Form Attachment A Attachment A Baseline Interview

Targeted Capacity Expansion Grants for Jail Diversion Programs

Appendix A - JailDiversionTCE_Baseline_Revised2006

Targeted Capacity Expansion Grants for Jail Diversion Programs

OMB: 0930-0277

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OMB No. 0930-0277

Expiration Date: 05/31/2009

The CMHS Jail Diversion

Targeted Capacity Expansion Initiative

BASELINE Interview Schedule

REVISED

CMHS Jail Diversion TCE Initiative

Baseline Instrument

GPRA

Contract/Grant ID: ___ -___ ___ ___ -___ ___ ___ ___ ___ ___ ___-___ ___

Grant Year: ___ ___ ___ ___

Interview Date: ___ ___/___ ___/___ ___ ___ ___

Study ID #: ___ ___ -- ___ ___ ___ ___ ___

(Site Code) (Program#) (Subject ID#)

Interviewer: _______________ -- ___ ___ ___

(First Name) (Interviewer ID#)

Target Arrest/Incident Date: ___ ___/___ ___/___ ___ ___ ___

SITE CODE

(Circle ONE)

LOCATION OF INTERVIEW

(Circle ONE)

Was anyone else present during the interview?

Hartford, Connecticut
Hillsborough County, Florida
Grant County, New Mexico
St. Louis, Missouri
Dauphin County, Pennsylvania
Nueces County, Texas

Community
Jail
Court
Other (Specify: ___________________)

[If YES] Who? ________

_____________________

Date Received by TAPA Center: __ __ / __ __ / __ __

Date Entered: __ __ / __ __ / __ __ Entered by: _____________________ -- ___ ___

First Name ID

Date Verified: __ __ / __ __ / __ __ Verified by: _____________________ -- ___ ___

First Name ID

FOR RESEARCH PURPOSES ONLY

Not to be duplicated without the expressed written consent of

The TAPA Center

Policy Research, Inc.

Delmar, New York 12054, (518) 439-7415

Table of Contents

Interviewer Instructions I

Informed Consent II

Introduction III

Part 1: GPRA Client Outcome Measures

Demographics 1
Education, Employment and Income 2
Drug and Alcohol Use 3
Family and Living Conditions 4
Crime and Criminal Justice Status 5
Mental and Physical Health Problems and Treatment 5

Part 2: Trauma and Posttraumatic Stress

D.C. Trauma Collaboration Study Violence and Trauma

Screening………………………………………………….6

Posttraumatic Stress Disorder Checklist (PCL-C)

[ADDED SINCE INITIAL OMB REVIEW] …….....…...8

Part 3: Perceived Coercion Scale (From MacArthur Mandated

Community Treatment Survey) 9

Part 4: Colorado Symptom Index 1991…………………………...10

End of Interview…………………………………………………...14

Interviewer Observation Questions………………………………..15

Interviewer Instructions

This interview form comprises the questions that are being collected across all study sites. This form should be administered to the respondent, in its entirety, PRIOR TO your project-specific interview.

There is a short introductory paragraph on page III that should be read to each respondent prior to conducting the interview. Please take time to review it prior to beginning the interview.

Read all questions exactly as worded so that each respondent is asked the same question in the same manner.

DO NOT read response categories unless there is an instruction in italics to do so on the form. Also, NEVER READ “NA”, “RF” & “DK” response categories. These are for your use ONLY and should be minimized as much as possible.

At the end of the interview, be sure to review the entire instrument for completeness and for accuracy of recording. Specifically, please review the instrument for:

missing data
recording errors and inconsistencies
complete cover page information
legibility

If additional explanation is required for a question(s), please add notes in the margins or use post-it notes. If data is missing, and it is not retrievable*, please note this directly on the form.

Complete the Interviewer Observation Questions on the last page of the instrument immediately following the end of the interview.

Be sure to complete the Baseline Person Tracking Program Information Form and attach it to the instrument BEFORE submitting the form to your data manager. THESE FORMS ARE FOR SITE USE ONLY AND MUST BE REMOVED FROM THE INSTRUMENTS PRIOR TO SHIPPING THEM TO THE TAPA CENTER.

* Typically, quantitative information is retrievable and qualitative information, including the information contained in the various scales, is not. However, the interviewer should review all of the missing data and make a determination whether or not the information can be obtained. If an item is deemed missing, this should be noted directly on the instrument before it is sent to the TAPA Center.

OBTAIN INFORMED CONSENT

Hi, I’m (Your Name) and I work for (Site Name)______.

Interviewer: Insert the fact sheet and consent form from your project here, and then read to the respondent.



INTRODUCTION

I’m going to read to you a set of questions exactly as they are worded so that each person is asked the same questions. We are interested in your personal opinion and experiences, so please be as accurate as you can in your response. Please take your time to respond and please feel free to ask me for clarification if you are not sure what is wanted. Sometimes I will be switching time frames and some of the questions might be repetitive. I apologize for this in advance and hope that you will bear with me when this happens. I will try to be very clear, but please ask me if you are not sure about the time period involved. Remember that your answers are confidential. This interview will last about 45 minutes. Do you have any questions before we start?

