occasional social use of alcohol only is okay
(_____)
K26.
To live without using any drugs or alcohol
(_____)
K27.
To plan for my future
(_____)
K28.
To be a good parent
(_____)
1 = Strongly disagree 2 = Disagree 3 = Not sure
-9 = N/A (has no children, no friends, etc.)
4 = Agree
5 = Strongly agree
K29.
I still think I have a drug problem and I probably should get help. (_____)
K30.
I think of myself as fully recovered. I no longer have problems related
to drug or alcohol use, and I don’t use them.
(_____)
K31.
I still use drugs, but I don’t see any problems with this.
(_____)
K32.
I still use alcohol, but I don’t see any problems with this.
(_____)
31
Let's talk briefly about the future.
[Display Show Card #25]
K33. Which one of these statements best describes what you think will happen to you in the future?
1 = Probably increase your drug usage
2 = Continue to use drugs like before
3 = Cut back your drug use: use on an occasional or more controlled basis
4 = Switch to using (or use more) alcohol
5 = Switch to using other, less serious drugs
6 = Quit for awhile, but start using again later
7 = Quit eventually, but slip a few times during recovery
8 = Quit forever, and never use again
9 = Continue your abstinence from drugs
10 = Other (specify)________________________________
(______)
[Display Show Card #26]
K34-39. In the next 6 months, what do you think your chances are of:
0 = Zero
1 = Very low (less than 10%)
2 = Low (about 25%)
3 = About “50/50”
4 = High (about 75%)
5 = Very high (85% or greater)
-8 = Really DK/unsure
-9 = Not applicable (has already finished education/vocational training;
can’t obtain job, have “decent social life,” or “straighten out life”
due to anticipated duration of incarceration)
K34.
Staying out of trouble with the authorities?
(_____)
K35.
"Sticking with" and finishing your education or vocational training?
(_____)
K36.
Getting and/or keeping a decent job? ...............................................
(_____)
K37.
Having a better relationship with your family? ................................
(_____)
K38.
Having a decent social life? ..............................................................
(_____)
K39.
Straightening out your life?. ..............................................................
(_____)
32
PART L: WURS-25
This set of questions is about how you were as a child.
[Display Show Card #27]
Looking at this card, please tell me, as a child:
(0) Not at all
(1) Somewhat
_____ L1.
_____ L2.
_____ L3.
_____ L4.
_____ L5.
_____ L6.
_____ L7.
_____ L8.
_____ L9.
_____ L10.
_____ L11.
_____ L12.
_____ L13.
_____ L14.
_____ L15.
_____ L16.
_____ L17.
_____ L18.
_____ L19.
_____ L20.
_____ L21.
_____ L22.
_____ L23.
_____ L24.
_____ L25.
(2) Moderately
(3) Quite a bit
4) Extremely
Did you have concentration problems, or were you easily distracted?
Were you anxious or worrying?
Were you nervous or fidgety?
Were you inattentive or daydreaming?
Were you hot or short-tempered or did you have a low boiling point?
Did you have temper outbursts or tantrums?
Did you have trouble with stick-to-it-tiveness, not following through, or failing to finish
things you started?
Were you stubborn or strong-willed?
Were you sad, blue, depressed, or unhappy?
Were you disobedient with parents, rebellious, or sassy?
Did you have a low opinion of yourself?
Were you irritable?
Were you moody, or did you have ups and downs?
Were you angry?
Did you act without thinking, or were you impulsive?
Did you have a tendency to be immature?
Did you have a guilty feeling, or were you regretful?
Did you lose control of yourself?
Did you have a tendency to be or act irrational?
Were you unpopular with other children, didn’t keep friends for long, or didn’t get
along with other children?
Did you have trouble seeing things from someone else’s point of view?
Did you have trouble with authorities, or trouble with school?
Were you overall a poor student, or a slow learner?
Did you have trouble with mathematics or numbers?
Were you not achieving up to your potential?
33
PART M: CIRCUMSTANCES, MOTIVATION, AND READINESS
How you feel can have a powerful effect on treatment. These feelings include your circumstances, the
problems in your life, your feelings about yourself, and your feelings about treatment. Consider each
of the questions below and indicate how closely they describe your own feelings.
M1 – M18. Please look at this card and tell me which answer best describes how much you agree or how
much you disagree with the statement that I make. [Display Show Card #28]
(1) Strongly Disagree
(2) Disagree
(3) Neither agree nor disagree
(4) Agree
(5) Strongly agree
M1. I am sure that I would go to jail if I didn’t enter treatment……………………………….…….(_____)
M2. I am sure that I would have come to treatment without the pressure
of my legal involvement………………………………………………………………….…….(_____)
M3. I am sure that my family will not let me live at home if I did not come to treatment………….(_____)
M4. I believe that my family/relationship will try to make me leave treatment
after a few months……………………………………………………………………………...(_____)
M5. I am worried that I will have serious money problems if I stay in treatment…………….…….(_____)
M6. Basically, I feel I have too many outside problems that will prevent me from
completing treatment (e.g. parents, spouse/relationship, children, loss of job,
loss of income, loss of education, family problems, loss of home/place to live)………….……(_____)
M7. Basically, I feel that drug use is a very serious problem in my life……………………….……(_____)
M8. Often I don’t like myself because of my drug use………………………………………….…..(_____)
M9. Lately, I feel if I don’t change, my life will keep getting worse………………………………..(_____)
M10. I really feel bad that my drug use and the way I’ve been living has hurt a lot of people……..(_____)
M11. It is more important to me than anything else that I stop using drugs…………………….…..(_____)
M12. I don’t really believe that I have to be in treatment to stop using drugs,
I can stop anytime I want……………………………………………………………………..(_____)
M13. I came to this program because I really feel that I’m ready to deal with myself in treatment...(_____)
M14. I’ll do whatever I have to do to get my life straightened out…………………………….…….(_____)
M15. Basically, I don’t see any other choice for help at this time except some kind of treatment….(_____)
M16. I don’t really think I can stop my drug use with the help of friends, family or religion,
I really need some kind of treatment………………………………………………………….(_____)
M17. I am really tired of using drugs and want to change, but I know I can’t do it on my own……(_____)
M18. I’m willing to enter treatment as soon as possible…………………………………………….(_____)
34
PART N: QUALITY OF LIFE
Now I’m going to ask you some questions about what your life is like, your health, what you do from
day-to-day, and how you feel about things. Please look at this card [Display Show Card #29]. This is
called the Terrible-Delighted Scale. During the interview, we’ll be using this scale to help you tell me
how you feel about different things in your life. All you have to do is tell me what on the scale best
describes how you feel.
(1) Terrible
(2) Unhappy
(3) Mostly dissatisfied
(5) Mostly Satisfied
(6) Pleased
(7) Delighted
(4) Mixed
N1. How do you feel about your life as a whole?……………………………..................... (_____)
[Living Situation]
N2. How do you feel about:
A. The living arrangements where you live?………………………………………….(_____)
B. The food there?…………………………………………………………………….(_____)
C. The rules there?…………………………………………………………………….(_____)
D. The privacy you have there?……………………………………………………….(_____)
E. The amount of freedom you have?…………………………………………………(_____)
F. The prospect of staying on where you currently live for a long period of time…….(_____)
N3. How do you feel about:
A. The people who live in the houses or apartments near you?………………………(_____)
B. People who live in this neighborhood?…………………………………………….(_____)
C. The outdoor space there is for you to use outside your home?…………………….(_____)
D. This neighborhood as a place to live?……………………………………………...(_____)
E. How safe you feel in this neighborhood?…………………………………………..(_____)
N4. [How do you feel about:
A. Your personal safety?……………………………………………………………...(_____)
B. How safe you are on the streets in your neighborhood?……………………………(_____)
C. How safe you are in the building where you live?………………………………….(_____)
D. The protection you have against being robbed or attacked?………………………..(_____)
E. Your chance of finding a policeman if you need one?……………………………...(_____)
35
Now let’s talk about some of the things you did with your time in the past week. I’m going to read you
a list of things people may do with their free time. For each of these, please tell me if you did it during
the past week.
[Daily Activities and Functioning]
N5. Did you:
A. Go for a walk?
(0) No
(1) Yes
B. Go to a movie or watch a play?
(0) No
(1) Yes
C. Watch television?
(0) No
(1) Yes
D. Go shopping?
(0) No
(1) Yes
E. Go to a restaurant or coffee shop?
(0) No
(1) Yes
F. Go to a bar?
(0) No
(1) Yes
G. Read a book, magazine or newspaper?
(0) No
(1) Yes
H. Listen to a radio?
(0) No
(1) Yes
I. Play cards?
(0) No
(1) Yes
J. Go for a ride in a bus or car?
(0) No
(1) Yes
K. Prepare a meal?
(0) No
(1) Yes
L. Work on a hobby?
(0) No
(1) Yes
M. Play a sport?
(0) No
(1) Yes
N1. Go to a meeting of some organization or social group which is
program related?
(0) No
(1) Yes
N2. Go to a meeting of some organization or social group which is
NOT program related?
(0) No
(1) Yes
O. Go to a park?
(0) No
(1) Yes
P. Go to a library?
(0) No
(1) Yes
N6. Overall, how would you rate your functioning in home, social, school, and work settings at the present
time? Would you say your functioning in these areas is excellent, good, fair, or poor?
(1) Excellent
(2) Good
(3) Fair
(4) Poor
36
Now, please look at the Terrible-Delighted Scale again [Show Card #29]
(1) Terrible
(2) Unhappy
(3) Mostly dissatisfied
(5) Mostly Satisfied
(6) Pleased
(7) Delighted
(4) Mixed
[Family]
N7. How do you feel about:
A. Your family in general…………………………………………………………………(_____)
B. How often you have contact with your family…………………………………………(_____)
C. The way you and your family act towards each other………………………………….(_____)
D. The way things are in general between you and your family…………………………..(_____)
[Social Relations]
N8. How do you feel about:
A. The things you do with other people…………………………………………………...(_____)
B. The amount of time you spend with other people……………………………………...(_____)
C. The people you see socially…………………………………………………………….(_____)
D. How you get along with other people in general………………………………………..(_____)
E. The chance you have to know people with whom you feel really comfortable…………(_____)
F. The amount of friendship you have in your life…………………………………………(_____)
[Finances]
N9. How do you feel about:
A. The amount of money you get from all sources………………………………………….(_____)
B. The amount of money you have to cover basic necessities (e.g. food, clothing, shelter)...(_____)
C. How comfortable and well-off you are financially……………………………………….(_____)
D. The amount of money you have available to spend for fun……………………………...(_____)
During the past 4 weeks, have you had any of the following problems with your work or other regular
daily activities as a result of your physical health?
N10. As a result of your physical health, have you:
A. Cut down on the amount of time you spend on work or other activities? ... (0) No
(1) Yes
B. Accomplished less than you would like?
(0) No
(1) Yes
C. Been limited in the kind of work or other activities you do?
(0) No
(1) Yes
D. Had difficulty performing work or other activities (e.g. it took extra effort) (0) No
(1) Yes
37
During the past 4 weeks, have you had any of the following problems with your work or other regular
daily activities as a result of any emotional problems such as feeling depressed or anxious?
N11. As a result of your emotional problems, have you:
A. Cut down on the amount of time you spend on work or other activities
(0) No
(1) Yes
B. Accomplished less than you would like?
(0) No
(1) Yes
C. Not done your work or other activities as carefully as usual?
(0) No
(1) Yes
N12. During the past 4 weeks, to what extent have your physical health or emotional health problems
interfered with your normal social activities with family, friends, neighbors, or groups?
[Read Response options aloud]
(0) Not at all
(1) Slightly
(2) Moderately
(3) Quite a bit
(4) Extremely
Please look at the Terrible-Delighted Scale again [Show Card #29]
(1) Terrible
(2) Unhappy
(3) Mostly dissatisfied
(5) Mostly Satisfied
(6) Pleased
(7) Delighted
(4) Mixed
N13. How do you feel about:
A. Your health in general…………………………………………………………………..(_____)
B. The medical care available to you if you need it………………………………………..(_____)
C. How often you see a doctor……………………………………………………………..(_____)
D. The chance you have to talk with a therapist……………………………………………(_____)
E. Your physical condition………………………………………………………………….(_____)
F. Your emotional well-being……………………………………………………………….(_____)
N14. Looking at the Terrible-Delighted Scale, how do you feel about your life as a whole………..(_____)
38
PART O: INDIANA JOB SATISFACTION SCALE
Are you currently employed? (0) No (1) Yes [If “NO” SKIP TO P1]
Please rate each of the following statements as they pertain to your current job.
[Display Show Card #30]
(1) Strongly Disagree
(2) Somewhat Disagree
(3) Somewhat Agree
(4) Strongly Agree
General Satisfaction
O1. I feel good about this job……………………………………………………………………....(______)
O2. This job is worthwhile………………………………………………………………………....(______)
O3. The working conditions are good……………………………………………………………...(______)
O4. I want to quit this job…………………………………………………………………….……(______)
O5. This job is boring………………………………………………………….…………………..(______)
Pay
O6. I am happy with the amount this job pays…………………………………………….……....(______)
O7. The vacation time and other benefits on this job are okay……………………………………(______)
O8. I need more money than this job pays………………………………………………………...(______)
O9. This job does not provide the medical coverage I need……………………………………….(______)
Advancement and Security
O10. I have a fairly good chance for promotion in this job……………………………….……….(______)
O11. This is a dead-end job…………………………………………………………….………….(______)
O12. I feel that there is a good chance of my losing this job in the future…………………….…..(______)
O13. I’ve received sufficient job training on my job………………………………………..……..(______)
O14. I receive sufficient work skills development which may help on future jobs………………..(______)
Supervision
O15. My supervisor is fair…………………………………………………………………………(______)
O16. My supervisor is hard to please………………………………………………………………(______)
O17. My supervisor praises me when I do my job well……………………………………………(______)
O18. My supervisor is difficult to get along with………………………………………………….(______)
O19. My supervisor recognizes my effort…………………………………………………………(______)
39
(1) Strongly Disagree
(1) Strongly Disagree
(2) Somewhat Disagree
(2) Somewhat Disagree
(3) Somewhat Agree
(3) Somewhat Agree
(4) Strongly Agree
(4) Strongly Agree
Co-Workers
O20. My co-workers are easy to get along with……………………………………………………(______)
O21. My co-workers are lazy………………………………………………………………………(______)
O22. My co-workers are unpleasant……………………………………………………………….(______)
O23. My co-workers don’t like me………………………………………………………………...(______)
O24. My co-workers help me to like this job more………………………………………………..(______)
O25. I have a co-worker I can rely on……………………………………………………………...(______)
O26. I have a co-worker I consider a friend………………………………………………………..(______)
How I feel on this Job
O27. I look forward to coming to work……………………………………………………………(______)
O28. I often feel tense on the job………………………………………………………………..…(______)
O29. I don’t know what’s expected of me on this job……………………………………………..(______)
O30. I feel physically worn out at the end of the day……………………………………………...(______)
O31. Working makes me feel like I’m needed…………………………………………………….(______)
O32. My job keeps me busy……………………………………………………………….………(______)
O33. I get to do a lot of different things on my job………………………………………………..(______)
O34. I am satisfied with my work schedule………………………………………………………..(______)
40
PART P: LIFESTYLE CRIMINALITY SCREENING FORM
P1. Have you ever failed to provide child support to at least one biological child?
(0) No
(1) Yes
(-9) N/A – no children
P2. Did you terminate your formal education prior to graduating from high school?
(0) No
(1) Yes
P3. What is the longest amount of time that you have ever held a job?
(0) Two or more years
(1) At least 6 months but less than 2 years
(2) Less than 6 months
(-9) N/A – never had a job
P4. How many times have you been terminated from a job due to irresponsibility or
quit for no apparent reason?
(0) None
(1) Once
(2) Two or more times
[INTERVIEWER: DO NOT ASK P5 QUESTION TO CLIENT]
P5. Does the client have a history of alcohol or substance abuse?
(0) No
(1) Yes
P6. Which answer best describes your marital background?
(0) Single with no children or married no divorces
(1) Single with child/children
(2) One prior divorce or separation
(3) Two or more prior divorces or separations
P7. How many tattoos do you have?
(0) No tattoos
(1) One to four separate tattoos
(2) More than 4 tattoos
41
P8. What offense were you convicted of that resulted in your referral to the TASC program?
[Read Response Options Aloud]
(1) DWI/DUI/Public Consumption/intoxication
(2) Use/possession of illegal drugs/paraphernalia
(10) Rape
(3) Forgery or fraud
(11) Murder
(4) Forgery of drug prescriptions
(12) Violence against other persons
(5) Fencing
(13) Weapons offenses
(6) Illegal gambling, running numbers, or bookmaking
(14) Vandalism
(7) Prostitution or pimping
(15) Vagrancy
(8) Burglary or auto theft
(16) Trafficking people across the border
(9) Robbery (armed or mugging)
(17) Other (specify) _________________
P9. How many prior arrests do you have for committing an intrusive offense such as rape, robbery, murder,
assault, or breaking and entering? [Read Response Options Aloud]
(0) None
(1) One or Two
(2) Three or more
P10. Did you use a weapon or threaten the use of a weapon while committing your instant offense, that is,
the offense for which you have currently been referred to the TASC program?
(0) No
(1) Yes
P11. Have you ever physically abused significant others (primarily family members)?
(0) No
(1) Yes
P12. Excluding your instant offense, how many prior non-traffic offenses have you been arrested for?
(0) One or none
(1) Two to four
(2) Five or more
P13. How old were you at the time of your first non-traffic arrest?
(0) 14 years of age or younger
(1) Older than 14 but younger than 19
(2) 19 or older
P14. Do you have a history of disruptive behavior in school?
(0) No
(1) Yes
42
PART Q: RISK ASSESSMENT BATTERY
Now we are going to discuss some rather personal issues regarding some of your drug use and sexual
behaviors in the past six months. Remember, you can refuse to answer any question, but we have
taken great care to protect the privacy of your answers.
Q1. In the past 6 months, did you inject drugs?
(0) No
(1) Yes
Q2. In the past 6 months, did you share needles or works? (0) No
(1) Yes
[IF “NO” SKIP TO Q9]
[IF “NO” SKIP TO Q7]
Q3. With how many different people did you share needles/works in the past 6
months? [Record verbatim and code according to responses]
(1)
(2)
(3)
(4)
(5)
One person
2 or 3 different people
4 to 6 different people
7 to 10 different people
11 or more different people
(________)
[Display Show Card #31]
Q4. In the past 6 months, how many times have you used a syringe/needle after someone without cleaning?
(0) Never
(1) A few times
(4) About once each week
(2) About once a month
(3) A few times each month
(5) A few times each week (6) Every day
(7) More than once a day
Q5. In the past 6 months, how many times have others used a needle/syringe after you
without cleaning?
(0) Never
(1) A few times
(4) About once each week
(2) About once a month
(3) A few times each month
(5) A few times each week (6) Every day
(7) More than once a day
Q6. In the past 6 months, how often have you shared needles with someone you knew or later found out had
AIDS or was positive for the AIDS virus?
(0) Never
(1) A few times
(4) About once each week
(2) About once a month
(3) A few times each month
(5) A few times each week (6) Every day
(7) More than once a day
43
Q7. Where did you get your needles from during the past 6 months?
[READ RESPONSES TO CLIENT – CIRCLE ALL THAT APPLY]
(1) From a diabetic
(6) Drug Dealer
(2) On the street
(7) Syringe seller (not drug dealer)
(3) Drugstore
(8) Health care facility / private doctor
(4) Shooting gallery
(9) Other (specify) _______________
(5) From a needle exchange program
[Display Show Card #31]
Q8. How often have you been to a shooting gallery in the past 6 months?
(0) Never
(1) A few times
(4) About once each week
(2) About once a month
(3) A few times each month
(5) A few times each week (6) Every day
(7) More than once a day
Q9. How often have you been to a crack house in the past 6 months?
(0) Never
(1) A few times
(4) About once each week
(2) About once a month
(3) A few times each month
(5) A few times each week (6) Every day
(7) More than once a day
[IF “NO” TO Q1 MEANING CLIENT DID NOT INJECT NOW SKIP TO Q15]
Q10. In the past 6 months, which statement best describes your way of cleaning your needles? [READ
RESPONSES TO CLIENT]
(1) I always use new needles
(2) I always clean my needles just before I shoot up
(3) After I shoot up I always clean my needles
(4) Sometimes I clean my needles, sometimes I don’t
(5) I never clean my needles
(________)
[IF “1” or “5” SKIP TO Q12]
[IF “2” or “3” or “4” ASK]
44
Q11. In the past 6 months, how did you clean your needles? [READ RESPONSES]
(1) Soap and water or water only
(2) Alcohol
(3) Bleach
(4) Boiling water
(5) Other (specify) _________________________________________
(________)
[Display Show Card #31]
Q12. In the past 6 months, how many times did you share rinse water?
(0) Never
(1) A few times
(4) About once each week
(2) About once a month
(3) A few times each month
(5) A few times each week (6) Every day
(7) More than once a day
Q13. In the past 6 months, how many times did you share a cooker?
(0) Never
(1) A few times
(4) About once each week
(2) About once a month
(3) A few times each month
(5) A few times each week (6) Every day
(4) About once each week
(5) A few times each week
(6) Every day
(7) More than once a day
(7) More than once a day
Q14. In the past 6 months, how many times did you share a cotton?
(0) Never
(1) A few times
(4) About once each week
(2) About once a month
(3) A few times each month
(5) A few times each week (6) Every day
(7) More than once a day
Now we are going to discuss some of the sexual practices you may have engaged in during the past 6
months.
Q15. Do you consider yourself to be:
(1) Straight/heterosexual
(2) Gay/Homosexual
(3) Bisexual
(________)
45
(4) About once each week
day
(5) A few times each week (6) Every day
(7) More than once a
Q16. With how many men have you had sex with in the past 6 months?
(0) 0 men
(1) 1 man
(2) 2 or 3 men
(3) 4 to 6 men
(4) 7 to 10 men
(5) 11 or more men
(________)
Q17. With how many women have you had sex with in the past 6 months?
(0)
(1)
(2)
(3)
(4)
(5)
0 women
1 woman
2 or 3 women
4 to 6 women
7 to 10 women
11 or more women
(________)
[IF “NO SEX IN THE PAST MONTHS” WITH EITHER MEN OR WOMEN SKIP TO Q24]
[IF ANY SEX IN THE PAST SIX MONTHS ASK]
[Display Show Card #31]
Q18. In the past 6 months, how often did you have sex so you could get drugs?
(0) Never
(1) A few times
(4) About once each week
(2) About once a month
(3) A few times each month
(5) A few times each week (6) Every day
(7) More than once a day
Q19. In the past 6 months, how often have you given drugs to someone so you could have sex with them?
(0) Never
(1) A few times
(4) About once each week
(2) About once a month
(3) A few times each month
(5) A few times each week (6) Every day
(7) More than once a day
Q20. In the past 6 months, how often were you paid money to have sex with someone?
(0) Never
(1) A few times
(4) About once each week
(2) About once a month
(3) A few times each month
(5) A few times each week (6) Every day
(7) More than once a day
46
(4) About once each week
(5) A few times each week (6) Every day
(7) More than once a
day (4) About once each week
(5) A few times each week (6) Every day
(7) More than once a
day
Q21. In the past 6 months, how often did you pay money to have sex with someone?
(0) Never
(1) A few times
(4) About once each week
(2) About once a month
(3) A few times each month
(5) A few times each week (6) Every day
(7) More than once a day
Q22. In the past 6 months, how many times did you have sex with someone you knew or later found out had
AIDS or was positive for the AIDS virus?
