OMB No. 0930-0277
Expiration Date: 05/31/2009
The CMHS Jail Diversion
Targeted Capacity Expansion Initiative
12-MONTH Interview Schedule
REVISD
CMHS Jail Diversion TCE Initiative
12-Month Instrument
GPRA
Contract/Grant ID: ___ -___ ___ ___ -___ ___ ___ ___ ___ ___ ___-___ ___
Grant Year: ___ ___ ___ ___
Interview Date: ___ ___/___ ___/___ ___ ___ ___
Study ID #: ___ ___ -- ___ ___ ___ ___ ___
(Site Code) (Program#) (Subject ID#)
Interviewer: _______________ -- ___ ___ ___
(First Name) (Interviewer ID#)
Date of Baseline Interview: ___ ___/___ ___/___ ___ ___ ___
Date of 6-Month Follow-up Interview: ___ ___/___ ___/___ ___ ___ ___
SITE CODE (Circle ONE) |
LOCATION OF INTERVIEW(Circle ONE) |
Was anyone else present during the interview? |
|
|
[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
1. Education, Employment and Income 1
Drug and Alcohol Use 3
Family and Living Conditions 3
Crime and Criminal Justice Status 4
Mental and Physical Health Problems and Treatment 5
Part 2: Trauma and Posttraumatic Stress
[PART 2 ADDED SINCE INITIAL OMB REVIEW]
D.C. Trauma Collaboration Study Violence and Trauma
Screening………………………………………………….6
Posttraumatic Stress Disorder Checklist (PCL-C)......…....8
Part 3: Perceived Coercion Scale (From MacArthur Mandated
Community Treatment Survey) 9
Part 4: Mental Health Statistics Improvement Program…………..10
Part 5: Colorado Symptom Index 1991…………………...………11
Part 6: Services Used…………………………………………...…15
End of Interview...............................................................................21
Interviewer Observation Questions………………………………..22
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.
* 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
GPRA
In the first few questions, I will ask you about your educational background and your employment
situation.
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: _______________________)
RF
DK
2.02 What is the highest level of education you have finished, whether or not you
have received a degree?
[01=1st grade, 12=12th 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
Are you currently employed?
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. 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 |
$ ___ ___ ___ ___ ___. |
b. Public assistance or other benefits, such as welfare, general assistance, or TANF (Temporary Assistance to Needy Families) |
0 |
1 |
8 |
9 |
$ ___ ___ ___ ___ ___. |
c. Retirement |
0 |
1 |
8 |
9 |
$ ___ ___ ___ ___ ___. |
d. SSI, SSDI, or Disability |
0 |
1 |
8 |
9 |
$ ___ ___ ___ ___ ___. |
e. Income from any illegal sources |
0 |
1 |
8 |
9 |
$ ___ ___ ___ ___ ___. |
g. Social Security Income (SSA)
|
0 |
1 |
8 |
9 |
$ ___ ___ ___ ___ ___. |
h. Food Stamps |
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 |
$ ___ ___ ___ ___ ___. |
f. Income from other sources that I did not mention [If YES, specify source(s): ___________________________ ________________________________________________]
|
0 |
1 |
8 |
9 |
$ ___ ___ ___ ___ ___. |
GPRA
For the following questions, I am going to ask you about your use of alcohol and drugs in the past 30 days.
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)
GPRA
Now I am going to ask about your living situation in the past 30 days.
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. 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 |
GPRA
Next, I am going to ask you about arrests and nights you have spent in jail in the past 30 days.
5.01 In the past 30 days how many times have you been arrested?
___ ___ (Code # of times) (RF 88; DK 99)
[If none, skip to 5.03]
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)
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.
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. ___ ___ |
Now I am going to ask you about outpatient mental health services you have received since your LAST interview with us, that is since ____/____; not just the past 30 days but since ____/____.
6.05 Have you received any outpatient mental health services since your LAST interview with us? By outpatient mental health services we mean seeing a doctor or nurse about taking psychiatric medications, individual, group, or family therapy, day treatment, case management or vocational/rehabilitation services. [Interviewer note: If respondent asks, see definition of vocational/rehabilitation services on page 16.]
0 No [If NO, skip to Part 3]
1 Yes
8 RF
9 DK
NOTE: BOTH SECTIONS OF PART 2 ADDED TO THE 6-MONTH INSTRUMENT SINCE INITIAL OMB REVIEW
Part 2: TraUMA and Posttraumatic stress
Section 1: D.C. Trauma Collaboration Study Violence and Trauma Screening
ADDED TO THE 6-MONTH INSTRUMENT SINCE INITIAL OMB REVIEW
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?
a. LIFETIME If ‘YES’ GO TO b. SINCE LAST INTERVIEW
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
At any time in your life have you witnessed a physical or sexual assault against a family member,
friend, or other significant person?
a. LIFETIME If ‘YES’ GO TO b. SINCE LAST INTERVIEW
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
At any time in your life has anyone touched you sexually when you did not want them to?
a. LIFETIME If ‘YES’ GO TO b. SINCE LAST INTERVIEW
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
At any time in your life has anyone forced you to have sex when you did not want to?
a. LIFETIME If ‘YES’ GO TO b. SINCE LAST INTERVIEW
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
At any time in your life has anyone slapped, pushed, grabbed, or shoved you?
a. LIFETIME If ‘YES’ GO TO b. SINCE LAST INTERVIEW
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
At any time in your life has anyone choked, kicked, bit, or punched you?