[EMPHASIZE] If at any time you feel you need a break or need to stop the interview, please let me know. We recognize that some of the questions may be difficult or upsetting, so we can take breaks or stop the interview as often as you need. Please don’t hesitate to ask.

Part 1: GPRA Client outcome measures

Section 1: Demographics

GPRA

1.01 Gender

1 Male

2 Female

3 Other (Specify: _______________________)

8 RF

9 DK

1.02 Are you Hispanic or Latino(a)?

0 No

1 Yes

8 RF

9 DK

1.03 What is your race? (Select one or more)

American Indian
Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
RF
DK

1.04 What is your date of birth? / /

Month Day Year

Section 2: Education, Employment, and Income

GPRA

In this next section, I will be asking you about your current activities, including school, job training and work. By “current”, I mean your activities in the community right before you were arrested or picked up for the offense which led you to the diversion program. That is before __/__/__ [Enter target arrest/incident date from front cover and use follow-back calendar to orient respondent to this time frame].

2.01 Are you currently enrolled in a school or job training program?

1 Not enrolled

2 Enrolled, full-time

3 Enrolled, part-time

Other (Specify: _______________________)

2.02 What is the highest level of education you have finished, whether or not you

have received a degree?

[01=1^st grade, 12=12^th grade, 13=college freshman, 16=college completion]

____ ____ (RF 88; DK 99)

Level in Years

2.02a If less than 12 years of education, do you have a Graduate

Equivalent Diploma (GED)?

0 No

1 Yes

8 RF

9 DK

2.03 Are you currently employed? [Clarify by focusing on status during most of the previous week before the arrest or incident for which the client was diverted, determining whether client worked at all or had a regular job but was off work.]

Are you…[Read each response option]

Employed full time (35+ hrs/week or would have been)
Employed part time
Unemployed, looking for work
Unemployed, disabled
Unemployed, volunteer
Unemployed, retired
Other – (Specify: )
RF

9 DK

2.04 I am going to read you a list of possible sources of money that you received in the past 30 days. By the past 30 days, I mean the 30 days before you were arrested or picked up for the offense which led you to the diversion program. Please remember that any information that you give me on your income is strictly confidential and your responses will not affect any services or money you receive. Approximately, how much did YOU receive in the past 30 days from… [Interviewer: Unless otherwise specified, all questions refer to pre-tax individual income]

[Repeat if needed] In the past 30 days, did you receive...	No	Yes	RF	DK	(If YES, ask:) How much? (RF 88888; DK 99999)
a. Wages or money from paid employment. This includes any wages or money received from legal AND “under the table” employment.	0	1	8	9	$ ___ ___ ___ ___ ___.
d. SSI, SSDI, or Disability	0	1	8	9	$ ___ ___ ___ ___ ___.
g. Social Security Income (SSA)	0	1	8	9	$ ___ ___ ___ ___ ___.
h. Food Stamps	0	1	8	9	$ ___ ___ ___ ___ ___.
b. Public assistance or other benefits, such as welfare, general assistance, or TANF (Temporary Assistance to Needy Families)	0	1	8	9	$ ___ ___ ___ ___ ___.
i. Veteran’s benefits	0	1	8	9	$ ___ ___ ___ ___ ___.
j. Unemployment or Worker’s Compensation	0	1	8	9	$ ___ ___ ___ ___ ___.
k. Child support or alimony	0	1	8	9	$ ___ ___ ___ ___ ___.
l. Income from a spouse or partner’s wages or other money	0	1	8	9	$ ___ ___ ___ ___ ___.
m. Money from family members or friends to buy food, pay rent, get medical care or anything else	0	1	8	9	$ ___ ___ ___ ___ ___.
c. Retirement	0	1	8	9	$ ___ ___ ___ ___ ___.
e. Income from any illegal sources	0	1	8	9	$ ___ ___ ___ ___ ___.
f. Income from other sources that I did not mention [If YES, specify source(s): ___________________________ ________________________________________________]	0	1	8	9	$ ___ ___ ___ ___ ___.

Section 3: Drug and Alcohol Use

GPRA

For the following questions, I am going to ask you about your use of alcohol and drugs in the past 30 days. Again, when I say past 30 days, I am referring to the 30 days before you were arrested or picked up for the offense which led you to the diversion program.

3.01 During the past 30 days how many days have you used the following?

Number of Days

a. Any alcohol (beer, wine, liquor) ____ ____ (RF 88; DK 99)

b. Alcohol to intoxication (5+ drinks in one setting) ____ ____ (RF 88; DK 99)

c. Illegal drugs ____ ____ (RF 88; DK 99)

Section 4: Family and Living Conditions

GPRA

Now I am going to ask about your living situation in the past 30 days. Again, the past 30 days refers to the 30 days before you were arrested or picked up for the offense which led you to the diversion program.