(0) Never
(1) A few times
(4) About once each week
(2) About once a month
(3) A few times each month
(5) A few times each week (6) Every day
(7) More than once a day
[Display Show Card #32]
Q23. In the past 6 months, how much time of the time did you use condoms when you had sex?
(0) None of the time, never
(1) Less than half the time
(2) About half the time
(3) Most of the time
(4) All the time, every time
Q24. Do you know your HIV status? If so, what is your HIV status? [READ RESPONSES]
(0) No, I don’t know my HIV status
(1) Yes, it’s negative
(2) Yes, it’s positive
(________)
[IF “POSITIVE” SKIP TO R1]
[IF “NEGATIVE” or “NOT SURE” ASK]
[Display Show Card #33]
Q25. How worried are you about getting HIV or AIDS?
(0) Not at all
(1) Slightly
(2) Moderately
(3) Considerably
(4) extremely
(________)
Q26. How worried are you that you may have already been exposed to the HIV or AIDS virus?
(0) Not at all
(1) Slightly
(2) Moderately
(3) Considerably
(4) extremely
(________)
Q27. How many times have you been tested for the HIV, the virus that causes AIDS?
0
1
2
3
4
5
6
7
8
9
10+
47
Q28. Did you get the results from the last HIV test that you took?
(0) No
(1) Yes
48
PART R: MOTIVATION FOR SEALING RECORDS
Now we are going to discuss the effect that your criminal record has had on your life.
STIGMA ENCOUNTERS
[Display Show Card #34]
(1) Strongly disagree
(2) Disagree
(3) Neither agree nor disagree (4) Agree
(5) Strongly Agree
R1. Because I have a criminal record, my family has acted differently towards me………………..(_____)
R2. Because I have a criminal record, my friends have acted differently towards me……………...(_____)
R3. Because I have a criminal record, it is hard for me to make new friends……………………….(_____)
R4. Because I have a criminal record, I have not applied for some jobs……………………………(_____)
R5. I feel that my criminal record keeps me from getting a good job……………………………….(_____)
R6. When I fill a job application I am intimidated by the criminal history section…………………(_____)
R7. I feel that my criminal record decreases my chances in obtaining
public assistance and housing…………………………………………………………………..(_____)
R8. People who know that I have a criminal record act suspicious around me……………………..(_____)
R9. A criminal record has actually enhanced my status in my community. I have gained
more respect from my peers…………………………………………………………………………(_____)
R10. I am embarrassed to have a criminal record…………………………………………………...(_____)
SEALING CRIMINAL RECORDS- MOTIVATION
R11. Having my record sealed will help me to find a better job……………………………………(_____)
R12. Having my record sealed will make it easier to make new friends……………………………(_____)
R13. Having my record sealed will make my family feel better about me………………………….(_____)
R14. Having my record sealed will give me a new start…………………………………………….(_____)
R15. Having my record sealed will help me get better public services and housing………………..(_____)
R16. It is not such a big deal having a criminal record, it is common in my community…………..(_____)
R17. My family has been negative toward me because of my legal situation………………………(_____)
R18. My friends have been negative toward me because of my legal situation…………………….(_____)
49
Strongly disagree
1
Disagree
2
Neither agree nor disagree
3
Agree
4
Strongly agree
5
R19. Even if I got my record sealed it would continue to create problems for me.
R20. I was aware of the implications of my plea at the time I appeared before a judge for my sentencing.
R21. Having my record sealed will be a positive milestone in my successful recovery.
R22. At the time of sentencing my main objective was to avoid serving any jail or prison time.
R23. I have been convicted of a felony; however that mistake does not mean I consider myself a criminal.
R24. Having my record sealed means that I should no longer be considered a criminal.
R25. Most employers and agencies have a way of finding out whether a criminal record exists.
R26. In Ohio, criminal record information is available to anyone that wants it.
R27. Once convicted of a felony, it is difficult to get a job that provides a good salary and benefits.
R28. It is difficult to get a minimum wage job after a felony conviction.
R29. Having a juvenile record negatively influenced the legal outcome of the case for which I was
originally referred to TASC. Note: If respondent says they don’t have any juvenile record, please
indicate Not Applicable.
YES
NO
R30. By law, a job applicant must disclose any prior criminal arrests or convictions if asked on a job
application or during a job interview.
YES
NO
50
LEGAL SANCTIONS: CLIENT PERSPECTIVES & EXPERIENCES
Instructions: I am going to read you a list of possible legal consequences that sometimes become a
problem for people that are arrested or convicted of a crime. Please tell me first which answer best
describes how much each possible consequence concerns you and then tell me whether or not you have
experienced any of the following consequences since you were arrested.
31a. Criminal background checks are conducted when applying for jobs in Ohio, how much does this concern
you?
Not at all
0
A little bit
Moderately
1
Quite a bit
2
3
Extremely
4
31b. I have been denied a job because of information revealed during a criminal background check.
YES
NO
R32a. Some employers may fire/demote someone if they have a criminal history, how much …………..?
R32b. I have lost a job, been demoted, or have been treated differently at work because of my legal situation.
R33a. Professional license can be denied, revoked, or suspended following arrest or conviction, how much……?
R33b. I have had a professional license denied, revoked, or suspended because of my legal situation.
R34a. Felons can be denied benefits under the Ohio public employee’s retirement system, how much….?
R34b. I have been denied retirement benefits because of my legal situation.
R35a Felons can be denied a driver’s license by the Department of Motor Vehicles, how much….?
R35b. I have been denied a driver’s license because of my legal situation.
R36a. Federal or local housing authorities can deny placement or assistance to felons, how much….?
R36b. I have been denied housing assistance because of my legal situation.
R37a. Felons may be prohibited from receiving food stamps, cash, and other public assistance, how much…?
R37b. I have been denied federally funded benefits and public assistance because of my legal situation.
R38a. Felons in Ohio are restricted from voting while incarcerated, how much does this concern you?
R38b. I have had problems registering to vote since my arrest.
R39a. Some felons are disqualified from consideration for foster care or adoptive placement, how much….?
R39b. I have been denied consideration for foster care or adoptive placement because of my legal situation.
R40a. The Board of Education can deny an education loan, grant, or work assistance to felons, how much…?
R40b. I have been denied educational assistance because of my legal situation.
R41a. Felons may be denied Medicaid or other healthcare benefits, how much does this concern you?
R41b. I have been denied Medicaid or other healthcare benefits because of my legal situation.
R42a. Felons may be denied admission to drug treatment, mental health, or other services, how much…?
R42b. I have been denied admission to drug treatment, mental health, other services because of my legal situation.
R43a. Felons may be denied a variety of personal loans (e.g. mortgage, car, personal credit), how much…?
R43b. I have been denied a personal loan because of my legal situation.
51
Social Role Scale
Instructions: Now I am going to ask you some questions about your life and the way you viewed yourself at
the time you came to TASC and about your life and your view of yourself now. Please tell me which
answer best describes your situation. Note: Retrospective questions (44) are to be asked only at the time of the
24-month interview. Forty-two month interview captures current perceptions (45) only.
R44. At the time of your initial involvement with TASC did you view yourself as [role]?
(0) Not at all
(1) Rarely
(2) Sometimes
(3) Often
(4) Always
(2) Sometimes
(3) Often
(4) Always
R45. Do you currently view yourself as {role]?
(0) Not at all
(1) Rarely
Role
44. Baseline
45. Current
1. Criminal
2. Worker
3. Addict/alcoholic
4. Parent
5. Caregiver
6. Recovering Person
7. Student
8. Victim
9. Survivor
10. Failure
11. Partner
12. Son/daughter
13. Person w/ a disability
14. Mentor
15. Spiritual person
16. Mental health consumer
17. Gang member
18. Athlete
52
Instructions: This next set of questions has to do with your prior experiences with the criminal justice
system, particularly the case for which you were referred to TASC and this program.
R46. Do you have a juvenile record (including any arrests, adjudications, or commitments)?
YES
NO
R47. Think back to when the judge originally referred you to TASC and this program, were you represented by:
(1) Public Defender
(2) Private Defense Attorney
(3) No representation
R48. Most of the information that helped you to decide what to plea was given to you by (choose one):
a) Public Defender
b) Private Defense Attorney
c) Prosecutor
d) Judge
e) Don’t know/Not sure
R49. Did anyone discuss with you the longer-term consequences of pleading guilty to a felony?
YES
NO
49a. If so, what were you told? ________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
R50. Were you given any legal alternatives to your case disposition for which you were originally referred to
TASC?
YES
NO
R50a. If so, what alternatives were you given? _____________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
53
PART S: CLIENT SERVICE UTILIZATION AND SATISFACTION
I would now like to ask you some questions about some of the services you may have received in the
past 6 months. Just so you know your responses to the following questions will not be reported back to
any clinical staff with whom you have worked. Your responses will not "get anybody into trouble" or
be used in any performance evaluation or affect any future services you might receive. We ask these
questions in order to gain a better understanding of what works and what doesn't work about drug
treatment. The questions we ask about treatment refer to the time in treatment when you were asked
to participate in the Second Chance Program. I will be asking you some questions about both your
contacts with your case manager and aftercare counselor.
This first set of questions will be about your contact with your case manager at TASC. These
questions do not apply to your work or contact with treatment providers or aftercare counselors.
[Display Show Card #35]
S1. During the past 12 months, how frequently did you have contact with your case manager at
TASC? This would include both phone contacts and personal visits.
(0) Never
(1) Less than once a month
(2) About once a month
(3) Twice a month
(4) About once a week
(5) More than once a week
[Display Show Card #36]
S2. During the past 30 days, how many contacts did you have with your TASC case manager? This would
include both phone contacts and personal visits.
(0) No contacts
(1) one to three contacts
(2) four to six contacts
(3) seven or more contacts
(4) discharged from TASC more than one month ago
S3. How many of these case manager contacts in the past 12 months were:
A.
B.
C.
D.
At the TASC office…………………………………………………………………………(______)
At a treatment agency………………………………………………………………………(______)
In the community such as at home, work, or court…………………………………………(______)
Telephone contacts…………………………………………………………………………(______)
S4. What was the single most helpful topic which you worked on with your case manager
in the past 12 months?
[Display Show Card #37]
S5. Looking at this showcard, please tell me which of the answers best describes how satisfied you are with
your TASC case manager in the past 12 months?
(1) Very dissatisfied
(2) Somewhat dissatisfied
(3) Somewhat satisfied
(4) Very satisfied
S6. Can you please tell me why you feel that way about your experience with your TASC case manager?
54
Now I would like to ask you some questions about any contact you may have had with a
representative from Community Re-entry. Just a reminder, these questions do not apply to
your contact with your case manager.
S7. Have you had any contact in the past 12 months with staff at Community Re-entry?
(0) No
(1) Yes
[IF “NO” SKIP to S14; OTHERWISE ASK]
[Display Show Card #38]
S8. During the past 12 months, how frequently did you have contact with a representative from Community
Re-entry? This would include both phone contacts and personal visits.
(0) Never
(1) Less than once a month
(2) About once a month
(3) Twice a month
(4) About once a week
(5) More than once a week
[Display Show Card #39]
S9. During the past 30 days, how many contacts did you have with a representative from Community Reentry? This would include both phone contacts and personal visits.
(0) No contacts
(1) one to three contacts
(2) four to six contacts
(3) seven or more contacts
(4) discharged from TASC more than one month ago
S10. How many of these Community Re-entry contacts in the past 12 months were:
A.
B.
C.
D.
At the TASC office…………………………………………………………………………(______)
At a treatment agency………………………………………………………………………(______)
In the community such as at home, work, or court…………………………………………(______)
Telephone contacts…………………………………………………………………………(______)
S11. What was the single most helpful topic which you worked on with your contact from
Community Re-entry in the past 12 months?
[Display Show Card #40]
S12. Looking at this Show Card, please tell me which of the answers best describes how satisfied you are
with your contact from Community Re-entry in the past 12 months?
(1) Very dissatisfied
(2) Somewhat dissatisfied
(3) Somewhat satisfied
(4) Very satisfied
S13. Can you please tell me why you feel that way about your experience with Community Re-entry?
55
Now I will ask you about a list of different topics that you may have worked on with either your case
manager or your contact at Community Re-entry. You don't need to identify which one of these
persons helped you, it can be either one. Please tell me if you worked on any of these following topics
with TASC or Community Re-entry in the past 12 months.
S14. Did you work on Life Skills such as: Cooking; Grocery Shopping, Using public transportation;
Washing clothes; Improving dress and appearance; Getting driver's license; Maintaining personal hygiene;
Improving diet, etc.
(0) No
(1) Yes
[IF “YES” ASK] [Display Show Card #41]
A. Looking at this showcard, please tell me which answer best describes how helpful
it was for you to work on and/or discuss your Life Skills with a counselor?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
S15. Did you work on Finances such as: Balancing checkbook; Using savings account; Using credit card
wisely; Controlling debts; Filing for bankruptcy; Saving money for specific goals; Maintaining budget;
Earning money legally; Getting public assistance; Getting social security, etc.
(0) No
(1) Yes
[IF “YES” ASK] [Display Show Card #41]
A. Looking at this showcard, please tell me which answer best describes how helpful it
was for you to work on and/or discuss your Finances with a counselor?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
S16. Did you work on Leisure such as: Seeking leisure activities; Seeking long term activities; Seeking
individual activities; Maintaining spouse/partner contact; Resolving conflict, etc.
(0) No
(1) Yes
[IF “YES” ASK] [Display Show Card #41]
A. Looking at this showcard, please tell me which answer best describes how helpful
it was for you to work on and/or discuss your Leisure activities with a counselor?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
S17. Did you work on Relationships such as: Maintaining family or friend contacts; Meeting spiritual
needs; Seeking community groups; Keeping pets; Resolving conflicts, etc.
(0) No
(1) Yes
[IF “YES” ASK] [Display Show Card #41]
A. Looking at this showcard, please tell me which answer best describes how helpful
it was for you to work on and/or discuss your Relationships with a counselor?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
56
S18. Did you work on Living Arrangements such as: Seeking new residence; Maintaining existing
residence; Finding a roommate; Cleaning residence; Entering halfway house; Entering domiciliary, etc.
(0) No
(1) Yes
[IF “YES” ASK] [Display Show Card #41]
A. Looking at this showcard, please tell me which answer best describes how helpful it
was for you to work on and/or discuss your Living arrangements with a counselor?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
S19. Did you work on Health such as: Getting adequate sleep; Exercising regularly; Scheduling medical
check-ups; Scheduling dental check-ups; Resolving health problems; Scheduling psychology counseling;
Scheduling drug counseling; Understanding my health; Following medical prescriptions; Understanding
Safe-sex practices, etc.
(0) No
(1) Yes
[IF “YES” ASK] [Display Show Card #41]
A. Looking at this showcard, please tell me which answer best describes how helpful it
was for you to work on and/or discuss your Health with a counselor?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
S20. Did you work on Internal Resources such as: Identifying goals; pursuing goals; expressing needs;
identifying strengths and talents; Following beliefs and values; Identifying accomplishments; Identifying
interests; Making decisions, etc.
(0) No
(1) Yes
[IF “YES” ASK] [Display Show Card #41]
A. Looking at this showcard, please tell me which answer best describes how helpful it
was for you to work on and/or discuss your Internal resources with a counselor?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
S21. Did you work on Recovery such as: Completing primary treatment; Discussing powerlessness over
alcohol and drugs; Following through with aftercare; Maintaining sobriety; Attending NA/AA/CA
meetings; Finding a sponsor; Maintaining contact with sponsor, etc.
(0) No
(1) Yes
[IF “YES” ASK] [Display Show Card #41]
A. Looking at this showcard, please tell me which answer best describes how helpful it
was for you to work on and/or discuss your Recovery with a counselor?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
57
The next set of questions have to do with some of the services you may or may not have received since
you entered TASC approximately six months ago. It may be that TASC or Community Re-entry
referred you to these services or it may be that you sought these services on your own.
S22. Have you received help with a food pantry or food vouchers in the past 6 months?
(0) No
(1) Yes
[IF “NO” SKIP TO S23; IF “YES” ASK]
A. How many times did you receive assistance from a food pantry or receive food vouchers in
the past 6 months?.............................................................................................(__________)
B. Was it your case manager or Community Re-entry that referred you to receive food
vouchers or assistance from a food pantry or did you locate these services on your own?
(1) Referred
(2) Found service without referral
C. Are you still receiving food vouchers or assistance from a food pantry?
(0) No
(1) Yes
[Display Show Card #41]
D. Looking at this showcard, please tell me which answer best describes how helpful it was for you
to receive this assistance?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
S23. Have you received credit counseling services in the past 6 months?
(0) No
(1) Yes
[IF “NO” SKIP TO S24; IF “YES” ASK]
A. How many times did you receive credit counseling services in the past 6
months?................................................................................(__________)
B. Was it your case manager or Community Re-entry that referred you to receive credit
counseling services or did you locate these services on your own?
(1) Referred
(2) Found service without referral
C. Are you still receiving credit counseling services?
(0) No
(1) Yes
[Display Show Card #41]
D. Looking at this showcard, please tell me which answer best describes how helpful it was for you
to receive this assistance?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
58
S24. Have you received services to help you with any unpaid electric, telephone or
other bills in the past 6 months?
(0) No
(1) Yes
[IF “NO” SKIP TO S25; IF “YES” ASK]
A. How many times did you receive services to help you with any unpaid bills in the past 12
months?.........................................................................................................(__________)
B. Was it your case manager or Community Re-entry that referred you to receive services to
help you with your unpaid bills or did you locate these services on your own?
(1) Referred
(2) Found service without referral
C. Are you still receiving services to help you with your unpaid bills?
(0) No
(1) Yes
[Display Show Card #41]
D. Looking at this showcard, please tell me which answer best describes how helpful it was for you
to receive this assistance?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
S25. Have you received housing assistance in the past 12 months?
(0) No
(1) Yes
[IF “NO” SKIP TO S26; IF “YES” ASK]
A. How many times did you receive housing assistance in the past 12 months?.......(__________)
B. Was it your case manager or Community Re-entry that referred you to receive housing
assistance or did you locate these services on your own?
(1) Referred
(2) Found service without referral
C. Are you still receiving housing assistance?
(0) No
(1) Yes
[Display Show Card #41]
D. Looking at this showcard, please tell me which answer best describes how helpful it was for you
to receive this assistance?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
59
S26. Have you received family or psychological counseling in the past 12 months?
(0) No
(1) Yes
[IF “NO” SKIP TO S27; IF “YES” ASK]
A. How many times did you receive family or psychological counseling in the past 6
months?..............................................................................................(__________)
B. Was it your case manager or Community Re-entry that referred you to receive family or
psychological counseling or did you locate these services on your own?
(1) Referred
(2) Found service without referral
C. Are you still receiving family or psychological counseling?
(0) No
(1) Yes
[Display Show Card #41]
D. Looking at this showcard, please tell me which answer best describes how helpful it was for you
to receive this assistance?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
S27. Have you received attorney or legal aid services in the past 6 months?
(0) No
(1) Yes
[IF “NO” SKIP TO S28; IF “YES” ASK]
A. How many times did you receive legal services in the past 12 months?...............(__________)
B. Was it your case manager or Community Re-entry that referred you to receive these legal
services or did you locate these services on your own?
(1) Referred
(2) Found service without referral
C. Are you still receiving legal services?
(0) No
(1) Yes
[Display Show Card #41]
D. Looking at this showcard, please tell me which answer best describes how helpful it was for you
to receive this assistance?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
60
S28. Have you received medical or hospital services in the past 12 months?
(0) No
(1) Yes
[IF “NO” SKIP TO S29; IF “YES” ASK]
A. How many times did you receive medical services in the past 12 months?..........(__________)
B. Was it your case manager or Community Re-entry that referred you to receive these
medical services or did you locate these services on your own?
(1) Referred
(2) Found service without referral
C. Are you still receiving medical services?
(0) No
(1) Yes
[Display Show Card #41]
D. Looking at this showcard, please tell me which answer best describes how helpful it was for you
to receive this assistance?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
S29. Have you sought assistance with clothing vouchers in the past 12 months?
(0) No
(1) Yes
[IF “NO” SKIP TO S30; IF “YES” ASK]
A. How many times did you receive clothing vouchers in the past 12 months?........(__________)
B. Was it your case manager or Community Re-entry that referred you to receive these
clothing vouchers or did you locate these services on your own?
(1) Referred
(2) Found service without referral
C. Are you still receiving clothing vouchers?
(0) No
(1) Yes
[Display Show Card #41]
D. Looking at this showcard, please tell me which answer best describes how helpful it was for you
to receive this assistance?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
61
S30. Have you sought assistance with substance abuse in self-help support groups such as AA, NA, CA,
or Alanon in the past 12 months?
(0) No
(1) Yes
[IF “NO” SKIP TO S31; IF “YES” ASK]
A. How many times did you receive assistance for substance abuse at self help support
groups such as AA, NA, CA, or Alanon in the past 12 months?...........................(________)
B. Was it your case manager or Community Re-entry contact that referred you to these selfhelp groups for substance abuse or did you locate these services on your own?
(1) Referred
(2) Found service without referral
C. Are you still attending self-help groups for substance abuse?
(0) No
(1) Yes
[Display Show Card #41]
D. Looking at this showcard, please tell me which answer best describes how helpful it was for you
to receive this assistance?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
S31. Have you received assistance with other self-help support groups such as Overeaters Anonymous
or Gamblers Anonymous in the past 12 months?
(0) No
(1) Yes
[IF “NO” SKIP TO S32; IF “YES” ASK]
A. How many times did you receive assistance for other self-help support groups such as
Overeaters Anonymous or Gamblers Anonymous in the past 12 months?..............(______)
B. Was it your case manager or Community Re-entry contact that referred you to these other
self-help groups or did you locate these services on your own?
(1) Referred
(2) Found service without referral
C. Are you still attending these other self-help groups?
(0) No
(1) Yes
[Display Show Card #41]
D. Looking at this showcard, please tell me which answer best describes how helpful it was for you
to receive this assistance?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
62
S32. Have you received assistance with work related or vocational services in the past 12 months?
(0) No
(1) Yes
[IF “NO” SKIP TO S33; IF “YES” ASK]
A. How many times did you receive assistance with work related or vocational services in the
past 6 months?.........................................................................................................(______)
B. Was it your case manager or Community Re-entry contact that referred you to these work
related or vocational services or did you locate these services on your own?
(1) Referred
(2) Found service without referral
C. Did you complete any work related or vocational services in the past 12 months?
(0) No
(1) Yes
[Display Show Card #41]
D. Looking at this showcard, please tell me which answer best describes how helpful it was for you
to receive this assistance?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
S33. Have you received assistance with school or educational services in the past 12 months?
(0) No
(1) Yes
[IF “NO” SKIP TO S34; IF “YES” ASK]
A. How many times did you receive assistance with school or educational services in the past 12
months?.........................................................................................................(______)
B. Was it your case manager or Community Re-entry contact that referred you to these
school or educational services or did you locate these services on your own?
(1) Referred
(2) Found service without referral
C. Did you complete any school or educational programs in the past 12 months?
(0) No
(1) Yes
[Display Show Card #41]
D. Looking at this showcard, please tell me which answer best describes how helpful it was for you
to receive this assistance?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
63
S34. Have you received treatment in a residential treatment program in the past 12 months?
(0) No
(1) Yes
[IF “NO” SKIP TO S35; IF “YES” ASK]
A. How many times did you receive treatment in a residential program in the past 12
months?.........................................................................................................(______)
B. Was it your case manager or Community Re-entry contact that referred you to residential
treatment or did you locate these services on your own?
(1) Referred
(2) Found service without referral
C. Are you currently living in a residential treatment program?
(0) No
(1) Yes
[Display Show Card #41]
D. Looking at this showcard, please tell me which answer best describes how helpful it was for you
to receive this assistance?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
S35. Have you received treatment in an outpatient treatment program in the past 12 months?
(0) No
(1) Yes
[IF “NO” SKIP TO S36; IF “YES” ASK]
A. How many times did you receive treatment in a outpatient program in the past 12
months?.........................................................................................................(______)
B. Was it your case manager or Community Re-entry contact that referred you to outpatient
treatment or did you locate these services on your own?
(1) Referred
(2) Found service without referral
C. Are you currently receiving outpatient treatment services?
(0) No
(1) Yes
[Display Show Card #41]
D. Looking at this showcard, please tell me which answer best describes how helpful it was for you
to receive this assistance?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
64
S36. Have you received treatment in a detox program in the past 12 months?
(0) No
(1) Yes
[IF “NO” SKIP TO S37; IF “YES” ASK]
A. How many times did you receive treatment in a detox program in the past 12
months?.........................................................................................................(______)
B. Was it your case manager or Community Re-entry contact that referred you to detox or
did you locate these services on your own?
(1) Referred
(2) Found service without referral
C. Are you currently receiving detox services?
(0) No
(1) Yes
[Display Show Card #41]
D. Looking at this showcard, please tell me which answer best describes how helpful it was for you
to receive this assistance?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
S37. How many of these treatments that you have received in the past 6 months were court ordered or in a
correctional facility?...............................................................................................................(_________)
S38. How long has it been since you left your last treatment program for an alcohol or drug problem?
Months_______
Weeks_______
The next set of questions have to do with any barriers to treatment or other services that you may
have encountered in the past 12 months.
S39. Please tell me, in the past 12 months have you encountered any of the following barriers to care:
A.
Had to wait too long to get an appointment
(0) No
(1) Yes
B.
Felt well or had no symptoms
(0) No
(1) Yes
C.
Had difficulty finding the right doctor or clinic
(0) No
(1) Yes
D.
Don’t want my insurance to know
(0) No
(1) Yes
E.
Don’t want my employer to know
(0) No
(1) Yes
F.
Don’t want my family or friends to know
(0) No
(1) Yes
65
G.
Not ready for treatment or other services
(0) No
(1) Yes
H.
Not ready, I still want to use alcohol and/or drugs
(0) No
(1) Yes
I.
Don’t want to be sick around people
(0) No
(1) Yes
J.
Too busy taking care of someone else right now (e.g. child, parent)
(0) No
(1) Yes
K.
Afraid because I don’t have citizenship
(0) No
(1) Yes
L.
Homelessness
(0) No
(1) Yes
M.
Don’t like doctors or clinics
(0) No
(1) Yes
N.
I won’t understand what’s going on because I don’t read or write very
well
(0) No
(1) Yes
O.
Feel too hopeless
(0) No
(1) Yes
P.
I won’t understand what’s going on because I don’t speak English very
well
(0) No
(1) Yes
Q.
Family, friends, others would disapprove of me seeking help
(0) No
(1) Yes
R.
Don’t have proper identification
(0) No
(1) Yes
S.
Too difficult to get admitted to care
(0) No
(1) Yes
T.
Putting it off
(0) No
(1) Yes
U.
Costs too much/no insurance coverage
(0) No
(1) Yes
V.
Care was not available when I needed it
(0) No
(1) Yes
W.
Had to wait too long in clinic
(0) No
(1) Yes
X.
Didn’t know where to go
(0) No
(1) Yes
Y.
Didn’t know what kind of doctor to see
(0) No
(1) Yes
66
Z.
Didn’t have a way to get there/transportation problem
AA. Too far to
BB. Clinic
CC. Fear
go
hours not convenient
of being treated rudely or unkindly
DD. Couldn’t
get an appointment
(0) No
(1) Yes
(0) No
(1) Yes
(0) No
(1) Yes
(0) No
(1) Yes
(0) No
(1) Yes
EE.
Child care not available
(0) No
(1) Yes
FF.
Couldn’t take time off of work
(0) No
(1) Yes
GG. Too embarrassed
(0) No
(1) Yes
HH. Didn’t
think anyone could help
(0) No
(1) Yes
II.
Afraid to find out what you may have
(0) No
(1) Yes
JJ.
Thought treatment would be unpleasant or painful
(0) No
(1) Yes
(0) No
(1) Yes
(0) No
(1) Yes
(0) No
(1) Yes
KK. Didn’t
LL.
want treatment
Didn’t want to deal with it
MM. Treated yourself
The next set of questions have to do with any Peer Support Groups you may have attended in the
past 12 months, specifically any "Winner's Circle" groups you may have participated in.
[ASK ONLY IF CLIENT IS EXPERIMENTAL]
S40. Were you informed by your TASC case manager that a Peer Support group called "Winner's Circle"
was available to you as part of the Second Chance Program?
(0) No
(1) Yes
S41. Did you attend any Winner's Circle meetings in the past 12 months?
(0) No
(1) Yes
67
[IF “NO” SKIP TO SECTION T; OTHERWISE ASK]
[Display Show Card #42]
S42. Looking at this showcard, please tell me how often did you attend these peer group support meetings in
the past 12 months?
(1) Once or twice (2) A few times (3-4) (3) About once a month (4) Every other week (5) Once a week
S43. Were these peer group support meetings usually started at the scheduled time?
(0) No
(1) Yes
S44. Was there a prayer recited at the beginning of every meeting?
(0) No
(1) Yes
S45. Were "Milestones of Recovery" recited at the beginning of every meeting?
(0) No
(1) Yes
S46. Was there a preamble recited at the beginning of every meeting?
(0) No
(1) Yes
S47. Was the Code of Ethics reviewed prior to every meeting?
(0) No
(1) Yes
S48. Were the rules of the group clearly posted in the meeting room?
(0) No
(1) Yes
S49. Did you find that the rules of the group were usually respected by the members of the group?
(0) No
(1) Yes
S50. Were these peer group meetings organized around topics of discussion? That is, was a topic picked
during each meeting (e.g. anger, depression, honesty, friendship) for the group to discuss?
(0) No
(1) Yes
[IF “YES” ASK]
A. How were topics of discussion usually picked? [Read response options aloud]
(1)
(2)
(3)
(4)
(5)
Chosen by meeting chairperson or leader
Suggested by one member of the group
Voted on by the entire group
Randomly selected from a list of topics
Other method (specify)______________________________________
[Display Show Card #43]
68
S51. Looking at this showcard, please tell me thinking back to the topics that were discussed during the
meetings you attended, how helpful was it to you to discuss these topics?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
S52. Looking at that same card, please tell me which answer describes how helpful you feel these peer
group meetings were for you?
(0) Not at all
(1) Somewhat
(2) moderately
(3) Considerably
(4) Extremely
S53. Based on your experiences with these peer support groups, would you recommend to a friend that
he/she attend a meeting?
(0) No
(1) Yes
69
PART T: INTERVIEWER IMPRESSIONS
TO BE COMPLETED IMMEDIATELY AFTER THE INTERVIEW
T1. END TIME
____ ____:____ ____
am/pm
a. Calculate Total length of interview
(___/___/___)
Minutes
DESCRIBE THE CLIENT:
T2.Weight:
..........................................................................................................(___)
1 = Emaciated 2 = Thin
T3.Grooming:
3 = Average
4 = Heavy
..................................................................................................(___)
1 = Poor
2 = Acceptable
3 = Good
4 = Excellent
T4.Attention to interviewer: ......................................................................................(___)
1 = Poor
2 = Acceptable
3 = Good
4 = Excellent
T5.Understanding of questions ..................................................................................(___)
1 = Poor 2 = Good
T6.Ability to articulate answers:................................................................................(___)
1 = Poor
2 = Acceptable
3 = Good
4 = Excellent
T7.Openness and honesty: .........................................................................................(___)
1 = Very poor
2 = Poor
3 = Acceptable
4 = Good
5 = Excellent
T8-10. Any signs of client:
T8.
T9.
T10.
Denial?
Drunkenness?
Drug intoxication?
None
Some
0
0
0
1
1
1
T11-19. At the time of the interview, was client:
T11.
T12.
T13.
T14.
T15.
T16.
T17.
T18.
T19.
A lot
2 ....................................(___)
2 ....................................(___)
2 ....................................(___)
(0) No
(1) Yes
Cooperative........................................................................................(___)
Suspicious ..........................................................................................(___)
Uncommunicative..............................................................................(___)
Obviously depressed, withdrawn .......................................................(___)
Obviously hostile ...............................................................................(___)
Obviously anxious/nervous................................................................(___)
Having trouble with reality testing, ..................................................(___)
thought disorders, paranoid thinking
Having trouble comprehending, ........................................................(___)
concentrating, remembering
Having suicidal thoughts ...................................................................(___)
70
T20.
How would you rate the accuracy of client's memory? .................................(___)
1 = Difficult to say
2 = Not very accurate
3 = Somewhat accurate
4 = Accurate
5 = Extremely accurate
T21.
How socially well-adjusted (able to adapt to society) would you ................(___)
say the client is?
1 = Not at all
T22.
2 = Very little 3 = Moderately
4 = Much
5 = Very much
How psychologically well adjusted (emotionally mature or stable) .............(___)
would you say the client is?
1 = Not at all
2 = Very little 3 = Moderately
4 = Much
5 = Very much
T23-25. What is your assessment of the validity (truthfulness) of the information the
client provided concerning her/his:
0= Not at all valid 1=Minimally valid 2=50/50 Valid/invalid 3=Mostly valid 4=Completely valid
T23.
Alcohol/drug usage? ..............................................................(___)
T24.
Involvement in criminal activity? ..........................................(___)
T25.
AIDS risk behavior? ..............................................................(___)
T27.
HOW WOULD YOU RATE THE ANSWERS GIVEN TO YOU?
T28.
OVERALL, HOW ATTENTIVE WAS CLIENT DURING THE INTERVIEW?
ATTENTIVE ...............................................................................1
SOMEWHAT INATTENTIVE OR UNINVOLVED .................2
EASILY DISTRACTED, NEEDED URGING TO
PAY ATTENTION, OR OFTEN REQUIRED
REPETITION OF QUESTIONS .................................................3
T29.
DID CLIENT GET LESS ATTENTIVE AS THE INTERVIEW
PROCEEDED?
VERY RELIABLE ..........................1
RELIABLE ......................................2
MARGINALLY RELIABLE...........3
UNRELIABLE.................................4
VERY UNRELIABLE.....................5
NOT AT ALL ..................................1
A LITTLE LESS..............................2
A LOT LESS ...................................3
71
COMMENTS:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
____________________________________________________________________________________________________
72
Show Card Responses
Program
Rehabilitation &
Restitution
Project
Show Card #1
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
One family house, duplex, or condominium
Apartment of other multiple family building
Mobile home/trailer
Hotel room, rooming house, or boarding house
Hospital or medical institution
Jail, prison, or other controlled environment
Residential treatment program
Group residence or halfway house
Homeless shelter
Street, abandoned building, or no regular place
Other (specify)
Show Card #2
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
P.
Q.
R.
S.
T.
NO IMPORTANT PLACES
FREEWAY
CHURCH
ABANDONED HOUSE/BUILDING
TROLLEY/BUS
DELI/CORNER STORE
DISCOUNT DEPARTMENT STORE
SHOPPING MALL/MARKET
STREET/CORNER/PARKING LOT
SCHOOL
LIQUOR STORE
PROJECTS
RECREATION CENTER/PARK/GYM
POLICE STATION
RESTAURANT/BAR
DOPE HOUSE/CRACK HOUSE
OTHER COMMERCIAL AREA
OTHER TRANSIT AREA
OTHER COMMUNITY CENTER
OTHER PLACE (specify)
Show Card #3
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
Both parents
Father mainly
Mother mainly
Spouse (and children)
Children only
Parent and children
Other relative
Member of the opposite sex (mate)
Member of the same sex (mate)
Other friends
Fellow jail/prison inmates
Other institution/hospital/shelter residents
Other treatment program residents
Alone
Other (specify)
Show Card #4
A.
B.
C.
D.
E.
F.
Not at All
Once or twice
A few times
About once a month
About once a week
Almost daily
G. Daily
Show Card #5
A.
B.
C.
D.
None
Low
Moderate
High
Show Card #6
A.
B.
C.
D.
E.
F.
Never
Rarely
Sometimes
Often
Almost always
Always
Show Card #7
A.
B.
C.
D.
E.
F.
G.
Both Parents
Father mainly
Mother mainly
Spouse (and children)
Children only
Parent and children
Other relative
H.
I.
J.
K.
L.
M.
N.
Member of the opposite sex (mate)
Member of the same sex (mate)
Other friends
Fellow jail/prison inmates
Other institution/hospital/shelter residents
Other treatment program residents
Other (specify)
Show Card #8
A.
B.
C.
D.
E.
F.
Never
Rarely
Sometimes
Often
Almost always
Always
Show Card #9
A.
B.
C.
D.
E.
Couldn’t be worse
Pretty bad
Okay
Pretty good
Couldn’t be better
Show Card #10a
Show Card #10b
A. Alcohol – any use
A. Other Amphetamines (uppers, diet pills)
B. Alcohol – to intoxication
B.
Minor Tranquilizers (librium, valium)
C. Inhalants (glue, gas, paint, liquid paper)
C.
Barbiturates (downers)
D. Marijuana/hashish
D. Other Sedatives/Hypnotics (quaaludes)
E. Hallucinogens (LSD, DMT, peyote)
E.
PCP
F. Crack/freebase
F.
Ecstasy (MDMA)
G. Cocaine (by itself)
G. Ketamine/Special K/Vitamin K
H. Heroin (by itself)
H. Rohypnol (Roofies)
I. Heroin and Cocaine (used together)
I.
GHB/Grievous Bodily Harm/Liquid Ecstasy
J. Prescribed Methadone
J.
More than one Drug at a time (excluding alcohol)
K. Street Methadone
K. Other (specify)
L. Other Opiates (codeine, morphine, Demerol
M. Methamphetamine/Speed/Ice
Show Card #11
A. Never
B. Several times a year
(less than once a month)
C. About once a month
D. About once every two weeks
E. About once a week
F. Several times a week
G. Every day
H. More than once a day
Show Card #12
A.
B.
C.
D.
E.
F.
Never
Rarely
Sometimes
Often
Almost always
Always
Show Card #13
A.
B.
C.
D.
E.
F.
G.
None
Very little
About ¼
About ½
About ¾
Almost All
All of it
Show Card #14
A. Professional or technical (accountant, architect, engineer,
lawyer, or judge, scientist, doctor, registered nurse,
teacher, social worker, writer, entertainer)
B. Manager and administrator (office/sales manager, school
administrator, government official, small business owner)
C. Sales (sales representative, insurance agent, real estate
broker, bond salesman, sales clerk or other sales people)
D. Clerical or office worker (bank teller, bookkeeper,
secretary, typist, postal clerk or carrier, ticket agent)
E. Craft and kindred (baker, carpenter, electrician,
bricklayer, mechanic, machinist, tool and die maker,
telephone installer)
F. Operative (assembler, checker, gas station attendant, meat
cutter, packer, laundry and dry-cleaning operative, miner
operative, welder, garage worker)
G. Transportation equipment operative (bus driver, cab
driver or chauffeur, truck driver and delivery man)
H. Non farm laborer (construction, freight handler,sanitation)
I. Private household worker (maid, butler, cook)
J. Service worker (cook, waiter, barber, janitor, practical
nurse, beautician, police officer, firefighter)
K. Farmer and farm manager
L. Farmer laborer (foreman, picker)
M. Military Service
Show Card #15
A.
B.
C.
D.
E.
F.
G.
Never
Rarely
About ¼ of the time
About ½ of the time
About ¾ of the time
Almost always
Always
Show Card #16
A.
B.
C.
D.
E.
None of them
One or a few of them
About ½ of them
Most of them
All of them
Show Card #17
A. None of my free time
B. Very little of my free time
C. About 25% of my free time
D. About 50% of my free time
E. About 75% of my free time
F. Almost all of my free time
G. All of my free time
Show Card #18
A.
B.
C.
D.
E.
Not at all
Slightly
Moderately
Considerably
Extremely
Show Card #19
A.
B.
C.
D.
Excellent
Good
Fair
Poor
Show Card #20
A.
B.
C.
D.
Not at all helpful
Somewhat helpful
Quite helpful
Extremely helpful
Show Card #21
A.
B.
C.
D.
E.
F.
Never
Rarely
Sometimes
Often
Almost always
Always
Show Card #22
A.
B.
C.
D.
E.
Strongly Disagree
Disagree
Not Sure
Agree
Strongly Agree
Show Card #23
A.
B.
C.
D.
E.
Not at all
Somewhat
Moderately
Quite a bit
Extremely
Show Card #24
A.
B.
C.
D.
E.
Strongly Disagree
Disagree
Not Sure
Agree
Strongly Agree
Show Card #25
A. Probably increase your drug use
B. Continue to use drugs like before
C. Cut back your drug use or use on an
occasional or more controlled basis
D. Switch to using (or use more) alcohol
E. Switch to using other, less serious drug
F. Quit for a while, but start using again later
G. Quit eventually but slip a few times during
recovery
H. Quit forever and never use again
I. Continue your abstinence from drugs
J. Other (specify)
Show Card #26
A.
B.
C.
D.
E.
F.
Zero
Very low (less than 10%)
Low (about 25%)
About 50/50
High (about 75%)
Very high (85% or greater)
Show Card #28
A.
B.
C.
D.
E.
Strongly Disagree
Disagree
Neither agree nor disagree
Agree
Strongly Agree
Show Card #29
A. Terrible
B. Unhappy
C. Mostly Dissatisfied
D. Mixed
E. Mostly Satisfied
F. Pleased
G. Delighted
Show Card #30
A. Strongly Disagree
B. Somewhat Disagree
C. Somewhat agree
D. Strongly agree
Show Card #31
A.
B.
C.
D.
E.
F.
G.
H.
Never
A few times
About once a month
A few times each month
About once each week
A few times each week
Every day
More than once a day
Show Card #32
A.
B.
C.
D.
E.
None of the time
Less than half the time
About half the time
Most of the time
All the time, every time
Show Card #33
A.
B.
C.
D.
E.
Not at all
Slightly
Moderately
Considerably
Extremely
Show Card #34
A.
B.
C.
D.
E.
Strongly Disagree
Disagree
Neither agree nor disagree
Agree
Strongly Agree
Show Card #34a
A.
B.
C.
D.
E.
Not at all
A little bit
Moderately
Quite a bit
Extremely
Show Card #34b
A.
B.
C.
D.
E.
Not at all
Rarely
Sometimes
Often
Always
SHOW CARD #35
A Never
B Less than once a month
C About once a month
D Twice a month
E About once a week
F More than once a week
SHOW CARD #36
A No Contacts
B One to three contacts
C Four to six contacts
D Seven or more contacts
E Discharged from TASC
more than 1 month ago
SHOW CARD #37
A Very Dissatisfied
B Somewhat Dissatisfied
C Somewhat Satisfied
D Very Satisfied
SHOW CARD #38
A Never
B Less than once a month
C About once a month
D Twice a month
E About once a week
F More than once a week
SHOW CARD #39
A No Contacts
B One to three contacts
C Four to six contacts
D Seven or more contacts
E Discharged from TASC
more than 1 month ago
SHOW CARD #40
A Very Dissatisfied
B Somewhat Dissatisfied
C Somewhat Satisfied
D Very Satisfied
SHOW CARD #41
A Not at all Helpful
B Somewhat Helpful
C Moderately Helpful
D Considerably Helpful
E Extremely Helpful
SHOW CARD #42
A Once or Twice
B A few times (3-4)
C About once a month
D Every other week (2x/month)
E Once a week
SHOW CARD #43
F. Not at all Helpful
G.Slightly Helpful
H.Moderately Helpful
I. Considerably Helpful
J. Extremely Helpful
APPENDIX B
CLIENT FOCUS GROUP MATERIALS
Client Focus Group Protocol..............................................................................................B1
Client Focus Group Telephone Script................................................................................B2
Cuyahoga County Client Focus Group Informed Consent Information Sheet and Signature
Form for Non-incarcerated Clients....................................................................................B3
Clermont County Client Focus Group Informed Consent Information Sheet and Signature
Form for Non-incarcerated Clients....................................................................................B4
Informed Consent Form to Audio Tape Focus Group.......................................................B5
FORM APPROVED
OMB No. 0930-xxxx
Expires MM/DD/YY
Client Focus Group Protocol
Public reporting burden for this collection of information is estimated to average 1 hour and 30
minutes per response, including the time for reviewing instructions and 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; Paperwork Reduction Project (0930-xxxx); Room 16-105, Parklawn
Building; 5600 Fishers Lane, 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 control number for this project is 0930-xxxx
I’d like to start by asking you some questions about your work with your TASC case manager.
1. Are you satisfied with the effort on the part of your case manager to provide you with referrals?
2. Are you satisfied with the frequency or quality of interaction with your case manager?
3. What was the single most helpful topic that you worked on with your case manager?
Now I’d like to discuss your perceptions or feelings regarding the substance abuse treatment or
other services that have already been provided to you.
4. What substance abuse treatment or other services are you currently receiving or did you previously
receive as part of your participation in the Second Chance Program?
Probe, if necessary:
• What types of drug treatment programs have you participated in?
• Have you received any counseling or support services?
• Have you received any additional services (e.g. vocational training)?
5. What was the reason you entered treatment or any of these other types of programs?
Probe, if necessary:
• Did you enter these treatment or other programs voluntarily or involuntarily?
• If voluntarily, what motivated you to get these services at that particular time?
• If involuntarily, what were the circumstances?
6. What is your opinion of the treatment or other services that you have received in this program?
Probe, if necessary:
• How helpful have these treatment services been?
• Would you say you are satisfied or dissatisfied with the services offered?
7. What was the single most helpful topic, which you worked on in treatment?
Now I’d like to discuss the accessibility of substance abuse treatment services and by that I mean
how convenient or inconvenient it is to obtain these services.
8. Overall, how easy or hard is it or was it for you to get substance abuse treatment services such as
access to drug treatment programs or other services you feel you need?
Probe, if necessary:
• If you already received these services, how easy or hard was it for you to obtain them?
• Are you aware of the different types of services that are available to you?
• What types of services do you feel you need that have not been provided to you?
• Do you know where to go to get the various types of services offered to you?
Now I’d like to discuss some of the difficulties you may have had in trying to access services.
9. What specifically might make it difficult to obtain substance abuse treatment services?
Probe, if necessary:
• Do you have any personal issues or concerns that would make it hard for you to obtain
substance abuse treatment services?
• Is substance abuse treatment a priority in your life right now? If not, what takes priority over
your treatment needs?
•
Have you tried to obtain these services but for some reason or another you have had trouble? If
so, what are some of the problems you have encountered?
SCRIPTS FOR RECRUITING FOCUS GROUP PARTICIPANTS BY PHONE
Script 1: If client is not available
Researcher: “Hello, my name is _____. May I speak with ______?”
Answer: “What is this about?”
Researcher: “I am calling from the National Development and Research Institutes
(NDRI). I am looking for ______. He is part of a research study conducted by EDC, and
we are calling to find out if he would be interested in participating in a focus group.”