4.01 In the past 30 days where have you been living most of the time?

1 Shelter (safe havens, TLC, low-demand facilities, reception centers, other temporary day or

evening facility)

Street/Outdoors (sidewalk, doorway, park, public or abandoned building)
Institution (hospital, nursing home, jail/prison)
Housed (own or someone else’s apartment, room, house, halfway house, residential treatment)

8 RF

9 DK

4.02 I am going to read you a list of problems and areas of life in which some people experience difficulties. I am going to ask you if you have been experiencing difficulties in these areas during the past week. When I say “during the past week”, I mean the week before you were arrested or picked up for the offense which led you to the diversion program. Please tell me, DURING THE PAST WEEK, to what extent have you been experiencing difficulty in the area of… [Read each response option and ALL examples]

DURING THE PAST WEEK, to what extent have you been experiencing difficulty in the area of… [ = Repeat]*	No Difficulty	A little Difficulty	Moderate Difficulty	Quite a bit of Difficulty	Extreme Difficulty	NA	RF	DK
a. Managing day to day life - for example, getting places on time, handling money, making everyday decisions	1	2	3	4	5	7	8	9
b. Household responsibilities - for example, shopping, cooking, laundry, keeping your room clean, other chores	1	2	3	4	5	7	8	9
c. Work - for example, completing tasks, performance level, finding or keeping a job	1	2	3	4	5	7	8	9
d. School - for example, academic performance, completing assignments, attendance	1	2	3	4	5	7	8	9
*e. Leisure time or recreational activities**	1	2	3	4	5	7	8	9
f. Developing independence or autonomy	1	2	3	4	5	7	8	9
g. Apathy or lack of interest in things	1	2	3	4	5	7	8	9
h. Confusion, concentration, or memory	1	2	3	4	5	7	8	9
i. Feeling satisfaction with your life	1	2	3	4	5	7	8	9

Section 5: Crime and Criminal Justice Status

GPRA

Next, I am going to ask you about arrests and nights you have spent in jail in the past 30 days. For these questions, please INCLUDE the offense for which you were arrested or picked up, leading you to the diversion program, even if this arrest/incident occurred MORE THAN 30 days ago.

5.01 In the past 30 days how many times have you been arrested?

___ ___ (Code # of times – Should be AT LEAST ONE) (RF 88; DK 99)

5.02 In the past 30 days how many times have you been arrested for drug-related offenses?

___ ___ (Code # of times) (RF 88; DK 99)

5.03 In the past 30 days how many nights have you spent in jail/prison?

___ ___ (Code # of nights) (RF 88; DK 99)

Section 6: Mental and Physical Health Problems and Treatment

GPRA

In this next set of questions, I am going to ask you about your health right now and different types of treatment you may have had in the past 30 days. When I say “right now”, I mean the period right before you were arrested or picked up for the offense which led you to the diversion program. When I say “during the past 30 days”, again I mean the 30 days before you were arrested or picked up.

6.01 How would you rate your overall health right now? Would you say it is excellent, very good, good, fair, or poor?

Excellent	Very Good	Good	Fair	Poor	RF	DK
1	2	3	4	5	8	9

6.02 During the past 30 days, did you receive INPATIENT treatment for:

	No	Yes	RF	DK	If YES, altogether for how many nights?
a. a physical complaint?	0	1	8	9	aa. ___ ___
b. mental or emotional difficulties?	0	1	8	9	bb. ___ ___
c. alcohol or substance abuse?	0	1	8	9	cc. ___ ___

6.03 During the past 30 days, did you receive OUTPATIENT treatment for:

	No	Yes	RF	DK	If YES, altogether how many times?
a. a physical complaint?	0	1	8	9	aa. ___ ___
b. mental or emotional difficulties?	0	1	8	9	bb. ___ ___
c. alcohol or substance abuse?	0	1	8	9	cc. ___ ___

6.04 During the past 30 days, did you receive EMERGENCY ROOM treatment for:

	No	Yes	RF	DK	If YES, altogether how many times?
a. a physical complaint?	0	1	8	9	aa. ___ ___
b. mental or emotional difficulties?	0	1	8	9	bb. ___ ___
c. alcohol or substance abuse?	0	1	8	9	cc. ___ ___

Part 2: TraUMA and Posttraumatic stress

Section 1: D.C. Trauma Collaboration Study Violence and Trauma Screening

Now I am going to ask you some questions about events in your life that are upsetting or stressful to most people. Some of these questions may not apply to you, but I have to ask them as is. Please think back over your whole life when you answer these questions. Some of these questions may be about upsetting events people don't usually talk about. Your answers are important to us, BUT you DO NOT have to answer any questions that you do not want to. Also, remember that your answers are completely confidential and will be used only for research purposes.

7.01 At any time in your life have you witnessed someone seriously injured or killed due to an

unnatural event such as a shooting, stabbing, or hit-and-run accident?