Answer: “I’m not sure where he is at but I have never heard him talk about a research
study. Can you tell me more about this research study?”
Researcher: “I am sorry but I really can’t tell you any more than I already have. _____
has been selected and has agreed to participate in this study. This is a confidential health
study and that is all I can tell you.”
Answer: “Then what should I tell him?”
Researcher: “You might tell him that he would be paid if he agrees to participate in this
focus group. A time and place for the group has been scheduled so can you please ask
him to call this number collect [recite phone number] so we can further discuss the
details.”
“We will need to determine soon whether this might be something he is interested in
doing so we really appreciate your forwarding this message. Thank you very much for
your help! Good bye!”
Script 2: If speaking directly with client
Researcher: “Hello, my name is _____. May I speak with ______?”
Answer: “This is _______ speaking. What is this about?”
Researcher: “I am calling from the National Development and Research Institutes
(NDRI). You have previously participated in some interviews as part of the EDC study.
Do you remember the project?”
Answer: “Yeah, I remember being interviewed last year. Is it time for another interview
already?”
1
Researcher: “Not just yet but someone from EDC will be contacting you to remind you
when it is time for your next interview. Our records indicate that you have been part of
the program for [6 months] now so I am calling to ask you whether or not you would be
interested in participating in the [6 month] focus group that we have scheduled.”
Answer: “A focus group? What is that?”
Researcher: “At the time of your first interview we had mentioned that at some point
during the study you might be asked to participate in a focus group. Basically, it is a
group discussion with 8-10 other clients. There will be two group leaders from NDRI
who are researchers. The group leader will ask some questions for anyone in the group to
answer. The questions will be about how you feel about the program and the services
that you may, or may not have received.”
Answer: “Do I have to participate in this focus group?”
Researcher: “Absolutely not! You do not have to participate in this focus group in order
to continue your participation in the study. You are helping us by taking part in a focus
group and therefore we will compensate you $35. If you agree to participate, we will
review the focus group information sheet with you when you arrive and give you a
chance to ask more questions then have you sign the form. We will also ask your
permission to audio tape these discussions for research purposes. However, participation
in any focus group is entirely voluntary and the decision is up to you. ”
Answer: “How long does it take?”
Researcher: “It takes about an hour and a half.” We have scheduled the next focus group
for [date] [time] [location]. Would you be able to participate?”
Answer: “Can I do it another time? I have something else to do that day.”
Researcher: “Because there are 8-10 other participants it is difficult to accommodate
individual scheduling requests as we have previously done for the one-on-one interviews.
Do you think you would be able to make the scheduled time?”
Note: If client can’t make the scheduled time the researcher will note on the
correspondence log when the client may be available in case the focus group session
has to be rescheduled.
2
FORM APPROVED
OMB No. 0930-0248
CUYAHOGA COUNTY, OHIO Expires 10/31/06
See burden statement on client focus group protocol
Program Rehabilitation and Restitution Project
Focus Group Discussion – Client Information Sheet
for Non-Incarcerated Clients
Introduction: You are being asked to take part in a discussion with 8-10 other clients
about the kinds of help you may have received with substance abuse, employment, and
social support. We are asking you because you can provide information regarding this
process. The focus group is being conducted as part of the evaluation of the Program
Restitution and Rehabilitation Project. The focus group will be conducted by staff from
the Center for the Integration of Research and Practice (CIRP) at the National
Development and Research Institutes, Inc. (NDRI).
Description of Procedures: If you decide to be in the focus group, you will be in a
meeting of clients who have also agreed to be in the group and 1 – 2 group leaders who
are researchers. The group leader will ask some questions for anyone in the group to
answer. These questions are about how you feel about the program and the services that
you may, or may not have received. The group will last about 1½ hours. The group will
be audio recorded only. Only first names of the participants will be used in the recorded
portion of the group to protect the identity of the participants.
Risks: There is a possibility that some of the things the group discusses may make you
uncomfortable. If this happens you can take a break and come back later, or you can
leave the discussion and not return to the room, or one of us can call your case manager
or another staff member or someone close to you. Also, other clients in the group could
tell someone what you said in the group. We ask everyone in the group to respect other
people’s privacy and not to talk about what is said in the group after it is over.
Benefits: This focus group is not being done to help you, personally. However, there is
some chance you will feel better after the focus group. What we learn from you may help
others in the future by making services and programs better.
Financial Considerations: You are helping us by participating in this focus group. We
will compensate you $35 for your participation.
Confidentiality: Because we have taken steps to protect your confidentiality, the risk of
unauthorized disclosure is minimal. To help keep information about you private and
confidential, we have applied for a Confidentiality Certificate from the federal agency
giving us money for the study, the Department of Health and Human Services. This
Certificate means that we cannot be forced to give information about you to others, even
if a court has ordered us to do so using a subpoena. However, if you say you have been
harming or abusing a child or an elderly person, we will be required to report that. If you
tell us you are going to physically hurt yourself or someone else, we will contact someone
who can help. If you commit a crime on our treatment premises or against a treatment
service provider, we will report such incidences to the proper authorities. Also, you can
give permission to let people know that you are in the study.
1
CUYAHOGA COUNTY, OHIO
If you have any questions about the interview, please ask the person who is interviewing
you. You can also call us to talk more about the session. If you have questions about the
study or feel you have been hurt by the study, you may call Harry K. Wexler, Ph.D. or
Gerald Melnick, Ph.D. at (212.845.4400), who are in charge of the study. If you have
questions about your rights as someone who is taking part in this study, you can call Dr.
Fred Streit, Executive Director/CEO of NDRI (888.845.4695).
Voluntary Participation: Your participation in this study is entirely voluntary. If you
choose not to participate, you will not be penalized or lose any benefits to which you
would otherwise be entitled; your decision will not affect your receiving the treatment or
the services you would have received if you had not been asked to participate in the
study.
Questions: Please feel free to ask any questions about anything that seems unclear to
you and to consider this research and consent form carefully before you sign.
2
CUYAHOGA COUNTY, OHIO
Program Rehabilitation and Restitution Project
Focus Group Discussion – Informed Consent Client Signature Form
for Non-Incarcerated Clients
I, ________________________________________________, hereby give my consent
and understand the Client Information Sheet and the informed consent form, including
the description of the study and its possible benefits, my role, possible risks and the steps
taken to protect me.
I understand the following:
My participation is voluntary;
I will be asked to talk about things like my satisfaction with the program
and use of the treatment and other services that were provided to me;
I do not have to answer specific questions;
There is no penalty for not providing any information;
I can refuse to participate at any point;
No names, only code numbers, will appear on my interview forms or
records;
The listing of assigned code numbers will be kept in a separate locked file,
with the code known only to the Principal Investigator and the Project
Director/Statistician;
All data will be kept in locked files accessible to the CIRP/NDRI project
research staff;
All written and published information will be reported as group data, with
no reference to individuals.
The focus group will be tape recorded, but my last name will not be used in
order to protect my identity.
This project does not guarantee that my criminal records will be sealed.
I HAVE READ THE ABOVE AND UNDERSTAND THE PURPOSE OF THE FOCUS
GROUP. I UNDERSTAND THAT THIS FOCUS GROUP IS A PART OF A
RESEARCH PROJECT IN WHICH I HAVE VOLUNTARILY AGREED TO TAKE
PART.
Client’s Signature
Date
Interviewer’s Signature
Date
Client ID Number (___/___/___/___/___/___/___/___)
3
FORM APPROVED
OMB No. 0930-0248
CLERMONT COUNTY, OHIO Expires 10/31/06
See burden statement on Client focus group protocol
Program Rehabilitation and Restitution Project
Focus Group Discussion – Client Information Sheet
for Non-Incarcerated Clients
Introduction: You are being asked to take part in a discussion with 11 other clients
about the kinds of help you may have received with substance abuse, employment, and
social support. We are asking you because you can provide information regarding this
process. The focus group is being conducted as part of the evaluation of the Program
Restitution and Rehabilitation Project. The focus group will be conducted by staff from
the Center for the Integration of Research and Practice (CIRP) at the National
Development and Research Institutes, Inc. (NDRI).
Description of Procedures: If you decide to be in the focus group, you will be in a
meeting of clients who have also agreed to be in the group and 1 – 2 group leaders who
are researchers. The group leader will ask some questions for anyone in the group to
answer. These questions are about how you feel about the program and the services that
you may, or may not have received. The group will last about 1 ½ hours. The group will
be audio recorded only. Only first names of the participants will be used in the recorded
portion of the group to protect the identity of the participants.
Risks: There is a possibility that some of the things the group discusses may make you
uncomfortable. If this happens you can take a break and come back later, or you can
leave the discussion and not return to the room, or one of us can call your case manager
or another staff member or someone close to you. Also, other clients in the group could
tell someone what you said in the group. We ask everyone in the group to respect other
people’s privacy and not to talk about what is said in the group after it is over.
Benefits: This focus group is not being done to help you, personally. However, there is
some chance you will feel better after the focus group. What we learn from you may help
others in the future by making services and programs better.
Financial Considerations: You are helping us by participating in this focus group. We
will provide you with a gift certificate valued at $35 for your participation.
Confidentiality: Because we have taken steps to protect your confidentiality, the risk of
unauthorized disclosure is minimal. To help keep information about you private and
confidential, we have applied for a Confidentiality Certificate from the federal agency
giving us money for the study, the Department of Health and Human Services. This
Certificate means that we cannot be forced to give information about you to others, even
if a court has ordered us to do so using a subpoena. However, if you say you have been
harming or abusing a child or an elderly person, we will be required to report that. If you
tell us you are going to physically hurt yourself or someone else, we will contact someone
who can help. If you commit a crime on our treatment premises or against a treatment
service provider, we will report such incidences to the proper authorities. Also, you can
give permission to let people know that you are in the study.
1
CLERMONT COUNTY, OHIO
If you have any questions about the interview, please ask the person who is
interviewing you. You can also call us to talk more about the session. If you have
questions about the study or feel you have been hurt by the study, you may call Harry K..
Wexler, Ph.D. or Gerald Melnick, Ph.D. at (212.845.4400), who are in charge of the
study. If you have questions about your rights as someone who is taking part in this
study, you can call Dr. Fred Streit, Executive Director/CEO of NDRI (888.845.4695).
Voluntary Participation: Your participation in this study is entirely voluntary. If
you choose not to participate, you will not be penalized or lose any benefits to which you
would otherwise be entitled; your decision will not affect your receiving the treatment or
the services you would have received if you had not been asked to participate in the
study.
Questions: Please feel free to ask any questions about anything that seems unclear to
you and to consider this research and consent form carefully before you sign.
2
CLERMONT COUNTY, OHIO
Program Rehabilitation and Restitution Project
Focus Group Discussion – Informed Consent Client Signature Form
for Non-Incarcerated Clients
I, ________________________________________________, hereby give my consent
and understand the Client Information Sheet and the informed consent form, including
the description of the study and its possible benefits, my role, possible risks and the steps
taken to protect me.
I understand the following:
My participation is voluntary;
I will be asked to talk about things like my satisfaction with the program
and use of the treatment and other services that were provided to me;
I do not have to answer specific questions;
There is no penalty for not providing any information;
I can refuse to participate at any point;
No names, only code numbers, will appear on my interview forms or
records;
The listing of assigned code numbers will be kept in a separate locked file,
with the code known only to the Principal Investigator and the Project
Director/Statistician;
All data will be kept in locked files accessible to the CIRP/NDRI project
research staff;
All written and published information will be reported as group data, with
no reference to individuals.
The focus group will be tape recorded, but my last name will not be used in
order to protect my identity.
This project does not guarantee that my criminal records will be sealed.
I HAVE READ THE ABOVE AND UNDERSTAND THE PURPOSE OF THE FOCUS
GROUP. I UNDERSTAND THAT THIS FOCUS GROUP IS A PART OF A
RESEARCH PROJECT IN WHICH I HAVE VOLUNTARILY AGREED TO TAKE
PART.
Client’s Signature
Date
Interviewer’s Signature
Date
Client ID Number (___/___/___/___/___/___/___/___)
3
FORM APPROVED
OMB No. 0930-0248
Expires 10/31/06
See burden statement on client focus group protocol
Program Rehabilitation and Restitution Project
Informed Consent to Make Audio Tapes for Non-Incarcerated Clients
Client Signature Form
I give my consent to the staff of the Program Rehabilitation and Restitution Project to
record this focus group on audio tapes. These tapes will be used as part of the research
study to find out how the program helps ex-offenders.
Both I and the interviewers will be careful not to mention full names or any other
information that could identify me or any other participant. If anyone accidentally does
so, that information will be deleted from the tape.
When completed, tapes will be identified by code numbers only; my name will not
appear on the tapes or their containers. Tapes will be stored in locked cabinets when not
in use. Tapes will be sent to the NDRI New York offices. Mailing systems with tracking
and receipt capabilities will be used to protect against the danger of losing the tapes.
I understand that I can refuse consent to audiotape a focus group in the future, even if I
agreed to this one. My decision will not affect my treatment or the services I receive. All
tapes will be destroyed three years after the completion of the Project.
I may revoke this permission at any time and request that my voice on the tapes be
deleted, by writing to:
Dr. Harry K. Wexler, Principal Investigator
NDRI
71 West 23rd St., 8th Floor
New York, NY 10010
Client’s Signature
Date
Interviewer’s Signature
Date
Client ID Number (___/___/___/___/___/___/___/___)
1
APPENDIX C
STAKEHOLDER SURVEY
Stakeholder Attitudinal Change Survey Cover Letter......................................................C1
Stakeholder Attitudinal Change Survey............................................................................C2
National Development and Research Institutes, Inc. (NDRI)
Center for the Integration of Research and Practice
71 West 23rd Street, 8th Floor
New York, NY 10010
[Date]
Re: Program Rehabilitation and Restitution Project Attitudinal Change Survey
Dear [Participant],
You are being asked to complete the attached “Stakeholder Attitudinal Change Scale” as part of
the Program Rehabilitation and Restitution Project. This study is funded by funded by the
federal Substance Abuse and Mental Health Services Administration’s Center for Substance
Abuse Treatment (CSAT). This survey was created by the evaluation team at National
Development and Research Institutes, (NDRI) Inc., which is a non-profit research organization
with a national reputation for substance abuse research.
As you may know, the Ohio Statute permits the sealing of records for first time nonviolent
felony offenders with no previous misdemeanor offenses (co-occurring misdemeanor offenses at
the time of the felony offense do not count) after a minimum of 3 years post supervision without
infractions. Charges that make some ineligible for sealing of records are: DUI, DUS, drag
racing, sex offenses and any other violent offense, crimes against a minor, some burglary
charges, and drug offenses involving large amounts of Schedule I and II substances, leaving the
scene of an accident, and odometer violations. The purpose of this project is to determine the
impact of record expungement on recidivism, substance treatment compliance, victim
awareness/restitution, and assimilation into a productive lifestyle.
The attached Attitudinal Change Survey will provide information to program developers on the
extent to which attitudes towards sealing records have been impacted positively or negatively
over the course of the project. Personnel from both state and local level agencies that have been
identified as key contributors to the program’s long-term viability and effectiveness are being
asked to complete this survey. You were selected because of your position as [TITLE] of
[AGENCY], which has been identified as a key stakeholder in our project.
This same survey will be administered at three different points taking approximately ten minutes
to complete each time. Although we hope you will fill out this survey and those to follow, your
participation is voluntary. Please be assured that NDRI will keep this information strictly
confidential, and that we will not release any information that can be linked directly to you. You
do not need to put your name on the survey as we use code numbers instead. We have included
a self-addressed stamped envelope for your convenience in returning the survey to NDRI.
A member of the research evaluation team can be reached at [1-800-xxx-xxxx] if you have any
questions about the study or the survey. We hope that you will be able to complete this survey
and we thank you in advance for your valuable time.
Sincerely,
Harry K. Wexler, PhD
Gerald Melnick, PhD
FORM APPROVED
OMB No. 0930-xxxx
Expires MM/DD/YY
Stakeholder Attitudinal Survey
Public reporting burden for this collection of information is estimated to average 10 minutes per
response, including the time for reviewing instructions and 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; Paperwork
Reduction Project (0930-xxxx); Room 16-105, Parklawn Building; 5600 Fishers Lane, 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
control number for this project is 0930-xxxx
Many states allow the ‘sealing’ of criminal records which limits who has access to the records,
but does not entirely destroy those records. Ordinarily, the repository of criminal records
retains the record and a limited number of agencies such as the criminal justice system, law
enforcement agencies, agencies granting teaching certificates, and adoption agencies continue
to have access to records in certain circumstances.
1. I think that the practice of sealing criminal records for offenders should be
discouraged.
1
Strongly Agree
2
Agree
3
Disagree
4
Strongly
Disagree
5
Don’t Know
2. I think that most felons deserve the type of second chance that the sealing of criminal
records would give them.
1
Strongly Agree
2
Agree
3
Disagree
4
Strongly
Disagree
5
Don’t Know
3. I think that sealing criminal records would encourage criminals to freely commit
more crimes.
1
Strongly Agree
2
Agree
3
Disagree
4
Strongly
Disagree
5
Don’t Know
4. I think that people have a right to have their criminal records sealed.
1
Strongly Agree
2
Agree
3
Disagree
4
Strongly
Disagree
5
Don’t Know
5. I support the sealing of criminal records for first time non-violent offenders.
e.g. status offenses such as burglary, possession of burglar tools, failure to appear,
forgery, panhandling, larceny etc.
1
Strongly Agree
2
Agree
3
Disagree
1
4
Strongly
Disagree
5
Don’t Know
6. I support the sealing of criminal records for some violent offenders.
e.g. Armed robbery, possession of weapon, attempted homicide, use of force,
aggravated assault
1
Strongly Agree
2
Agree
3
Disagree
4
Strongly
Disagree
5
Don’t Know
7. I support the sealing of criminal records for drug use arrests or convictions.
1
Strongly Agree
2
Agree
3
Disagree
4
Strongly
Disagree
5
Don’t Know
4
Strongly
Disagree
5
Don’t Know
8. I think sealing of criminal records is too lenient.
1
Strongly Agree
2
Agree
3
Disagree
9. I think the process of sealing records should be made as simple as possible.
1
Strongly Agree
2
Agree
3
Disagree
4
Strongly
Disagree
5
Don’t Know
10. People should be encouraged to seek to have their records sealed.
1
Strongly Agree
2
Agree
3
Disagree
2
4
Strongly
Disagree
5
Don’t Know
APPENDIX D
STAKEHOLDER FOCUS GROUPS
Stakeholder Focus Group Recruitment Letter...................................................................D1
Stakeholder Focus Group Informed Consent Information Sheet and Signature Form......D2
Stakeholder Focus Group Protocol....................................................................................D3
National Development and Research Institutes, Inc. (NDRI)
Center for the Integration of Research and Practice
71 West 23rd Street, 8th Floor
New York, NY 10010
[Date]
Re: Program Rehabilitation and Restitution Project focus group discussion
Dear [Participant],
You are invited to participate in a focus group discussion of the Program Rehabilitation and
Restitution Project. This study is funded by funded by the federal Substance Abuse and Mental
Health Services Administration’s Center for Substance Abuse Treatment (CSAT). The focus
group discussion will be facilitated by the evaluation team at the National Development and
Research Institutes, (NDRI) Inc, which is a non-profit research organization with a national
reputation for substance abuse research.
As you may know, the Ohio Statute permits the sealing of records for first time nonviolent
felony offenders with no previous misdemeanor offenses (co-occurring misdemeanor offenses at
the time of the felony offense do not count) after a minimum of 3 years post supervision without
infractions. The purpose of this project is to determine the impact of record expungement on
recidivism, substance treatment compliance, victim awareness/restitution, and assimilation into a
productive lifestyle.
The focus group will include participants from both the state and local level that have been
identified as key contributors to the program’s long-term viability and effectiveness. During this
meeting, you will have the opportunity to share your experiences with and opinions of the
Second Chance treatment model implemented for this study, the services provided as part of the
study, and the perceived impact of expungement on the process.
The focus group will be held on [DATE] from [TIME1] until [TIME2] at [PLACE].
will be provided. You were selected because you [TITLE] of
[AGENCY], which has been identified as a key stakeholder in our project. Although we hope
you will join us, your participation is voluntary. The focus group session will be audio taped.
Pleased be assured that NDRI will keep anything you say during the focus group strictly
confidential, and that NDRI will not release any information that can be linked directly to you.
A member of the research evaluation team will be contacting you by telephone to invite you to
participate and answer any questions you may have about the study. You are also welcome to
call us at [1-800-xxx-xxxx].
We hope that you will be able to join us for this important discussion.
Sincerely,
Harry K. Wexler, PhD
Gerald Melnick, PhD
FORM APPROVED
OMB No. 0930-0248
Expires 10/31/06
See burden statement on stakeholder focus group protocol
Program Rehabilitation and Restitution Project
Focus Group Discussion – Stakeholder Information Sheet
Introduction: You are being asked to take part in a discussion with 11 other stakeholders
in the community regarding the Program Rehabilitation and Restitution (PRR) Project.
The focus group is being conducted as part of the evaluation of the PRR Project. The
focus group will be conducted by staff from the Center for the Integration of Research
and Practice (CIRP) at the National Development and Research Institutes, Inc. (NDRI).
Description of Procedures: If you decide to be in the focus group, you will be in a
meeting of stakeholders who have also agreed to be in the group and 1 – 2 group leaders
who are researchers. The group leader will ask some questions for anyone in the group to
answer. These questions are about how you feel about the program, services that may or
may not be offered, and the expungement process. The group will last about 1 ½ hours.
The group will be audio recorded only. Names of the participants will not be used in the
recorded portion of the group to protect the identity of the participants.
Risks: There is a possibility that some of the things the group discusses may make you
uncomfortable. If this happens you can take a break and come back later, or you can
leave the discussion and not return to the room. Also, other stakeholders in the group
could tell someone what you said in the group. We ask everyone in the group to respect
other people’s privacy and not to talk about what is said in the group after it is over.
Benefits: This focus group is not being done to help you, personally. However, what we
learn from you may help others in the future by making services and programs better.
Confidentiality: Because we have taken steps to protect your confidentiality, the risk of
unauthorized disclosure is minimal. To help keep information about you private and
confidential, we have applied for a Confidentiality Certificate from the federal agency
giving us money for the study, the Department of Health and Human Services. This
Certificate means that we cannot be forced to give information about you to others, even
if a court has ordered us to do so using a subpoena.
If you have any questions about the interview, please ask the person who is
interviewing you. You can also call us to talk more about the session. If you have
questions about the study or feel you have been hurt by the study, you may call Harry K.
Wexler, Ph.D. or Gerald Melnick, Ph.D. at (212.845.4400), who are in charge of the
study. If you have questions about your rights as someone who is taking part in this
study, you can call Dr. Fred Streit, Executive Director/CEO of NDRI (888.845.4695).
Voluntary Participation: Your participation in this study is entirely voluntary. If
you choose not to participate, you will not be penalized or lose any benefits to which you
would otherwise be entitled.
Questions: Please feel free to ask any questions about anything that seems unclear to
you and to consider this research and consent form carefully before you sign.
1
Program Rehabilitation and Restitution Project
Focus Group Discussion – Informed Consent Stakeholder Signature Form
I, ________________________________________________, hereby give my consent
and understand the Stakeholder Information Sheet and the informed consent form,
including the description of the study and its possible benefits, my role, possible risks and
the steps taken to protect me.
I understand the following:
My participation is voluntary;
I will be asked to talk about things like my satisfaction with the program
and use of the treatment and other services that have been provided;
I do not have to answer specific questions;
There is no penalty for not providing any information;
I can refuse to participate at any point;
No names will be used during the focus group discussion;
The listing of stakeholder participants will be kept in a separate locked file,
known only to the Principal Investigator and the Project Director;
All data will be kept in locked files accessible to the CIRP/NDRI project
research staff;
All written and published information will be reported as group data, with
no reference to individuals.
The focus group will be tape recorded, but name will not be used in order to
protect my identity.
I HAVE READ THE ABOVE AND UNDERSTAND THE PURPOSE OF THE FOCUS
GROUP. I UNDERSTAND THAT THIS FOCUS GROUP IS A PART OF A
RESEARCH PROJECT IN WHICH I HAVE VOLUNTARILY AGREED TO TAKE
PART.
Stakeholder’s Signature
Date
Interviewer’s Signature
Date
2
FORM APPROVED
OMB No. 0930-xxxx
Expires MM/DD/YY
Stakeholder Focus Group Protocol
Public reporting burden for this collection of information is estimated to average 1 hour and 30
minutes per response, including the time for reviewing instructions and 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; Paperwork Reduction Project (0930-xxxx); Room 16-105, Parklawn
Building; 5600 Fishers Lane, 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 control number for this project is 0930-xxxx
Let’s start by talking about system changes that have occurred in Cuyahoga County
1. What are some of the factors responsible for fewer sealing eligible referrals than were projected?
2. Many of our referrals come from diversion programs such as EIP and ILC. Is there any sense that
these sorts of alternatives have become increasingly popular? If so, why?
3. Do you believe that the diversion track provides more incentive to clients to succeed as opposed to
sealing (i.e. imposing a felony that can subsequently be sealed)?
• What is it about diversion programs that are likely to be effective?
• What is it about record sealing that is likely to be effective?
4. Our data tells us that there is a considerable age difference between standard court (median
age=20) and diversion clients (median age=28). How would you explain this difference?
• Is this in anyway a function of legal representation? If so, how?
• To what extent is this attributable to factors related to the client? That is, is it a matter of
resources, stake in conformity or the lack thereof, or image and presentation?
• When faced with a plea opportunity involving a conviction, are offenders likely to minimize the
stigma of felony conviction simply because they are able to avoid jail time?
Now I’d like to ask you some questions regarding stigma avoidance.
5. Do you feel that most felons deserve the second chance afforded to them?
6. Under what circumstances should these sorts of programs be used or for what types of offenders?
7. Do you perceive any negative impacts of diversion programs or sealing?
Now, I’d like to discuss the treatment model implemented for the Second Chance Program.
8. What is your opinion of the intensive case management model implemented for this program
regarding its’ potential influence on treatment success (e.g. recovery or relapse)?
• Can reducing caseloads and increasing the frequency of client contacts or the quality of
supervision have a positive effect on treatment success?
• Is the linkage to additional services in the community by TASC case managers and following
the completion of TASC something that might have a positive effect on treatment success?
9. Do you feel that those clients receiving the strengths based case management intervention will be
more successful when compared to other TASC clients?
• If so, in what areas are they most likely to be successful? Criminal behavior? Drug use?
• If so, which components of the model do you believe have the greatest impact?
• If not, how could this model be improved to achieve more favorable results?
Now I’d like to discuss your perceptions regarding the substance abuse treatment services
that are offered to Second Chance Program participants.
10. What is your overall opinion of the services available to clients in the Second Chance Program?
Probe, if necessary:
• Do you believe there are a sufficient number of programs and services available to clients?
• Do you believe the right kinds of programs and services are offered to clients?
APPENDIX E
MULTIMODALITY QUALITY ASSURANCE (MQA) INSTRUMENTS
MQA Cover Letter............................................................................................................E1
Clinical Supervisor Survey................................................................................................E2
Administrative Survey.......................................................................................................E3
Staff Survey.......................................................................................................................E4
National Development and Research Institutes, Inc. (NDRI)
Center for the Integration of Research and Practice
71 West 23rd Street, 8th Floor
New York, NY 10010
Dear [Program Director],
We are asking for your participation in completing the Community-Based Multimodality
Quality Assurance Instrument (MQA) as part of an evaluation of our special TASC strengthbased case management project (see attached). There are three forms of the MQA, an
Administrative Director Form, a Clinical Supervisor Form, and a Primary Treatment Staff Form,
that we are asking your agency to complete, each of which will take a total of approximately 45
minutes. The forms can be distributed to staff to complete at a staff meeting or some other time
convenient to the program. A self-addressed, postage paid envelope will be distributed with the
instrument for staff and supervisors to send these forms directly to NDRI.
The MQA is a self-report instrument designed to bridge the gap between expensive fieldaudits and program self-descriptions. The instrument includes five domains of quality assurance:
Organizational characteristics consist of funding levels, program capacity and occupancy rate,
waiting time, and evaluation and research activities. Staffing information includes staff ratios,
recruitment, background and experience, turnover, incentives, training, and supervision. Program
characteristics consist of the program setting, physical facilities, client recruitment, intake,
treatment planning, discharge planning, surveillance, and procedures for monitoring treatment.
Client characteristics include any special populations (e.g., dually diagnosed, developmental
impairment, violent offender, gender, age, etc.), demographics, medical conditions, and drug and
criminal histories of the clients. Treatment components consist of the type of services provided
and separate scales that measure the treatment goals and elements associated with the therapeutic
community, cognitive-behavioral therapy, and 12-Step treatment modalities. Additional scales
examine organizational culture and the treatment process. Staff satisfaction is measured on 4
point Likert-type scales. Satisfaction items for each topic appear at the end of the relevant section
to reduce contamination in rating different aspects of the program.
The Multimodality Quality Assurance Instrument (MQA) was developed to provide a
relatively inexpensive system for program directors and oversight agencies to monitor treatment
programs. It is designed as a state of the art measure of “what works” in substance abuse
treatment and the national quality assurance criteria for health care organizations set forth by the
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). At the program level
its intended uses include helping programs to become more facile in self monitoring, helping
programs prepare for accreditation, establishing and improving program quality, and helping
programs to qualify for more funding opportunities. For treatment agencies, the MQA provides a
means of monitoring what an individual treatment program says it is doing, and the degree to
which it is actually implementing the stated program. A unique feature of the MQA measures
program implementation by the degree to which clinical supervisors, primary treatment staff, and
clients report the same activities and emphasis within the program.
Please feel free to contact me at (212) 845-4426 if there is any additional information that you
may need.
Sincerely,
Gerald Melnick, Ph.D.
Senior Principal Investigator
Form Approved
OMB No. 0930-xxxx
Expires mm/dd/yy
Public reporting burden for this collection of information is estimated to
average 45 minutes per response, including the time for reviewing
instructions and completing 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; Paperwork Reduction Project
(0930-xxxx); Room 16-105, Parklawn Building; 5600 Fishers Lane,
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 control
number for this project is 0930-xxxx.
Clinical Supervisor Perspective
Community-Based Residential
Substance Abuse Treatment Programs
Multimodality Quality Assurance Scales (MQA) ©
Gerald Melnick, Ph.D.
Frank Pearson, Ph.D.
National Development and Research Institutes, Inc.
71 West 23rd Street, 8th Floor,
New York, NY 10010
© Gerald Melnick, Ph.D. and Frank Pearson, Ph.D.
National Development and Research Institutes, Inc.
71 West 23rd Street, 8th Floor
New York, NY 10021
April 7, 2006
Not to be reproduced or quoted without the permission of the authors.
2
MULTIMODALITY QUALITY ASSURANCE SCALES (MQA)
GUIDE TO THE MQA CLINICAL SUPERVISOR SECTION
Section 2 is to be completed by the Clinical
Director. In some programs this may be the
same individual as the Chief Administrative
Officer. In large programs there may be several
clinicians in supervisory roles, these supervisory
clinicians should complete Section 2.
The MQA is designed to provide reports to
program directors and others based on a wide
array
of
organizational
and
treatment
characteristics. This report focuses on four
perspectives: the program director, clinical
supervisors, line staff (substance abuse
counselors), and clients. The objective of the
report is to compare programs to other similar
programs, and to identify the means by which
they can become more efficient in their use of
resources, and more effective in creating client
satisfaction and change.
Section 3 is to be completed by substance
abuse counselors and the primary clinical staff
that are directly responsible for client care.
Section 4 is to be completed by the program’s
clients.
Who should be responsible for answering the
MQA items?
Please complete the following questionnaire on
the basis of the latest information about your
treatment program. Missing information will lead
to gaps in our ability to provide feedback about
your program. Therefore, we ask you to be
careful to answer each of the questions.
There are four sections of the MQA:
Section 1 is to be completed by the Chief
Administrative Officer of the program
If you have any questions (or if you have any comments to make), please feel free to contact Dr.
Gerald Melnick (212) 845-4426 or e-mail him at [email protected]
3
MULTIMODALITY QUALITY ASSURANCE
INSTRUCTIONS:
1. Use “9” to answer items when you do not know the answer.
2. You may check more than one response for items describing facts about the program.
3. Throughout the questionnaire there are areas for you to express how satisfied or dissatisfied you are with
the elements in your program at present.
Please insert one of the following responses in the satisfaction rating box:
0 = Very Dissatisfied
1 = Somewhat Dissatisfied
2 = Somewhat Satisfied
3 = Very Satisfied
Or
9 to designate Unknown, or “I have no information about this”
Please use the lines provided to explain any 0 or 1 ratings you gave (of course, feel free to explain any of
your ratings).
NOTE: Please do not skip over any items! Completeness is very important for us to understand
your opinion of the program!
4
1. Name of Program:
2. Program Address:
3. Today’s Date
Month - Day - Year
4. Gender:
Male
ڤ
Female ڤ
Please answer the following questions to the best of your knowledge:
STAFF TRAINING
5.
Is there a program orientation that all new treatment staff receive?
6.
Does the program provide in-service staff training?
YES
YES
ڤNO
ڤNO
IF YES, what were the:
Number
a. Number of meetings in the last 12 months?
b. Duration of the usual meeting (in minutes)?
c. Number of staff involved in average session?
d. Number of staff sent to training sessions outside the program?
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
PERCENT
e. Percent of in-service training focusing on theory and content?
f. Percent of in-service training focusing on practice and skills?
5
ﭬﭭﭫ
ﭬﭭﭫ
SATISFACTION RATING:
7.
How satisfied are you with in-service staff training? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: _______________________________________________________________________
SUPERVISION THROUGH STAFF MEETINGS
8.
Are there regularly scheduled formal staff meetings during which
clients are discussed?
→ IF NO, skip to question number 11
9.
When are these meetings scheduled?
a. Daily
YES
ڤNO
ﭬﭫmin.
Usual duration per meeting ﭬﭫmin.
Usual duration per meeting ﭬﭫmin.
Usual duration per meeting ﭬﭫmin.
Usual duration per meeting ﭬﭫmin.
Usual duration per meeting ﭬﭫmin.
Usual duration per meeting
b. Two or three times a week
c. Weekly
d. Two or three times a month
e. Monthly
f. Less frequently than a month
SATISFACTION RATING:
10.
How satisfied are you with supervision in formal staff meetings? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: _______________________________________________________________________
SUPERVISION THROUGH INDIVIDUAL STAFF MEETINGS
11. Are there regularly scheduled individual supervisory meetings between
a supervisor and individual clinical staff members?
→ IF NO, skip to question number 14
6
YES
ڤNO
12. When are they scheduled? (Check ONLY one)
a. Daily
ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES
b. Two or three times a week
c. Weekly
d. Two or three times a
month
e. Monthly
f. Less frequently than a
month
ﭬﭫmin.
Usual duration per meeting ﭬﭫmin.
Usual duration per meeting ﭬﭫmin.
Usual duration per meeting ﭬﭫmin.
Usual duration per meeting ﭬﭫmin.
Usual duration per meeting ﭬﭫmin.
Usual duration per meeting
SATISFACTION RATING:
13.
How satisfied are you with individual supervision? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: _______________________________________________________________________
COUNSELOR AND CLIENT INFLUENCE
14.
For the items below, please indicate what actually happens at the program
a. How often are supervisor(s) asked by the
program director for suggestions about program
policies?
b. How often do supervisor(s) ask counselors for
their opinions and suggestions about treatment
issues?
c. How often do supervisor(s) ask counselors for
their opinions and suggestions about program
policies?
d. How often do supervisors ask clients for their
opinions and suggestions about treatment issues?
7
Never
0
Sometimes
1
Usually
2
Always
3
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
e. How often do supervisors ask clients for their
opinions and suggestions about program
policies?
f. The program is open to new methods and
techniques?
g. The program is open to issues of cultural
diversity?
15.
Never
0
Sometimes
1
Usually
2
Always
3
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
For the items below, please indicate what actually happens at the program
None
0
Very Little
1
Moderate
Amount
2
Great Deal
3
a. How much influence do supervisor(s)
have on program policies?
.0.
.1.
.2.
.3.
b. How much influence do supervisor(s)
have on treatment decisions?
.0.
.1.
.2.
.3.
c. How much influence do counselors have
on program policies?
.0.
.1.
.2.
.3.
d. How much influence do counselors
have on treatment decisions?
.0.
.1.
.2.
.3.
e. How much influence do clients have on
program policies?
.0.
.1.
.2.
.3.
f. How much influence do clients have on
treatment decisions
.0.
.1.
.2.
.3.
SATISFACTION RATING:
16.
How satisfied are you with clinical supervisor influence on decision-making?
(Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ________________________________________________________________________
8
3
Very
Satisfied
INTAKE ASSESSMENT
17. Does the initial client evaluation include:
(Please check a YES or NO response)
ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
a. Drug abuse history assessment
YES
b. Criminal history assessment
c. Medical assessment
d. Psychiatric assessment
e. Trauma assessment
f. Educational assessment
g. Work/Vocational assessment
h. Family assessment
i. Strengths/Skills assessment
j. Motivational assessment
k. Other (Specify):__________________
18. What diagnostic instruments are used at intake and for what purpose are they used?
Except for the ASI, please send us a copy of all instruments listed below.
Purpose of Instrument
PROGRAM
RISK
ASSIGNMENT ASSESSMENT
a. ASI (Addiction
Severity Index)
b. Other (Name)
__________________
c. Other (Name)
__________________
d. Other (Name)
__________________
e. Other (Name)
__________________
f. Other (Name)
________________
9
NEEDS
ASSESSMENT
MEASURE
CHANGE
OVER TIME
OTHER USE
(SPECIFY
BELOW)
SATISFACTION RATING:
19.
How satisfied are you with the intake assessment? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: _______________________________________________________________________
PROGRAM STRUCTURE
20.
What manuals and protocols does your program provide? (Check your response)
ڤNO ڤ
YES ڤNO ڤ
a. Does this program have a written treatment protocol?
YES
b. Does this program have an administrative policy manual?
c. Is there a structured approach to treatment that the program follows with all clients (for
example, a specific number and type of group and/or individual sessions that clients must
attend)?
YES
ڤNO ڤ
d. Is there a structured content to client groups or individual sessions (For example,
client workbooks, or set of activities that must be followed)?
YES
ڤNO ڤ
f. Please indicate how important it is for staff members to follow the program’s structure and content exactly with
clients. In other words, how much variation from protocol is tolerated? Check your answer below:
0.
No Variation
Tolerated
21.
1
A Low Level of
Variation Tolerated
2
A Medium Level of
Variation Tolerated
What percentage of your time is spent on paperwork?
10
3.
A High Level of
Variation Tolerated
ڤ ڤ ڤ%
SATISFACTION RATING:
22. How satisfied are you with the way that the program has been defined? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: _______________________________________________________________________
DRUG SCREENING POLICY AND PRACTICE
23.
Does your program conduct any drug or alcohol testing?
→ If NO, skip to question number 32.
24.
What method of sample collection is used?
a. Urine samples
b. Hair samples
c. Breathalyzer
d. Other (Specify)________________
25.
YES
ڤNO
ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES
Drug testing is conducted:
(CHECK ALL THAT APPLY)
a. At Random days and times
(for example, it can occur at any day at almost any waking hour)
b. At regular scheduled days and times
(for example, only on Tuesdays between 1:00 and 3:00 p.m.)
c. Only when use is suspected
26. What percentage of clients are tested each week?
ڤ ڤ ڤ%
27. What percentage of clients are tested each month?
ڤ ڤ ڤ%
28.
On what basis are clients included for testing?
(CHECK ALL THAT APPLY)
11
ڤ
ڤ
ڤ
a. All clients are tested
b. For cause (suspicion that particular inmates are using drugs)
c. Random testing
d. To satisfy legal mandates (probation/parole requirements)
e. Other (Specify) __________________________________
__________________________________________________
ڤ
ڤ
ڤ
ڤ
ڤ
29. What are the consequences of a positive drug test?
(CHECK ALL THAT APPLY)
a. Verbal reprimand
b. Loss of privileges
c. Discharge from program
d. Learning experience (Special counseling or activities)
e. None
f. Other (Specify) __________________________________
30.
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
Are consequences of a positive drug test applied in graduated steps?
(for example, a second violation has more severe consequences than
the first violation)
YES
ڤNO
SATISFACTION RATING:
31. How satisfied are you with the drug screening policy in your program? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ________________________________________________________________
TREATMENT PLANNING
32.
Do all clients have a treatment plan?
YES
ڤNO
33. What percent of your clients have a treatment plan…
12
(When NONE, enter 0)
Percent
ﭬﭭﭫ
ﭬﭭﭫ
a. Completed at intake?
b. Completed within 30 days of
admission?
34.
What percent of your clients’ treatment plans are periodically updated?
→ IF you indicate 0, skip to question number 37
35. How often are treatment plans updated? (Please check only ONE box)
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
a. Weekly
b. Every 2 weeks
c. More frequently than once a month but
less than every 2 weeks
d. Once a month
e. Every 2-3 months
e. Less frequently than every 3 months
f. When the client reaches a specific stage
or level
g. Other (Specify)___________________
36.
Who participates in updating the treatment plans?
(Please answer ALL items a through h)
Never
0
.0.
Sometimes
1
.1.
Usually
2
.2.
Always
3
.3.
b. Case manager
.0.
.1.
.2.
.3.
c. Clinical supervisor
d. Social worker, Psychiatrist, or
Psychologist
e. Client
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
f. Client’s family
.0.
.1.
.2.
.3.
g. Probation or parole agent
.0.
.1.
.2.
.3.
h. Other (Specify)_______________
.0.
.1.
.2.
.3.
a. Primary counselor
37. What are the major components of the treatment plan?
(Check all that apply)
13
ڤ ڤ ڤ%
a. Assessment/Diagnosis
b. Short term goals
c. Long term goals
d. Psychological goals
e. Employment goals
f. Health status
g. Other
(specify):__________________________
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
38. Is there clear consistent documentation of client progress related to the treatment plan?
.0
Never
1
Sometimes
2
Usually
3
Always
SATISFACTION RATING:
39. How satisfied are you with the treatment planning process? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: _______________________________________________________________________
DISCHARGE PLANNING
40.
Is there a discharge plan for clients completing your programs?
→ IF NO, skip to question number 46
41.
Who participates in formulating the discharge plan?
(Please answer ALL items a. through i.)
YES
ڤNO
Never
0
.0.
Sometimes
1
.1.
Usually
2
.2.
Always
3
.3.
b. Case manager
c. Social worker, Psychiatrist, or
Psychologist
d. Clinical supervisor
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
e. Client
.0.
.1.
.2.
.3.
f. Client’s family
.0.
.1.
.2.
.3.
g. Probation or parole agent
.0.
.1.
.2.
.3.
a. Primary counselor
14
h. Aftercare staff
.0.
.1.
.2.
.3.
i. Other (Specify) __________________
.0.
.1.
.2.
.3.
42. Do you have aftercare service agreements with vocational/educational
substance abuse treatment, etc., agencies if you are discharging to
another geographic location?
43. What percent of your clients scheduled to be released meet with an
aftercare provider (agencies that provide vocational/educational services,
substance abuse treatment, etc.)?
44.
What percent of your clients scheduled to be released meet with an
aftercare provider more than once?
YES
ڤNO
ﭬﭭﭫ%
ڤ ڤ ڤ%
SATISFACTION RATING:
45.
How satisfied are you with the discharge planning process? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, Explain: _______________________________________________________________________
LIST OF SERVICES
46.
Educational/Vocational:
The following items refer to whether separate classes or training sessions are provided
in each of the following areas.
Provided?
a. High school/G.E.D. classes
b. Other basic educational classes
(reading, math, etc.)
c. Vocational training
d. Job readiness
e. Other (Specify) _________________
ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES
15
SATISFACTION RATING:
47.
How satisfied are you with the educational/vocational services? (Please Check One)
.0
Very
Dissatisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: _______________________________________________________________________
48.
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
Social Skills Training:
The following items refer to whether specific classes or training sessions are provided in each
of the following areas.
Provided?
a. Communication skills
ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES
b. Personal hygiene
c. Parenting skills
d. Leisure time activities skills
e. Stress management
f. Anger management
g. Money management
h. Other (Specify) ______________
SATISFACTION RATING:
49.
How satisfied are you with the social skills training program? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: _______________________________________________________________________
16
3
Very
Satisfied
50. What other services does your program provide?
Provided?
a. Vocational assessment (finding out what job skills you have)
b. Vocational counseling
b. Job placement
c. Family planning education
d. Mental health services
e. Basic health education
f. Substance abuse education
g. AIDS prevention
h. Location of housing
i. Assistance with entitlements
j. Legal assistance
k. Other (specify)_______________________________
ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES
51. What medical screening tests are provided by the program?
Provided?
a. HIV/AIDS testing
ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES
b. TB testing
c. Hepatitis testing
d. Other (Specify)________________
SATISFACTION RATING:
52. How satisfied are you with the other services listed above? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: _______________________________________________________________________
17
3
Very
Satisfied
SAFETY OF PROGRAM CLIENTS
53. What has been the safety record of your program over the past 12 months?
Number
a. How many clients physically assaulted another
person in the program?
b. How many clients were physically assaulted
while in the program?
ﭬﭭﭫ
ﭬﭭﭫ
c. How many clients were sexually assaulted or
harassed while in the program?
ﭬﭭﭫ
d. How many clients were found with contraband,
such as drugs?
ﭬﭭﭫ
SATISFACTION RATING:
54. How satisfied are you with the program’s safety record? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: _______________________________________________________________________
EMERGENCY INTERVENTIONS
55.
Is there an arrangement for conducting unscheduled crisis sessions
with clients during regular program hours?
(for treatment by your program, not medical treatment)
YES
ڤNO
IF YES, Specify: ________________________________________________________________
______________________________________________________________________________
56.
Is there an arrangement for conducting unscheduled crisis sessions
after regular program hours?
YES
ڤNO
IF YES, Specify: _________________________________________________________________
18
_______________________________________________________________________________
SATISFACTION RATING:
57. How satisfied are you with the emergency interventions? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: _______________________________________________________________________
TREATMENT EMPHASIS
58. What does your program emphasize the most?
Pick NO MORE THAN THREE choices that reflect the most important aims of your program
by checking one box in each column. PLEASE LEAVE REMAINING BOXES BLANK.
Mark only ONE box
in each column
a. Reduce criminal recidivism (new crimes)
b. Treat the clients’ substance abuse problem
c. Reduce psychological or emotional problems
d. Create self-reliance and positive social and work
attitudes
e. Treat the whole person - not the particular
problems the individual may have
f. Create global changes in identity
g. Increase self-understanding
h. Increase self-esteem and confidence
i. Increase trust in a Higher Power
j. Help clients change their surroundings to help deal
with their problems
k. Abstinence from drug/alcohol use
l. Help clients with housing and employment
m. Change thinking patterns that lead to drug use
19
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
n. Other (Specify)
____________________________
ڤ
ڤ
ڤ
SATISFACTION RATING
59. How satisfied are you that the emphasis of your program is best suited for the clients?
(Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: _______________________________________________________________________
TREATMENT INTERVENTIONS
60. How true is each of these about your program?
Not Used/
Not Applicable
0
Slightly
Important
1
Moderately
Important
2
Very
Important
3
a. General meetings that include of all staff and clients
together
.0.
.1.
.2.
.3.
b. Supportive counseling
.0.
.1.
.2.
.3.
c. Confrontational strategies
.0.
.1.
.2.
.3.
d. Group counseling with counselor
.0.
.1.
.2.
.3.
e. Peer-led groups
.0.
.1.
.2.
.3.
f. Individual counseling by peer who has not had formal
training in counseling
.0.
.1.
.2.
.3.
g. Individual drug counseling
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
j. Individual psychotherapy
.0.
.1.
.2.
.3.
k. Contingency management (e.g. token economy,
contingency contracts)
.0.
.1.
.2.
.3.
m. Cognitive behavioral therapy
.0.
.1.
.2.
.3.
n. Family therapy
.0.
.1.
.2.
.3.
o. 12-Step meetings at the program
.0.
.1.
.2.
.3.
h. Informal interactions between staff and clients (not in
meetings or counseling sessions)
i. Informal interactions between clients (not in meetings of
counseling sessions)
20
p. Relapse prevention
.0.
.1.
.2.
.3.
q. Milieu therapy
.0.
.1.
.2.
.3.
Not Used/
Not Applicable
0
Slightly
Important
1
Moderately
Important
2
Very
Important
3
r. Reality therapy
.0.
.1.
.2.
.3.
s. Case management
.0.
.1.
.2.
.3.
t. Other (Specify)___________________
.0.
.1.
.2.
.3.
SATISFACTION RATING
61. How satisfied are you with the program’s delivery of interventions for your program?
(Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: _______________________________________________________________________
TREATMENT TECHNIQUES
62. How true is each of these about your program?
SCALE A
a. Program uses group settings involving the confrontation of
negative behavior
b. In this program, feedback from other clients (peers) is more
important than staff counseling
c. Clients have as much contact with counselors outside of formal,
individual, or group counseling sessions as they have in those
sessions
d. Counselors share their personal experiences and feelings with
clients
e. There is a full day’s program (8 or more hours) of required
activities and meetings
f. Staff members confront unacceptable behavior outside of individual
and group counseling
g. Clients confront unacceptable behavior by other clients outside of
formal group sessions
h. Clients share responsibility for making this program work
21
Not
True
0
Somewhat
True
1
Mostly
True
2
Very
True
3
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
i. Clients frequently help each other
.0.
.1.
.2.
.3.
j. Clients who violate the program rules receive a penalty
or sanction
.0.
.1.
.2.
.3.
Not
True
0
Somewhat
True
1
Mostly
True
2
Very
True
3
k. Work is used as part of the therapeutic program
.0.
.1.
.2.
.3.
l. Staff serve as role models for the clients
.0.
.1.
.2.
.3.
m. Senior clients serve as role models for newer clients
.0.
.1.
.2.
.3.
n. Clients get increased privileges as they advance in the program
.0.
.1.
.2.
.3.
o. Clients get increased job responsibilities as they advance in the
program
.0.
.1.
.2.
.3.
SATISFACTION RATING
63. How satisfied are you with the use of the interventions in SCALE A? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: _______________________________________________________________________
64. How true is each of these about your program?
SCALE B
a. Encourages clients to practice telling themselves about how to act
correctly
b. Encourages clients to praise themselves for behaving well
c. Helps clients practice saying no to drugs when they are offered
d. Encourages clients to stop and think before acting
e. Helps clients to identify “trigger” situations for taking drugs
f. Explains the use of thought stopping techniques
g. Encourages clients to find enjoyable things to do besides drugs or
alcohol
22
Not
True
0
Somewhat
True
1
Mostly
True
2
Very
True
3
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
h. Encourages clients to communicate with others in an assertive, but nonviolent way
i. Emphasizes problem solving techniques to deal with frustration
j. Emphasizes thinking about the consequences of using drugs
k. Helps clients to recognize errors in thinking
l. Uses contracts that involve punishment or rewards
m. Helps clients to develop a plan to return to abstinence if they slip and
use drugs or alcohol
n. Uses behavioral rehearsal or role playing to act out situations
o. Teaches clients how to deal with urges and cravings for drugs or alcohol
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
Not
True
0
Somewhat
True
1
Mostly
True
2
Very
True
3
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
SATISFACTION RATING
65. How satisfied are you with the use of the treatment techniques in SCALE B? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: _______________________________________________________________________
66. How true is each of these about your program?
SCALE C
a. Emphasizes the need to rely on a “Higher Power”
b. Emphasizes the need to seek external support to recover (you cannot
do it alone)
c. Emphasizes that recovery from substance abuse is a life long process
requiring ongoing attendance at 12-Step meetings
d. Provides recovery literature, such as the Big Book, pamphlets, or
serenity prayer posters
e. Emphasizes the need to admit the loss of control over drugs and/or
alcohol (powerlessness)
f. Encourages the need for spiritual growth
23
Not
True
0
Somewhat
True
1
Mostly
True
2
Very
True
3
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
g. Discusses a “one day at a time” approach to abstinence
.0.
.1.
.2.
.3.
h. Discusses “stinking thinking”
.0.
.1.
.2.
.3.
i. Explains the importance of working the 12-Step program consistently
.0.
.1.
.2.
.3.
Not
True
0
Somewhat
True
1
Mostly
True
2
Very
True
3
j. Discusses the goals and strategies of the 12-Step program
.0.
.1.
.2.
.3.
k. Explains how to work the 12-Step program
.0.
.1.
.2.
.3.
l. Explains the reasons why the 12-Steps work
.0.
.1.
.2.
.3.
m. Discusses the nature of the “sponsoring relationship”
.0.
.1.
.2.
.3.
n. Discusses the barriers to affiliation with the 12-Step program
.0.
.1.
.2.
.3.
o. The program hosts different types of 12-Step meetings, such as the
‘Step Meeting’ and discussion ‘Round Robin’
.0.
.1.
.2.
.3.
SATISFACTION RATING
67. How satisfied are you with the use of the interventions in SCALE C? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: _______________________________________________________________________
ORGANIZATIONAL CULTURE QUESTIONNAIRE
68. How true is each of these about your program?
a. Clients and staff really feel like a part of the program
b. People in the program are glad to have the opportunity to participate in
this program
c. People around here do not have a lot of respect for this program
d. People know what is expected of them in this program
e. People in this program do not push each other to understand
themselves better
f. Administration and staff are really open to what clients say
24
Not
True
0
Somewhat
True
1
Mostly
True
2
Very
True
3
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
g. I feel that people are not interested in helping each other in this
program
h. Clients and staff do not feel supported by the program
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
i. This program has high standards of behavior
.0.
.1.
.2.
.3.
j. The standards of behavior in this program are pretty well spelled out
.0.
.1.
.2.
.3.
Not
True
0
Somewhat
True
1
Mostly
True
2
Very
True
3
k. Administration is not interested in what other people think
.0.
.1.
.2.
.3.
l. The program puts a lot of trust in people
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
x. I think that the staff believes in the clients
.0.
.1.
.2.
.3.
y. People in this program do what they can to help the others
.0.
.1.
.2.
.3.
z. Administration and staff are not good at responding to problems
.0.
.1.
.2.
.3.
aa. I think that the people in the program believe in each other to do what
is right
.0.
.1.
.2.
.3.
m. If clients can fulfill the expectations of this program, then they have
really accomplished something
n. The program focuses not on what people did, but why they used to do
it
o. I think that the program is not clear in letting people know what is
wanted from them
p. I think that the staff in the program are trying to do what is best for the
clients
q. The goals that they set for people in this program are pretty high, but
they can be reached
r. The people in this program like each other
s. I do not think that the program is well organized (runs smoothly)
t. I feel that clients and staff do not have opportunities to tell people in
charge of the program what they think
u. Administration and staff run a pretty tight ship around here
v. People around here are pretty interested in understanding how the
other person feels
w. People around here do not feel a commitment to each other
25
SATISFACTION RATING:
69. How satisfied are you with the organizational culture at your program?
(Please Check One)
0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: __________________________________________________________________
WITHIN-PROGRAM COMMUNICATION
70.
Use the scale below to indicate what actually happens at your program.
a. Program director starts discussions about program problems/concerns with
clinical supervisors.
b. Clinical supervisors start discussions about program problems/concerns
with program director.
c. Clinical supervisors start discussions about program problems/concerns
with each other. (Ignore if only 1 clinical supervisor)
d. Clinical supervisors start discussions about program problems/concerns
with counselors.
e. Counselors start discussions about problems/concerns about the program
with clinical supervisors.
f. Clinical supervisors start discussions about program problems/concerns with
clients.
g. Clients start discussions about problems/concerns about the program with
clinical supervisors.
0
Never
1
Rarely
2
Sometimes
3
Often
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
SATISFACTION RATING:
71. How satisfied are you with the communication within the program? (Please Check One)
0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: __________________________________________________________________
26
DECISION-MAKING SCALE
72. Using the scale below, please rate how strongly you agree with each of the following
statements about decision-making at this program.
Not
True
0
Somewhat
True
1
Mostly
True
2
Very
True
3
a. We have open and frank discussions about our
differences
.0.
.1.
.2.
.3.
b. Disagreements are generally resolved fairly
.0.
.1.
.2.
.3.
c. Staff are divided into small cliques that do not
communicate well
.0.
.1.
.2.
.3.
d. We actively seek out a variety of opinions
.0.
.1.
.2.
.3.
e. Most viewpoints are given serious consideration
.0.
.1.
.2.
.3.
f. People are afraid to speak up for fear of
ridicule/retaliation
.0.
.1.
.2.
.3.
g. We are not afraid to disagree
.0.
.1.
.2.
.3.
h. We learn a lot from considering each others’ opinions
.0.
.1.
.2.
.3.
.2.
.3.
i. Individuals who disagree with the majority are likely to
.0.
.1.
have a hard time
* The item content in this scale is based on: Kirchmeyer, C. & Cohen, A. (1992).
SATISFACTION RATING:
73.
How satisfied are you with the decision-making process at this program?
(Please Check One)
0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: __________________________________________________________________
27
3
Very
Satisfied
DEMOGRAPHICS:
74. Are you Hispanic or Latino?
YES
ڤNO
a. If yes, what ethnic group do you consider yourself?
Select one or more:
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
1. Central American
2. Cuban
3. Dominican
4. Mexican
5. Puerto Rican
6. South American
7. Other, Specify:_________________
75. What is your race? (Select one or more)
Select one or more:
a. Black or African American
b. Asian
c. American Indian
d. Native Hawaiian or other Pacific Islander
e. Alaska Native
f. White
g. Other, Specify:___________________
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
76. Any other comments you would like to make not covered by the questions above:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
28
____________________________________________________________________________________________
Reminder: All of your responses to the questions are important,
so please check through the questionnaire
to see that no questions have been skipped.
29
National Development and Research Institutes, Inc.
71 West 23rd Street, 8th Floor, New York, NY 10010
30
Form Approved
OMB No. 0930-xxxx
Expires mm/dd/yy
Public reporting burden for this collection of information is estimated to
average 45 minutes per response, including the time for reviewing
instructions and completing 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; Paperwork Reduction Project
(0930-xxxx); Room 16-105, Parklawn Building; 5600 Fishers Lane,
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 control
number for this project is 0930-xxxx.
Administrator Perspective
Community-Based Residential
Substance Abuse Treatment Programs
Multimodality Quality Assurance Scales (MQA) ©
Gerald Melnick, Ph.D.
Frank Pearson, Ph.D.
National Development and Research Institutes, Inc.
71 West 23rd Street, 8th Floor,
New York, NY 10010
© Gerald Melnick, Ph.D. and Frank Pearson, Ph.D.
National Development and Research Institutes, Inc.
71 West 23rd Street, 8th Floor
New York, NY 10021
April 7, 2006
Not to be reproduced or quoted without the permission of the authors.
2
MULTIMODALITY QUALITY ASSURANCE SCALES (MQA)
GUIDE TO THE MQA ADMINISTRATORS SECTION
Section 2 is to be completed by the Clinical Director. In
some programs this may be the same individual
Administrative Officer. In large programs there may be
several clinicians in supervisory roles, these supervisory
The MQA is designed to provide reports to program
directors and others based on a wide array of
organizational and treatment characteristics. This report
focuses on four perspectives: the program director, clinical
supervisors, line staff (substance abuse counselors), and
clients. The objective of the report is to compare programs
to other similar programs, and to identify the means by
which they can become more efficient in their use of
resources, and more effective in creating client satisfaction
and change.
Section 3 is to be completed by substance abuse
counselors and the primary clinical staff that are
directly responsible for client care.
Section 4 is to be completed by the program’s
clients.
Who should be responsible for answering the MQA items?
Please complete the following questionnaire on the
basis of the latest information about your treatment
program. Missing information will lead to gaps in our
ability to provide feedback about your program.
Therefore, we ask you to be careful to answer
each of the questions.
There are four sections of the MQA:
Section 1 is to be completed by the Chief
Administrative Officer of the program.
If you have any questions (or if you have any comments to make), please feel free to contact Dr.
Gerald Melnick (212) 845-4426 or e-mail him at [email protected]
3
MULTIMODALITY QUALITY ASSURANCE SCALES (MQA)
COMMUNITY-BASED SUBSTANCE ABUSE
TREATMENT PROGRAMS
April 7, 2006
SECTION I
ADMINISTRATOR’S SECTION
The program administrator should complete this form.
INSTRUCTIONS:
1. Use “9” to answer items when you do not know the answer.
2. You may check more than one response where applicable
3. Throughout the questionnaire there are areas for you to express how satisfied or dissatisfied you
are with the elements in your program.
Please insert one of the following responses in the satisfaction-rating box:
0 = Very Dissatisfied
1 = Somewhat Dissatisfied
2 = Somewhat Satisfied
3 = Very Satisfied
Or
9 to designate Unknown, or “I have no information about this”
Please use the lines provided to explain any 0 or 1 ratings you gave (of course, feel free to explain any of
your ratings).
NOTE: Please do not skip over any items! Completeness is very important for us to understand
your opinion of the program!
4
ORGANIZATIONAL INFORMATION
1. Name of Program:
2. Type of Program:
ڤ
ڤ
ڤ
ڤ
ڤ
a. Prison-based
b. Jail
c. Community residential
d. Community outpatient
e. Hospital-based
3.
Program Address:
STREET ADDRESS
CITY
STATE
ZIP CODE
-PHONE NUMBER
(
4.
)
--
FAX
(
)
Name of person completing this form:
LAST NAME
--
FIRST NAME
TITLE:
Primary Responsibility: _____________________________________________________
_________________________________________________________________________
5
5.
PHONE NUMBER
(
)
--
FAX
(
)
--
E-MAIL ADDRESS
DATE
-Month –
-Day -- Year
6. Is your program:
(Check ONE)
a. Private for Profit?
b. Private Non Profit?
c. Publicly Funded?
d. Mixture? Please Describe:
_______________________
ڤ
ڤ
ڤ
ڤ
7. Is your program part of a larger agency to which it reports?
YES
ڤNO
IF YES, Name of larger agency: _______________________________________________
8. How long has the program been admitting clients?
ﭬﭫYEARS
ﭬﭫMONTHS
a. IF less than 2 years, indicate total months
b. IF not yet admitting clients, explain: _______________________________
9. What is the program’s capacity and occupancy rate. Please indicate the:
Number
a. Maximum number of participants (at any one time) for which the program is designed?
b. Average number of participants enrolled in program?
c. Number of clients admitted in the past 12 months?
10. Is this program accredited by (Please check a YES or NO response):
a. Joint Commission on the Accreditation of Health Care Organizations
(JCAHCO)?
6
YES
ڤNOڤ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
b. Food and Drug Administration (FDA)?
YES
a. Have fixed fees?
ڤNOڤ
ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNOڤ
YES ڤNOڤ
YES ڤNOڤ
YES ڤNOڤ
YES
b. Have a sliding scale, based on ability to pay?
c. Take clients who cannot pay anything and/or have scholarships?
d. Require co-payment or a registration fee in some cases?
e. Have some contracts (For example, with City or State)?
c. Drug Enforcement Administration (DEA)?
d. Commission on Accreditation of Rehabilitation Facilities (CARF)?
e. State Agency/Office? (Please Specify):
____________________________
f. Local (City or County) Agency/Office?
(Please Specify):______________________________________________
g. Other? (Please
Specify):_________________________________________
YES
ڤNOڤ
11. Does this program (Please check a YES or NO response):
12. Does this program accept (Please check a YES or NO response):
a. Private insurance other than HMOs?
ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES
b. HMO or other managed care contracts?
c. Medicare?
d. Medicaid?
e. State disability insurance/workers’ compensation?
f. Criminal Justice funding?
g. Department of Children’s Services funding?
h. Research/Evaluation funds, e.g., NIDA, CSAT?
7
i. Other? (Please Specify): ________________________________________
13.
ڤNO ڤ
What best describes your program? (please check ONE response):
a. Residential (6 months or more)
b. Residential (more than 30 days but less than 6 months)
c. Residential (less than 30 days)
d. Drug Free Outpatient
e. Methadone Outpatient
f. Other (Please Specify): ___________________________________
14.
YES
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
What is the therapeutic orientation of the program?
(CHECK ALL THAT APPLY)
a. Therapeutic Community
b. Cognitive-Behavioral Therapy
c. Mutual Self Help (i.e., 12 Step programs such as AA)
d. Methadone Treatment
e. Other (Specify): ______________________________
ڤ
ڤ
ڤ
ڤ
ڤ
15. IF more than one is checked above, but one type is the primary emphasis of the program,
check which one:
a. Therapeutic Community
b. Cognitive-Behavioral Therapy
c. Mutual Self Help (i.e., 12 Step programs such as AA)
d. Methadone Treatment
e. Other (Specify): ______________________________
16.
What is the program’s planned duration of stay?
a. Is the planned duration of stay:
8
ڤ
ڤ
ڤ
ڤ
ڤ
i. The same for everyone?
ii. Not the same for everyone?
ڤ
ڤ
b. IF planned duration of stay is SAME FOR EVERYONE, indicate the number of months:
ﭬﭫ
i. Number of months
c. IF planned duration of stay is VARIABLE: What is the average
percent of clients who stay:
Percent
i. Three months or less
ii . Four to five months
iii. Six to nine months
iv. Ten to twelve months
v. More than 1 year
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
17. Is the program specifically designed to meet the needs of a “special” population? If so, which?
(CHECK ALL THAT APPLY)
a. No special populations
b. Males only
c. Females only
d. Pregnant or parenting women
e. Juveniles (Specify ages):_________________
f. Co-occurring Disorder (Psychiatric and substance abuse)
g. Homeless
h. HIV/AIDS
i. Criminal Justice
j. Veterans
k. Specific cultural group
(Specify):____________________
l. Other (Specify): ________________________________
18.
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
What are the restrictions (rules specifying the types of clients who will NOT be
admitted to your substance abuse treatment program)?
9
(CHECK ALL THAT APPLY.)
a. No exclusionary criteria
b. Juveniles
c. Psychiatric or emotional problems
d. Mental retardation
e. Medical condition (HIV/AIDS, hepatitis, etc)
f. History of violence
g. Sex offender
h. Arson
i. Pregnancy
j. Other (Specify) ________________________________
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
19. What percent of clients are referred to your program in the following ways?
Percent
a. Mandated/ordered into the program by criminal justice
system
b. Self Referrals (Walk-ins)
c. Referred from Child Welfare
d. Referred from Department of Social Services
(Public Assistance)
e. Referred from Employee Assistance Programs
f. Other (Specify):_______________________________
20.
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
FOR SELF REFERRALS, what recruitment methods are used? ____________________
______________________________________________________________________
21. Is there a waiting list for entry into the program?
IF YES, what is the average length of time in days
someone has to wait to enter the program?
10
YES
ڤNO
ڤ ڤ ڤDAYS
22.
What best describes the program evaluation/research conducted in the previous 12 months?
ڤNOڤ
YES ڤNO
ڤ
YES ڤNO
ڤ
YES ڤNO
ڤ
a. The program conducts its own evaluation of services.
YES
b. There is evaluation of services by the state.
c. The program participates in an external evaluation &
follow-up studies of program clients.
d. The program participates in treatment research studies.
23.
Does the program use objective evaluation include measures
of client progress during treatment?
YES
Please Specify: _________________________________________
______________________________________________________
FACILITIES
24.
25.
Is your program a residential program?
→ If NO, skip to question number 30
Are clients’ bedrooms shared?
YES
YES
ڤNO
IF YES, On average how many clients share a bedroom?
11
ڤNO
ﭬﭫCLIENTS
ڤNO
26.
Please answer the following questions about your program’s physical space:
ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
a. Does the typical client bedroom have windows?
YES
b. Does the typical client bedroom have a door that closes?
c. Does the typical client bedroom have floor to ceiling walls?
d. Does the typical client bedroom have an attached bathroom?
e. Do clients have enough personal space?
f. Does the program provide enough group space?
g. Does the program provide enough recreational space?
27.
Do children live on site?
YES
ڤNO
28. Using the following scale, rate clients’ bedrooms and furnishings in terms of the
qualities listed below:
0
Very Poor
1
Inadequate
2
Adequate
3
Very Good
a. Comfort
.0.
.1.
.2.
.3.
b. Lighting
.0.
.1.
.2.
.3.
c. Ventilation
.0.
.1.
.2.
.3.
d. State of repair
.0.
.1.
.2.
.3.
e. Cleanliness/odor
.0.
.1.
.2.
.3.
f. Privacy
g. Ability to customize
space
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
0
Very Poor
1
Inadequate
2
Adequate
3
Very Good
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
h. Adequate amount of
space
i. General quality
29.
What is the quality of the food in the program? (Check One)
0
Very Poor
30.
1
Inadequate
2
Adequate
What are the program’s physical facilities?
12
3
Very Good
a. Are there decorative pictures or posters in the program areas frequented
by clients?
b. Are there motivational/informational program posters hanging in areas
frequented by clients (i.e. 12 Step posters, etc.)?
c. Are there group meeting rooms?
d. Do counselors have individual offices?
e. Does the typical counselor’s office have floor to ceiling walls and a door?
f. Does the program managerial staff have separate offices?
ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES
31. Using the following scale, rate primary substance abuse counselors offices and
furnishings in terms of qualities listed below:
0
Very Poor
1
Inadequate
2
Adequate
3
Very Good
a. Comfort
.0.
.1.
.2.
.3.
b. Lighting
.0.
.1.
.2.
.3.
c. Ventilation
.0.
.1.
.2.
.3.
d. Adequate amount of space
.0.
.1.
.2.
.3.
e. State of repair
.0.
.1.
.2.
.3.
f. Cleanliness/odor
.0.
.1.
.2.
.3.
g. Privacy for counseling
.0.
.1.
.2.
.3.
h. No primary substance abuse
counselors offices
ڤ
32. Using the following scale, rate your program’s common interior areas of the building
(lobby area, waiting/reception areas, meeting space, recreational space etc.)
on the qualities listed below:
Very Poor
0
Inadequate
1
Adequate
2
Very Good
3
a. Comfort
.0.
.1.
.2.
.3.
b. Lighting
.0.
.1.
.2.
.3.
c. Ventilation
.0.
.1.
.2.
.3.
d. State of repair
.0.
.1.
.2.
.3.
e. Cleanliness/odor
.0.
.1.
.2.
.3.
h. Adequate amount of space
.0.
.1.
.2.
.3.
13
i. General quality
33.
.0.
.1.
.2.
.3.
In what type of neighborhood is your program located?
(Please check only ONE.)
a. Middle class residential (urban/suburban)
b. Working class residential (urban/suburban)
c. Inner city/urban residential
d. Rural residential
e. Average commercial area
f. Run down commercial area
g. Mixed commercial/residential
h. Other (Specify): _______________________________
34.
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
Using the following scale, rate the safety of your program’s surrounding neighborhood:
(Check One)
0
Very
Unsafe
1
Somewhat
Unsafe
2
Somewhat
Safe
3
Very
Safe
SATISFACTION RATING
35.
How satisfied are you with the program’s space? (Please Check One)
0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ________________________________________________________________________
FUNDING LEVEL
36.
What is the most recent 12 month period on which program will be reporting fiscal data in this
survey:
ﭬﭫ- ﭬﭫ-ﭬﭫ
Month Day
to
Year
ﭬﭫ- ﭬﭫ-ﭬﭫ
Month Day
14
Year
37.
Total current annual revenue of all types for program
during this period:
38.
Is the level of funding per client fixed?
YES
ڤNO
IF YES, indicate the amount of funding per client per month:
39.
40.
Is the program deficit funded?
YES
ﭬﭫ, ﭬﭭﭫ, ﭬﭭﭫ
$
ﭬﭭﭫ, ﭬﭭﭫ
$
ڤNO
Please enter budgets below.
ڤ, ﭬﭭﭫ, ﭬﭭﭫ
a. What is the total budget for personnel (salary and fringe)?
$
b. What is the total budget for non personnel expenses?
$
ڤ, ﭬﭭﭫ, ﭬﭭﭫ
SATISFACTION RATING
41. How satisfied are you with the level of funding? (Please Check One)
0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ________________________________________________________________________
15
3
Very
Satisfied
STAFF BACKGROUND
42. Indicate the number of the primary substance abuse counselors (staff directly delivering core
treatment) in your program having the following characteristics.
a. What is the total number of primary substance abuse counselors?
ﭬﭭﭫ
Counselors
c. What is the educational background of the primary substance abuse counselors?
(INDICATED HIGHEST CATEGORY ATTAINED)
Number of
Counselors
i. No High School diploma and no G.E.D
ii. Technical school degree but no H.S diploma or G.E.D. degree
iii. Completed High School or G.E.D
iv. Some college but no degree
v. Two year college associate degree
vi. Four year college degree (e.g. B.A. or B.S.)
vii. Graduate education
16
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
d. How many of your primary substance abuse counselors have:
(WHEN NONE, ENTER 0, DO NOT LEAVE BLANK)
Number of
Counselors
i. Specialized training in substance abuse treatment outside the
program, e.g. credits toward CASAC?
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ii. Credentials in substance abuse treatment?
iii. Certification in a general mental health specialty
such as psychology
e. How many primary substance abuse counselors have the following years of experience
working in substance abuse treatment?
(WHEN NONE, ENTER 0, DO NOT LEAVE BLANK)
Number
of Staff
i. Less than 1 year
ii. One to two years
iii. Three to five years
iv. More than five years
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
f. How many of the primary substance abuse counselors
are known to be recovering (i.e. have been in treatment)?
(If NONE, enter 0)
ﭬﭭﭫ
Counselors
SATISFACTION RATING
43.
How satisfied are you with the background of your primary substance abuse counselors?
(Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ________________________________________________________________________
44. For each category of staff, indicate the number of staff currently employed:
(If NONE, enter 0)
Number
Number
Full-time Staff Part-time Staff
a. Administrative Staff
ﭬﭭﭫ
ﭬﭭﭫ
b. Clinical Supervisors
17
ﭬﭭﭫ
ﭬﭭﭫ
c. Drug Counselors
d. Vocational or Rehabilitation Counselors
e. Physician’s Assistant or Nurse Practitioner
f. Registered Nurse or Licensed Nurse Practitioner
g. Physicians
h. Psychiatrists
i. Social Workers
j. Psychologists
k. Clergy or Religious Counselors
l. Family therapists
m. How many volunteers does the program use?
n. Other (Specify):______________________________
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
SATISFACTION RATING
45. How satisfied are you with the staff coverage? (Please Check One)
0
Very
Dissatisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ______________________________________________________________________
46.
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
How many primary treatment staff have been employed in this program:
(If NONE, enter 0)
Number
a. Less than six months?
b. Six to twelve months?
c. One to two years?
d. More than two years?
47.
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
During the past 12 months, how many types of staff have left the program voluntarily for any
reason (for example, to take another job, return to school, raise a family, etc.)?
18
Number
a. Primary treatment staff (directly involved
with client treatment of counseling)
ﭬﭭﭫ
ﭬﭭﭫ
b. Supervisory clinical treatment staff
STAFF
STAFF
SATISFACTION RATING
48. How satisfied are you with the staff rate of turnover? (Please Check One)
0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ________________________________________________________________________
POLICIES AND INCENTIVES
49. What is the average salary of an…
a. Entry level counselor?
b. Senior counselor?
c. Clinical supervisor?
ﭬﭭﭫ, ﭬﭭﭫper year.
$ﭬﭭﭫ, ﭬﭭﭫper year.
$ﭬﭭﭫ, ﭬﭭﭫper year.
$
50. In the past year, did the primary treatment staff receive a
standard pay increase?
YES
ڤNO
ڤ ڤ ڤ%
a. IF YES, what was the average percent of increase?
51. Does the program give incentive pay raises?
YES
ڤNO
a. IF YES, how many primary treatment staff members received merit pay
raises? For what reason?
____________________________________________________________
52. In the past year, did any primary treatment staff members
receive promotions?
19
YES
ﭬﭭﭫ
ڤNO
Number
Staff
a. IF YES, how many received promotions?
ﭬﭭﭫ
Number
Staff
53. Does the program use any other primary treatment staff incentives?
YES
ڤNO
IF YES,
Specify Incentive 1 _________________________________________________________
Specify Incentive 2 _________________________________________________________
Specify Incentive 3 _________________________________________________________
54.
How many personal and vacation days (not counting holidays such as
Thanksgiving and the Fourth of July) is the average full time salaried
primary substance abuse counselors entitled to per year?
55.
How many sick days are primary substance abuse counselors entitled
to per year?
56.
Do primary substance abuse counselors receive paid medical benefits?
57. Does the compensation package for primary substance abuse
ﭬﭫ
ﭬﭫ
Number
DAYS
Number
DAYS
YES
ڤNO
YES
ڤNO
SATISFACTION RATING
58.
How satisfied are you with the staff policies and incentives? (Please Check One)
0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ________________________________________________________________________
counselors include pensions?
DECISION-MAKING
59. What formal methods does your program have for obtaining employees’ feedback or input into
decision making?
20
a. Staff Representation on the board of directors
YES
ڤNO ڤ
b. Quality improvement teams
(i.e., Total Quality Management or Continuous Quality Improvement)
YES
ڤNO ڤ
c. Staff representation on management team
YES
d. Staff suggestion box
ڤNO ڤ
YES ڤNO ڤ
e. Staff committees responsible for specific management/administrative duties.
(e.g., committees for hiring staff, staff discipline, review of policies and procedures, etc.)
YES
ڤNO ڤ
f. Rotating staff memberships on management team
(i.e., staff takes turns as members of management meetings)
YES
ڤNO ڤ
g. We do not distinguish between staff and manager, all staff members are part of the
management team
YES
ڤNO ڤ
h. The program conducts regular staff meetings to get feedback or input on the program
i. The program conducts regular client focus groups to get feedback or input on the program
j. The program conducts regular staff focus groups to get feedback or input on the program
k. Other (Describe) _______________
60.
ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES
How often do you have staff meetings?
More than once a week
Weekly
Monthly
Less than monthly
61. For the items below, please indicate what actually happens at the program:
a. How often do you ask counselors for their
opinions and suggestions about treatment
issues?
b. How often do you ask counselors for their
opinions and suggestions about program
policies?
c. How often are clients asked for their
opinions and suggestions about treatment
issues?
d. How often are clients asked for their
opinions and suggestions about program
policies?
e. How often are clinical supervisors asked for
21
Never
0
Sometimes
1
Usually
2
Always
3
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
their opinions and suggestions about
treatment issues?
f. How often are clinical supervisors asked for
their opinions and suggestions about
program policies?
g. The program is open to new methods
and techniques?
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
h. The program is open to issues of cultural
diversity?
.0.
.1.
.2.
.3.
62.
For the items below, please indicate what actually happens at the program:
None
0
Very Little
1
Moderate
Amount
2
Great Deal
3
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
e. How much influence do
clients have on treatment decisions
.0.
.1.
.2.
.3.
f. How much influence do clients
have on program policies?
.0.
.1.
.2.
.3.
a. How much influence do counselors
have on treatment decisions?
b. How much influence do
counselors have on program
policies?
c. How much influence do clinical
supervisors have on treatment
decisions?
d. How much influence do
clinical supervisors have on
program policies?
SATISFACTION RATING
63.
How satisfied are you with the program’s decision-making process? (Please Check One)
0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ________________________________________________________________________
22
3
Very
Satisfied
CLIENT CHARACTERISTICS
64. What is the current age distribution of your clients?
(WHEN NONE, ENTER 0, DO NOT LEAVE BLANKS)
Percent
a. 15 or Under
b. 16-18
c. 19-20
d. 21-25
e. 26-30
f. 31-40
g. 41-50
h. 51 and Older
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
65. What is the current medical status of your clients?
(IF NONE, ENTER 0, DO NOT LEAVE BLANKS)
Percent
a. Pregnant (during time in program)
b. HIV Positive
c. Full-blown AIDS
d. Hepatitis
e. TB
f. Co-occurring mental health
g. Other (Specify) ____________
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
23
66. How many of your clients were employed during the year prior to entering your program?
(IF NONE, ENTER 0, DO NOT LEAVE BLANKS)
a. Full time employed (35 hours or more per
week with no seasonal layoffs)
b. Part time employed
c. Seasonally employed
d. Unemployed
e. Other (Specify)_____________________
Percent
Don’t
Know
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ڤ
ڤ
ڤ
ڤ
ڤ
DRUG HISTORY OF CLIENTS CURRENTLY IN TREATMENT
67. Drug of Choice
Indicate the percent of your current clients according to their most recent drug use.
A single individual should be counted only once according to his or her drug of choice.
(WHEN NONE, ENTER 0, DO NOT LEAVE BLANKS)
Percent
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
a. Heroin and other opiates
b. Non-crack cocaine
c. Crack/Rock
24
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
d. Amphetamines
e. Barbiturates/Tranquilizers
f. Marijuana/Hashish
g. LSD
h. PCP
i. Inhalants
j. Other nonprescription drugs
k. Alcohol
l. Designer/Club drugs
m. Other (Specify) ________________
68.
Any Substance
What percent of your clients have used each of the following substances at some time
during the year prior to entering your program?
A single individual should be counted in more than one cell if he/she used more than one substance.
(WHEN NONE, ENTER 0, DO NOT LEAVE BLANKS)
Percent
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
a. Heroin
b. Non-crack cocaine
c. Crack/Rock
25
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
d. Amphetamines
e. Barbiturates/Tranquilizers
f. Marijuana/Hashish
g. LSD
h. PCP
i. Inhalants
j. Other nonprescription drugs
k. Alcohol
l. Designer/Club drugs
m. Other (Specify) ________________
ڤ ڤ ڤ%
69. What is the percent of current clients with illegal injection drug use (lifetime)?
(WHEN NONE, ENTER 0)
70. What is the percent of current clients with illegal injection drug use in the
year prior to entering your program? (WHEN NONE, ENTER 0)
71.
ڤ ڤ ڤ%
How many clients are given prescribed medication?
(WHEN NONE, ENTER 0, DO NOT LEAVE BLANKS)
Percent
a. Clients take prescribed medications for physical illness
b. Clients take prescribed medications for psychiatric or
emotional problems
c. Clients take prescribed medications for substance abuse
treatment (i.e. methadone, naltroxone, buprenephrine, etc.)
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
72.
What percent of your clients have been convicted of a crime
other than possession of drugs?
73.
What percent of your clients have been convicted of the following crimes?
(WHEN NONE, ENTER 0, DO NOT LEAVE BLANKS)
ڤ ڤ ڤ%
Percent
a. Crimes of violence (include murder, rape, aggravated assault, and robbery)
26
ﭬﭭﭫ
b. Crimes against property (burglary, larceny, auto theft, arson, and fencing)
c. Drug sales and/or distribution
d. Prostitution
e. Possession of drugs
f. Child abuse
g. Driving under the influence
h. Other types of crimes
i. Criminal history not available
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
SAFETY OF PROGRAM CLIENTS
74.
What problems with client violence has your program had over the past 12 months?
Number
a. How many clients physically assaulted another
person in the program?
b. How many clients were physically assaulted
while in the program?
ﭬﭭﭫ
ﭬﭭﭫ
c. How many clients were sexually assaulted or
harassed while in the program?
ﭬﭭﭫ
d. How many clients were found with contraband,
such as drugs?
ﭬﭭﭫ
SATISFACTION RATING
75.
How satisfied are you with the program’s safety record? (Please Check One)
0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: __________________________________________________________________
ORGANIZATIONAL CULTURE QUESTIONNAIRE
76.
How true is each of these about your program?
27
3
Very
Satisfied
Not
True
0
Somewhat
True
1
Mostly
True
2
Very
True
3
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
i. This program has high standards of behavior
.0.
.1.
.2.
.3.
j. The standards of behavior in this program are pretty well spelled out
.0.
.1.
.2.
.3.
k. Administration is not interested in what other people think
.0.
.1.
.2.
.3.
l. The program puts a lot of trust in people
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
Not
True
0
Somewhat
True
1
Mostly
True
2
Very
True
3
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
x. I think that the staff believes in the clients
.0.
.1.
.2.
.3.
y. People in this program do what they can to help the others
.0.
.1.
.2.
.3.
a. Clients and staff really feel like a part of the program
b. People in the program are glad to have the opportunity to participate in
this program
c. People around here do not have a lot of respect for this program
d. People know what is expected of them in this program
e. People in this program do not push each other to understand
themselves better
f. Administration and staff are really open to what clients say
g. I feel that people are not interested in helping each other in this
program
h. Clients and staff do not feel supported by the program
m. If clients can fulfill the expectations of this program, then they have
really accomplished something
n. The program focuses not on what people did, but why
they used to do it
o. I think that the program is not clear in letting people know what is
wanted from them
p. I think that the staff in the program are trying to do what is
best for the clients
q. The goals that they set for people in this program are pretty high, but
they can be reached
r. The people in this program like each other
s. I do not think that the program is well organized (runs smoothly)
t. I feel that clients and staff do not have opportunities to tell people in
charge of the program what they think
u. Administration and staff run a pretty tight ship around here
v. People around here are pretty interested in understanding how the
other person feels
w. People around here do not feel a commitment to each other
28
z. Administration and staff are not good at responding to problems
.0.
.1.
.2.
.3.
aa. I think that the people in the program believe in each other to do what
is right
.0.
.1.
.2.
.3.
SATISFACTION RATING
77.
How satisfied are you with the organizational culture at your program?
(Please Check One)
0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: __________________________________________________________________
WITHIN-PROGRAM COMMUNICATION
78. Use the scale below to indicate what actually happens at your program.
29
a. Program director starts discussions about program problems/concerns with
clinical supervisors.
b. Clinical supervisors start discussions about program problems/concerns
with program director.
c. Program director starts discussions about program problems/concerns with
counselors.
d. Counselors start discussions about program problems/concerns with
program director.
e. Program director starts discussions about program problems/concerns with
clients.
f. Clients start discussions about program problems/concerns with program
director.
Never
0
Rarely
1
Sometimes
2
Often
3
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
SATISFACTION RATING:
79.
How satisfied are you with the communication within the program? (Please Check One)
0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: __________________________________________________________________
DECISION-MAKING SCALE
80.
Using the scale below, please rate how strongly you agree with each of the following statements
about decision-making at this program.
Not
True
0
Somewhat
True
1
Mostly
True
2
Very
True
3
.0.
.1.
.2.
.3.
b. Disagreements are generally resolved fairly
.0.
.1.
.2.
.3.
c. The staff are divided into small groups that do not
communicate well
.0.
.1.
.2.
.3.
d. We actively seek out a variety of opinions
.0.
.1.
.2.
.3.
a. We have open and frank discussions about our
differences
30
Not
True
0
Somewhat
True
1
Mostly
True
2
Very
True
3
e. Most viewpoints are given serious consideration
.0.
.1.
.2.
.3.
f. People are afraid to speak up for fear of ridicule
.0.
.1.
.2.
.3.
g. We are not afraid to disagree
.0.
.1.
.2.
.3.
h. We learn a lot from considering each others’ opinions
.0.
.1.
.2.
.3.
i. Individuals who disagree with the majority are likely to
have a hard time
.0.
.1.
.2.
.3.
* The item content for scale is based on: Kirchmeyer, C. & Cohen, A. (1992).
SATISFACTION RATING:
81.
How satisfied are you with the decision-making process at this program? (Please Check One)
0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: __________________________________________________________________
STAFF AND CLIENT DEMOGRAPHICS
82.
How many of the primary substance abuse counselors are Hispanic or Latino?
→ If zero, skip to question 83.
ﭬﭭﭫ
ﭬﭭﭫ
31
Number of Male Counselors
Number of Female Counselors
a.
Of these Hispanic or Latino primary substance abuse counselors, what ethnic group(s) do
they belong to?
Number of Male Staff
Number of Female Staff
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
1. Central American
2. Cuban
3. Dominican
4. Mexican
5. Puerto Rican
6. South American
7. Other, Specify:_________________
83.
How many of the primary substance abuse counselors are:
Number of Male Staff Number of Female Staff
a. Black or African American
b. Asian
c. American Indian
d. Native Hawaiian or other Pacific Islander
e. Alaska Native
f. White
g. Other, Specify:___________________
84. What percent of clients are Hispanic or Latino?
→ If zero, skip to question 86.
ﭬﭭﭫ
ﭬﭭﭫ
Percent of Male Clients
Percent of Female Clients
32
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
85. What is the current ethnic distribution among Hispanic or Latino clients?
(WHEN NONE, ENTER 0, DO NOT LEAVE BLANKS)
Percent
a. Central American
b. Cuban
c. Dominican
d. Mexican
e. Puerto Rican
f. South American
g. Other, Specify:_____________________________
86.
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
What percent of clients are:
Percent
a. Black or African American
b. Asian
c. American Indian
d. Native Hawaiian or other Pacific Islander
e. Alaska Native
f. White
g. Other, Specify:_____________________________
87.
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
ﭬﭭﭫ
Any other comments you would like to make not covered by the questions above:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
33
Reminder: All of your responses to the questions are important,
so please check through the questionnaire
to see that no questions have been skipped.
National Development and Research Institutes, Inc.
71 West 23rd Street, 8th Floor, New York, NY 10010
34
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average 45 minutes per response, including the time for reviewing
instructions and completing 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; Paperwork Reduction Project
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Staff Perspective
Community-Based Residential
Substance Abuse Treatment Programs
Multimodality Quality Assurance Scales (MQA) ©
Gerald Melnick, Ph.D.
Frank Pearson, Ph.D.
National Development and Research Institutes, Inc.
71 West 23rd Street, 8th Floor,
New York, NY 10010
© Gerald Melnick, Ph.D. and Frank Pearson, Ph.D.
National Development and Research Institutes, Inc.
71 West 23rd Street, 8th Floor
New York, NY 10021
April 7, 2006
2
Not to be reproduced or quoted without the permission of the authors.
3
MULTIMODALITY QUALITY ASSURANCE SCALES (MQA)
GUIDE TO THE MQA
FOR PROGRAM CLIENTS
treatment program. Your name and any other
personal identification is not included in the
questionnaire. All of the information is grouped
together at NDRI and only the grouped
information is available to people outside
NDRI. All individual questionnaires are
destroyed after the information is entered into
the NDRI database.
The MQA is designed to help programs become
better at creating client change and more client
satisfaction. One way that it does this is by
looking at the program from many different points
of view. In this way, you and other people can
have an effect on changing and improving the
program. The information from the MQA will
become part of a report to the program director
and others responsible for the program. The
report will consider everyone’s point of view and
make suggestions about how the program can
become a better place and have a more positive
impact on clients.
COMPLETENESS: Since we are not asking
you to identify yourself, we have no way of
contacting you if there is information missing.
Missing information makes any results
questionable. Therefore, we ask you to be
careful to answer each of the questions.
CONFIDENTIALITY: Your answers to the
questionnaire are entirely confidential. The
research is being conducted by the National
Development & Research Institutes, Inc.
(NDRI), a not-for-profit organization that
conducts research in substance abuse
treatment. NDRI is entirely separate from the
QUESTIONS: If you have any questions (or if
you have any comments to make), please feel
free to contact: Dr. Gerald Melnick, (212) 8454426, or by e-mail: [email protected]
4
MULTIMODALITY QUALITY ASSURANCE SCALES (MQA)
STAFF SURVEY
INSTRUCTIONS:
1.
Use “9” to answer questions for which you have no information.
2.
You may check more than one response for items describing facts about the
program.
3.
Throughout the questionnaire there are areas for you to express how satisfied or
dissatisfied you are with the elements in your program at present.
Please check one of the following responses in the satisfaction-rating box:
0 = Very Dissatisfied
1 = Somewhat Dissatisfied
2 = Somewhat Satisfied
3 = Very Satisfied
Or
9 to designate unknown, or “I have no information about this”
Please use the lines provided to explain any 0 or 1 ratings you gave (of course, feel free to explain any of
your ratings).
NOTE: Please do not skip over any items! Completeness is very important for us to understand
your opinion of the program!
5
1. Name of Program:
2. Program Address:
3. Today’s Date
--Month -- Day -- Year
4. Gender:
Male
ڤ
Female
ڤ
Please answer the following questions to the best of your knowledge:
STAFF TRAINING
5. Is there a program orientation that all new treatment staff receive?
6. Does the program provide in-service staff training?
YES
ڤNO
YES
ڤNO
YES
ڤNO
IF YES, what were the:
ﭬﭫ
ﭬﭫ
a. Number of meetings in last 12 months?
b. Number of staff involved in average session?
7. Does the program send staff to training sessions outside the program?
SATISFACTION RATING:
8. How satisfied are you with in-service staff training? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ___________________________________________________________________
6
3
Very
Satisfied
SUPERVISION THROUGH STAFF MEETINGS
9. Are there regularly scheduled formal staff meetings during
which clients are discussed?
YES
ڤNO
IF YES, when are they scheduled?
(Please check ONE)
ڤ
b. Two or three times a week
ڤ
c. Weekly
ڤ
d. Two or three times a month
ڤ
e. Monthly
ڤ
f. Less frequently than once a month ڤ
a. Daily
SATISFACTION RATING:
10. How satisfied are you with supervision in formal staff meetings? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ______________________________________________________________________
SUPERVISION THROUGH INDIVIDUAL MEETINGS
11. Are there regularly scheduled individual supervisory meetings between a
supervisor and individual clinical staff members?
→ IF NO, skip to question number 15
12. When are these meetings scheduled? (Please check ONE)
ڤ
b. Two or three times a week
ڤ
c. Weekly
ڤ
d. Two or three times a month
ڤ
e. Monthly
ڤ
f. Less frequently than once a month ڤ
a. Daily
7
YES
ڤNO
SATISFACTION RATING:
13. How satisfied are you with individual supervision? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ______________________________________________________________________
COUNSELOR INFLUENCE
14. For the items below, please indicate what actually happens at the program:
a. How often does your supervisor ask for
counselor opinions and suggestions
about treatment issues?
b. How often does your supervisors ask
counselors for their opinions and
suggestions about program policies?
c. How often does the program director
ask for counselors opinions and
suggestions about treatment issues?
d. How often does the program director
ask for counselors opinions and
suggestions about program policies?
e. The program is open to new methods
and techniques?
f. The program is open to issues of cultural
diversity?
Never
0
Sometimes
1
Usually
2
Always
3
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
15. For the items below, please indicate what actually happens at the program:
None
0
Very Little
1
Moderate
Amount
2
Great Deal
3
a. How much influence do
counselors have on treatment issues?
.0.
.1.
.2.
.3.
b. How much influence do
counselors have on program policies?
.0.
.1.
.2.
.3.
16. What percentage of your time is spent on paperwork?
8
ڤ ڤ ڤ%
SATISFACTION RATING
17. How satisfied are you with staff influence on decision-making? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ________________________________________________________________________
STAFF INCENTIVES
18. Please check a YES or NO answer:
a. In the past year, did the staff receive a standard (fixed %) pay increase?
b. Does the program give incentive pay raises?
c. In the past year, did any staff members receive promotions?
d. Does the program use any other staff incentives?
ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES
IF YES to item d.
Specify Incentive 1 _______________________________________________________________
Specify Incentive 2 _______________________________________________________________
Specify Incentive 3 ____________________________________________________________________________
SATISFACTION RATING:
19. How satisfied are you with the staff incentives? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ____________________________________________________________________
FACILITIES
20. Is this a residential program?
YES
ڤNO
→ If NO, skip to question number 25
9
3
Very
Satisfied
21. Are clients’ bedrooms shared?
YES
ڤNO
ﭬﭫCLIENTS
IF YES, On average how many clients share a bedroom?
22. Please answer the following questions about your program’s physical space:
a. Do clients have enough personal space?
ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES
b. Does the program provide enough group space?
c. Does the program provide enough recreational space?
23. What is the quality of the food in the program?
.0
Very Poor
1
Inadequate
2
Adequate
3
Very Good
24. Using the following scale, rate your program’s common interior areas of the building
(lobby area, waiting/reception areas, meeting space, recreational space, etc.)
on the qualities listed below:
Very Poor
0
Inadequate
1
Adequate
2
Very Good
3
a. Comfort
.0.
.1.
.2.
.3.
b. Lighting
.0.
.1.
.2.
.3.
c. Ventilation
.0.
.1.
.2.
.3.
d. State of repair
.0.
.1.
.2.
.3.
e. Cleanliness/odor
.0.
.1.
.2.
.3.
f. Adequate amount of
space
.0.
.1.
.2.
.3.
g. General quality
.0.
.1.
.2.
.3.
10
SATISFACTION RATING
25. How satisfied are you with the program’s space? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ____________________________________________________________________
SAFETY OF PROGRAM CLIENTS (participants in the treatment program)
26. What has been the safety record of your program over the past 12 months?
Number
a. How many clients physically assaulted another
person in the program?
ﭬﭭﭫ
b. How many clients were physically assaulted
while in the program?
ﭬﭭﭫ
c. How many clients were sexually assaulted or
harassed while in the program?
ﭬﭭﭫ
d. How many clients were found with contraband,
such as drugs?
ﭬﭭﭫ
SATISFACTION RATING:
27. How satisfied are you with the program’s safety record? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: _______________________________________________________________________
11
3
Very
Satisfied
INTAKE ASSESSMENT
28. Does the initial evaluation include (Please answer each item):
ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
a. Drug abuse history
YES
b. Criminal history assessment
c. Medical assessment
d. Psychiatric assessment
e. Trauma assessment
f. Educational assessment
g. Work/Vocational assessment
h. Family assessment
i. Strengths/Skill assessment
j. Motivational assessment
k. Other (specify)___________
SATISFACTION RATING:
29. How satisfied are you with the intake assessment? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: _______________________________________________________________________
DRUG SCREENING
30. Does your program conduct any drug or alcohol testing?
→ IF NO, skip to question number 37
12
YES
ڤNO
31. On what basis are clients selected for testing?
(CHECK ALL THAT APPLY)
a. All clients are tested
b. For cause (suspicion that particular inmates are using drugs)
c. Random testing
d. To satisfy legal mandates (probation/parole requirements)
e. Other (Specify) ___________________________________
ڤ
ڤ
ڤ
ڤ
ڤ
32. Drug testing is conducted:
(CHECK ALL THAT APPLY)
a. At random days and times
(for example, it can occur at any day at almost any waking hour)
ڤ
b. At regular scheduled days and times
(for example, only on Tuesdays between 1:00 and 3:00 p.m.)
ڤ
ڤ
c. Only when use is suspected
33. What are the consequences of a positive drug test?
(CHECK ALL THAT APPLY):
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
a. Verbal reprimand
b. Loss of privileges
c. Discharge from program
d. Learning experience
(special counseling or activities)
e. None
f. Other (Specify) ________________________
34. Are consequences of a positive drug test applied in graduated steps?
(For example, a second violation has more severe consequences than
the first violation.)
13
YES
ڤNO
SATISFACTION RATING:
35. How satisfied are you with the drug screening policy in your program? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ______________________________________________________________________
PROGRAM STRUCTURE
36. What manuals and protocols does your program provide? (Check your response)
ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
a. Does this program have a treatment protocol?
YES
b. Does this program have a clinical policy manual?
c. Does this program have an administrative policy manual?
ڤ
DON’T KNOW ڤ
DON’T KNOW ڤ
DON’T KNOW
d. Is there a structured approach to treatment that the program follows with
all clients (for example, a specific number and type of group and/or
individual sessions that clients must attend)?
YES
ڤNO ڤ
DON’T KNOW
ڤ
e. Is there a structured content to client groups or individual sessions (for
example, client workbooks, or set of activities that must be followed)?
YES
ڤNO ڤ
DON’T KNOW
ڤ
f. Please indicate how important it is for staff members to follow the program’s structure and content exactly with
clients. In other words, how much variation from protocol is tolerated? Check your answer below:
0
No Variation
Tolerated
1
A Low Level of
Variation Tolerated
2
A Medium Level of
Variation Tolerated
37. What percentage of your time is spent on paperwork?
3.
A High Level of
Variation Tolerated
ڤ ڤ ڤ%
SATISFACTION RATING
38. How satisfied are you with the way that the program has been defined? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ______________________________________________________________________
14
3
Very
Satisfied
TREATMENT PLANNING
39. Do all clients have a treatment plan?
YES
ڤNO
40. What percent of your clients have a treatment plan…
(When NONE, enter 0)
Percent
ﭬﭭﭫ
ﭬﭭﭫ
a. Completed at intake?
b. Completed within 30 days of
admission?
41. What percent of your clients’ treatment plans are periodically updated?
→ IF you indicate 0, skip to question number 45
ڤ ڤ%
42. How often are treatment plans updated? (Please check only ONE box)
a. Weekly
b. Every 2 weeks
c. More frequently than once a month but
less than every 2 weeks
d. Once a month
e. Every 2-3 months
e. Less frequently than every 3 months
f. When the client reaches a specific stage
or level
g. Other (Specify)___________________
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
43. Who participates in updating the treatment plans? (Please answer ALL items a through h)
Never
0
.0.
Sometimes
1
.1.
Usually
2
.2.
Always
3
.3.
b. Case manager
.0.
.1.
.2.
.3.
c. Clinical supervisor
d. Social worker, Psychiatrist, or
Psychologist
e. Client
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
f. Client’s family
.0.
.1.
.2.
.3.
g. Probation or parole agent
.0.
.1.
.2.
.3.
h. Other (Specify)_______________
.0.
.1.
.2.
.3.
a. Primary counselor
15
44. Is there clear consistent documentation of client progress related to the treatment plan?
0
Never
1
Sometimes
2
Usually
3
Always
SATISFACTION RATING:
45. How satisfied are you with the treatment planning process? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ______________________________________________________________________
DISCHARGE PLANNING
46. Is there a discharge plan for clients completing your program?
→ IF NO, skip to question number 53
47. Who participates in formulating the discharge plan?
(Please answer ALL items a through i)
Never
Sometimes
0
1
a. Primary counselor
.0.
.1.
YES
ڤNO
Usually
2
.2.
Always
3
.3.
b. Case manager
c. Social Worker, Psychiatrist, or
Psychologist
d. Clinical supervisor
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
e. Client
.0.
.1.
.2.
.3.
f. Client’s family
.0.
.1.
.2.
.3.
g. Probation or parole agent
.0.
.1.
.2.
.3.
h. Aftercare staff
.0.
.1.
.2.
.3.
i. Other (Specify)______________
.0.
.1.
.2.
.3.
48. Does the discharge plan usually provide for attending aftercare
(agencies that provide vocational/educational services, substance
abuse treatment, etc.)?
YES
49. What percent of your clients scheduled to be released meet with an
aftercare provider?
ڤ ڤ ڤ%
16
ڤNO
50. What percent of your clients scheduled to be released meet with an
aftercare provider more than once?
ڤ ڤ ڤ%
SATISFACTION RATING:
51. How satisfied are you with the discharge planning process? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ______________________________________________________________________
LIST OF SERVICES
52. Educational/Vocational
The following items refer to whether separate classes or training sessions are provided in each of the
following areas.
Provided?
a. High school/G.E.D. classes
ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES
b. Other Basic educational classes
(reading, math, etc.)
c. Vocational training
d. Job readiness
e. Other (Specify) _________________
SATISFACTION RATING:
53. How satisfied are you with the educational/vocational services? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: _______________________________________________________________________
17
3
Very
Satisfied
54. Social Skills Training:
The following items refer to whether specific classes or training sessions are provided in
each of the following areas.
Provided?
a. Communication skills
b. Personal hygiene
c. Parenting skills
d. Leisure time activities skills
e. Stress management
f. Anger management
g. Money management
h. Other (Specify) ______________
ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES
SATISFACTION RATING:
55. How satisfied are you with the social skills training program? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: _______________________________________________________________________
56. What other services does your program provide?
Provided?
a. Vocational assessment (finding out what job skills you have)
b. Vocational counseling
b. Job placement
c. Family planning education
d. Mental health services
e. Basic health education
f. Substance abuse education
g. AIDS prevention
18
ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES
ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
YES ڤNO ڤ
h. Location of housing
YES
i. Assistance with entitlements
j. Legal assistance
k. Other (specify)_______________________________
SATISFACTION RATING
57. How satisfied are you with the other services listed above? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ______________________________________________________________________
EMERGENCY INTERVENTIONS
58. Is there an arrangement for conducting unscheduled crisis sessions
with clients during regular program hours?
(for treatment by your program, not medical treatment)
YES
ڤNO
IF YES, Specify: ___________________________________________________________
59. Is there an arrangement for conducting unscheduled crisis sessions
after regular program hours?
YES
ڤNO
IF YES, Specify: _______________________________________________________________
SATISFACTION RATING
60. How satisfied are you with the emergency interventions? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ______________________________________________________________________
19
3
Very
Satisfied
TREATMENT EMPHASIS
61. What does your program emphasize the most?
Pick NO MORE THAN THREE choices that reflect the most important aims of your program by
checking one box in each column. PLEASE LEAVE REMAINING BOXES BLANK.
Mark only ONE box
in each column
a. Reduce criminal recidivism (new crimes)
b. Treat the clients’ substance abuse problem
c. Reduce psychological or emotional problems
d. Create self-reliance and positive social and work
attitudes
e. Treat the whole person – not the particular
problems the individual may have
f. Create global changes in identity
g. Increase self-understanding
h. Increase self-esteem and confidence
i. Increase trust in a Higher Power
j. Help clients change their surroundings to help deal
with their problems
k. Abstinence from drug/alcohol use
l. Help clients with housing and employment
m. Change thinking patterns that lead to drug use
n. Other (Specify)
____________________________
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
SATISFACTION RATING
62. How satisfied are you that the emphasis of your program is best suited for the clients?
(Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ________________________________________________________________________
20
3
Very
Satisfied
TREATMENT INTERVENTIONS
63. How true is each of these about your program?
Not Used/
Not Applicable
0
Slightly
Important
1
Moderately
Important
2
Very
Important
3
a. General meetings the include all staff and clients
together
.0.
.1.
.2.
.3.
b. Supportive counseling
.0.
.1.
.2.
.3.
c. Confrontational strategies
.0.
.1.
.2.
.3.
d. Group counseling with counselor
.0.
.1.
.2.
.3.
e. Peer-led groups
.0.
.1.
.2.
.3.
f. Individual counseling by peer who has not had formal
training in counseling
.0.
.1.
.2.
.3.
g. Individual drug counseling by trained counselor
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
j. Individual psychotherapy
.0.
.1.
.2.
.3.
k. Contingency management (e.g. token economy,
contingency contracts)
.0.
.1.
.2.
.3.
m. Cognitive behavioral therapy
.0.
.1.
.2.
.3.
n. Family therapy
.0.
.1.
.2.
.3.
o. 12-Step meetings at the program
.0.
.1.
.2.
.3.
p. Relapse prevention
.0.
.1.
.2.
.3.
q. Milieu therapy
.0.
.1.
.2.
.3.
r. Reality therapy
.0.
.1.
.2.
.3.
s. Case management
.0.
.1.
.2.
.3.
t. Other (Specify)___________________
.0.
.1.
.2.
.3.
h. Informal interactions between staff and clients (not in
meetings or counseling sessions)
i. Informal interactions between clients (not in meetings or
counseling sessions)
SATISFACTION RATING
64. How satisfied are you with the program’s delivery of the interventions for your program?
(Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ________________________________________________________________________
21
3
Very
Satisfied
TREATMENT TECHNIQUES
65. How true is each of these about your program?
Not
True
0
Somewhat
True
1
Mostly
True
2
Very
True
3
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
h. Clients share responsibility for making this program work
.0.
.1.
.2.
.3.
i. Clients frequently help each other
.0.
.1.
.2.
.3.
j. Clients who violate the program rules receive a penalty
or sanction
.0.
.1.
.2.
.3.
k. Work is used as part of the therapeutic program
.0.
.1.
.2.
.3.
l. Staff serve as role models for the clients
.0.
.1.
.2.
.3.
m. Senior clients serve as role models for newer clients
.0.
.1.
.2.
.3.
n. Clients get increased privileges as they advance in the program
.0.
.1.
.2.
.3.
o. Clients get increased job responsibilities as they advance in the
program
.0.
.1.
.2.
.3.
SCALE A
a. Program uses group settings involving the confrontation of
negative behavior
b. In this program, feedback from other clients (peers) is more
important than staff counseling
c. Clients have as much contact with counselors outside of formal,
individual, or group counseling sessions as they have in those
sessions
d. Counselors share their personal experiences and feelings with
clients
e. There is a full day’s program (8 or more hours) of required activities
and meetings
f. Staff members confront unacceptable behavior outside of individual
and group counseling
g. Clients confront unacceptable behavior by other clients outside of
formal group sessions
SATISFACTION RATING
66. How satisfied are you with the use of the interventions in SCALE A? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ______________________________________________________________________
22
3
Very
Satisfied
67. How true is each of these about your program?
Not
True
0
SCALE B
a. Encourages clients to practice telling themselves about how to act
correctly
b. Encourages clients to praise themselves for behaving well
c. Helps clients practice saying no to drugs when they are offered
d. Encourages clients to stop and think before acting
e. Helps clients to identify “trigger” situations for taking drugs
f. Explains the use of thought stopping techniques
g. Encourages clients to find enjoyable things to do besides drugs or
alcohol
h. Encourages clients to communicate with others in an assertive, but nonviolent way
i. Emphasizes problem solving techniques to deal with frustration
j. Emphasizes thinking about the consequences of using drugs
k. Helps clients to recognize errors in thinking
l. Uses contracts that involve punishment or rewards
m. Helps clients to develop a plan to return to abstinence if they slip and use
drugs or alcohol
n. Uses behavioral rehearsal or role playing to act out situations
o. Teaches clients how to deal with urges and cravings for drugs or alcohol
Somewhat Mostly
True
True
1
2
Very
True
3
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
SATISFACTION RATING
68. How satisfied are you with the use of the treatment techniques in SCALE B? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ______________________________________________________________________
23
3
Very
Satisfied
69. How true is each of these about your program?
Not
True
0
Somewhat
True
1
Mostly
True
2
Very
True
3
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
g. Discusses a “one day at a time” approach to abstinence
.0.
.1.
.2.
.3.
h. Discusses “stinking thinking”
.0.
.1.
.2.
.3.
i. Explains the importance of working the 12-Step program consistently
.0.
.1.
.2.
.3.
j. Discusses the goals and strategies of the 12-Step program
.0.
.1.
.2.
.3.
k. Explains how to work the 12-Step program
.0.
.1.
.2.
.3.
l. Explains the reasons why the 12-Steps work
.0.
.1.
.2.
.3.
m. Discusses the nature of the “sponsoring relationship”
.0.
.1.
.2.
.3.
n. Discusses the barriers to affiliation with the 12-Step program
.0.
.1.
.2.
.3.
o. The program hosts different types of 12-Step meetings, such as the
‘Step Meeting’ and discussion ‘Round Robin’
.0.
.1.
.2.
.3.
SCALE C
a. Emphasizes the need to rely on a “Higher Power”
b. Emphasizes the need to seek external support to recover (you cannot
do it alone)
c. Emphasizes that recovery from substance abuse is a life long process
requiring ongoing attendance at 12-Step meetings
d. Provides recovery literature, such as the Big Book, pamphlets, or
serenity prayer posters
e. Emphasizes the need to admit the loss of control over drugs and/or
alcohol (powerlessness)
f. Encourages the need for spiritual growth
SATISFACTION RATING
70. How satisfied are you with the use of the interventions in SCALE C? (Please Check One)
.0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: ________________________________________________________________________
24
3
Very
Satisfied
ORGANIZATIONAL CULTURE QUESTIONNAIRE
71. How true is each of these about your program?
Not
True
0
Somewhat
True
1
Mostly
True
2
Very
True
3
a. Clients and staff really feel like a part of the program
.0.
.1.
.2.
.3.
b. I’m glad that I have the opportunity to participate in this program
.0.
.1.
.2.
.3.
c. I do not have a lot of respect for this program
.0.
.1.
.2.
.3.
d. People know what is expected of them in this program
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
i. This program has high standards of behavior
.0.
.1.
.2.
.3.
j. The standards of behavior in this program are pretty well spelled out
.0.
.1.
.2.
.3.
k. Administration is not interested in what I think
.0.
.1.
.2.
.3.
l. The program puts a lot of trust in people
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
x. I think that the staff believes in the clients
.0.
.1.
.2.
.3.
y. I would do what I could to help this program
.0.
.1.
.2.
.3.
z. Administration and staff aren’t good at responding to problems
.0.
.1.
.2.
.3.
e. People in this program don’t push each other to understand themselves
better
f. Administration and staff are really open to what clients say
g. I feel that people are not interested in helping each other in this
program
h. Clients and staff do not feel supported by the program
m. If clients can fulfill the expectations of this program, then they have
really accomplished something
n. The program focuses not on what people did, but why they
used to do it
o. I think that the program isn’t clear in letting people know what is
wanted from them
p. I think that the staff in the program are trying to do what is best for the
clients
q. The goals that they set for people in this program are pretty high, but
they can be reached
r. I like the people in this program
s. I don’t think that the program is well organized (runs smoothly)
t. I feel that clients and staff do not have opportunities to tell people in
charge of the program what they think
u. Administration and staff run a pretty tight ship around here
v. People around here are pretty interested in understanding how the
other person feels
w. I don’t feel a commitment to the other people here
25
aa. I think that the people in the program believe in me to do what is right
26
.0.
.1.
.2.
.3.
SATISFACTION RATING:
72. How satisfied are you with the organizational culture at your program? (Please Check One)
0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
3
Very
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: __________________________________________________________________
WITHIN-PROGRAM COMMUNICATION
73. Use the scale to indicate what actually happens at your program.
Often
1
Sometimes
2
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
.0.
.1.
.2.
.3.
f. Counselors start discussions about program problems/concern with clients.
.0.
.1.
.2.
.3.
g. Clients start discussions about program problems/concerns with counselors.
.0.
.1.
.2.
.3.
Never
Rarely
0
a. Program director starts discussions about program problems/concerns about
program with counselors.
b. Counselors start discussions about program problems/concerns with the
program director.
c. Clinical supervisors start discussions about program problems/concerns
with counselors.
d. Counselors start discussions about program problems/concerns with clinical
supervisors.
e. Counselors start discussions about program problems/concerns with other
counselors.
3
SATISFACTION RATING:
74. How satisfied are you with the communication within the program? (Please Check One)
0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: __________________________________________________________________
27
3
Very
Satisfied
DECISION-MAKING SCALE *
75. Using the scale below, please rate how strongly you agree with each of the following statements about
decision-making at this program (includes counselors, interns, supervisors, support staff, etc.)
Not
True
0
Somewhat
True
1
Mostly
True
2
Very
True
3
a. We have open and frank discussions about our differences
.0.
.1.
.2.
.3.
b. Disagreements are generally resolved fairly
.0.
.1.
.2.
.3.
c. The staff is divided into small groups that do not communicate well
.0.
.1.
.2.
.3.
d. We actively seek out a variety of opinions
.0.
.1.
.2.
.3.
e. Most viewpoints are given serious consideration
.0.
.1.
.2.
.3.
f. People are afraid to speak up for fear of ridicule/retaliation
.0.
.1.
.2.
.3.
g. We are not afraid to disagree
.0.
.1.
.2.
.3.
h. We learn a lot from considering each others’ opinions
.0.
.1.
.2.
.3.
.1.
.2.
.3.
i. Individuals who disagree with the majority are likely to have a hard
.0.
time
*The item content for this scale is based on: Kirchmeyer, C. & Cohen, A. (1992)
SATISFACTION RATING:
76. How satisfied are you with the decision-making process at this program? (Please Check One)
0
Very
Dissatisfied
1
Somewhat
Dissatisfied
2
Somewhat
Satisfied
9.
Unknown
I have no information
about this
IF 0 or 1, explain: __________________________________________________________________
DEMOGRAPHICS:
77.
Are you Hispanic or Latino?
YES
ڤNO
28
3
Very
Satisfied
a. If yes, what ethnic group do you consider yourself?
Select one or more:
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
1. Central American
2. Cuban
3. Dominican
4. Mexican
5. Puerto Rican
6. South American
7. Other, Specify:_________________
78.
What is your race? (Select one or more)
Select one or more:
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
a. Black or African American
b. Asian
c. American Indian
d. Native Hawaiian or other Pacific Islander
e. Alaska Native
f. White
g. Other, Specify:___________________
79. Any other comments you would like to make not covered by the questions above:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
29
Reminder: All of your responses to the questions are important,
so please check through the questionnaire
to see that no questions have been skipped.
30
National Development and Research Institutes, Inc.
71 West 23rd Street, 8th Floor, New York, NY 10010
31
| File Type | application/pdf |
| File Modified | 2006-07-21 |
| File Created | 2006-07-20 |