a. LIFETIME If ‘YES’ GO TO b. SINCE LAST INTERVIEW
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
At any time in your life has anyone threatened you with, or actually used, a knife, gun, or other weapon to scare or hurt you?
a. LIFETIME If ‘YES’ GO TO b. SINCE LAST INTERVIEW
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
At any time in your life have you been afraid that a specific person (whether it was someone you
knew well or not) would hurt you physically?
a. LIFETIME If ‘YES’ GO TO b. SINCE LAST INTERVIEW
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
ADDED TO THE 6-MONTH INSTRUMENT SINCE INITIAL OMB REVIEW
PCL-C for DSM-IV (11/1/94) Weathers, Litz, Huska, & Keane National Center for PTSD -Behavioral Science Division
INSTRUCTIONS: Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each one carefully, then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past month.
|
Not at all |
A little bit |
Moderately |
Quite a bit |
Extremely |
RF |
DK |
|
1 |
2 |
3 |
4 |
5 |
8 |
9 |
|
1 |
2 |
3 |
4 |
5 |
8 |
9 |
|
1 |
2 |
3 |
4 |
5 |
8 |
9 |
|
1 |
2 |
3 |
4 |
5 |
8 |
9 |
|
1 |
2 |
3 |
4 |
5 |
8 |
9 |
|
1 |
2 |
3 |
4 |
5 |
8 |
9 |
|
1 |
2 |
3 |
4 |
5 |
8 |
9 |
|
1 |
2 |
3 |
4 |
5 |
8 |
9 |
|
1 |
2 |
3 |
4 |
5 |
8 |
9 |
|
1 |
2 |
3 |
4 |
5 |
8 |
9 |
|
1 |
2 |
3 |
4 |
5 |
8 |
9 |
|
1 |
2 |
3 |
4 |
5 |
8 |
9 |
|
1 |
2 |
3 |
4 |
5 |
8 |
9 |
|
1 |
2 |
3 |
4 |
5 |
8 |
9 |
|
1 |
2 |
3 |
4 |
5 |
8 |
9 |
|
1 |
2 |
3 |
4 |
5 |
8 |
9 |
|
1 |
2 |
3 |
4 |
5 |
8 |
9 |
Part 2: perceived coercion scale
(from macarthur mandated community treatment survey)
The next set of questions asks about how you felt about receiving outpatient mental health services.
Please answer “True” or “False” to the following questions:
8.01 I felt free to do what I wanted about receiving outpatient mental health services.
False |
True |
RF |
DK |
0 |
1 |
8 |
9 |
8.02 I chose to receive outpatient mental health services.
False |
True |
RF |
DK |
0 |
1 |
8 |
9 |
8.03 It was my idea to receive outpatient mental health services.
False |
True |
RF |
DK |
0 |
1 |
8 |
9 |
8.04 I had a lot of control over whether I received outpatient mental health services.
False |
True |
RF |
DK |
0 |
1 |
8 |
9 |
8.05 I had more influence than anyone else on whether I received outpatient mental health services.
False |
True |
RF |
DK |
0 |
1 |
8 |
9 |
Part 3: MENTAL HEalth statistics IMPROVEMENT PROGRAM
In the next section, I am going to ask you about how you are handling your daily life as a result of the services you have received from or been referred to by the jail diversion program. Please refer only to those services you received as a result of your participation in the jail diversion program, even if you are no longer in the program.
|
Strongly Agree |
Agree |
I am Neutral |
Disagree |
Strongly Disagree |
NA |
RF |
DK |
|
11.01 |
I deal more effectively with daily problems. |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
9 |
11.02 |
I am better able to control my life. |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
9 |
11.03 |
I am better able to deal with crisis. |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
9 |
11.04 |
I am getting along better with my family. |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
9 |
11.05 |
I do better in social situations. |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
9 |
11.06 |
I do better in school and/or work. |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
9 |
11.07 |
My symptoms are not bothering me as much. |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
9 |
Do you currently attend a self-help group? By “self-help group,” I mean a group formed by
people who share similar experiences or problems who meet regularly to provide support to one another. The choices are: Yes, No, or Self-Help Not Available.
Yes |
No |
Self-Help Not Available |
RF |
DK |
1 |
2 |
3 |
8 |
9 |
[If “Yes”, Go to 11.08a. Otherwise, skip to Part 4]
11.08a How often do you participate – daily, weekly, monthly or occasionally?
Daily |
Weekly |
Monthly |
Occasionally |
RF |
DK |
1 |
2 |
3 |
4 |
8 |
9 |
Part 4: colorado symptom index 1991
I am now going to ask you a series of questions about how you have been feeling or things that have happened in the past month.
9.01 In the past month, how often have you felt nervous, tense, worried, frustrated, or afraid?
[Read each response option]
At least every day |
Several times a week |
Several times during the month |
Once during the month |
Not at all |
RF |
DK |
1 |
2 |
3 |
4 |
5 |
8 |
9 |
9.02 In the past month, how often have you felt depressed? [Read each response option]
At least every day |
Several times a week |
Several times during the month |
Once during the month |
Not at all |
RF |
DK |
1 |
2 |
3 |
4 |
5 |
8 |
9 |
9.03 In the past month, how often have you felt lonely? [Read each response option]
At least every day |
Several times a week |
Several times during the month |
Once during the month |
Not at all |
RF |
DK |
1 |
2 |
3 |
4 |
5 |
8 |
9 |
9.04 a. In the past month, how often have others told you that you acted “paranoid” or “suspicious”?
[Read each response option]
At least every day |
Several times a week |
Several times during the month |
Once during the month |
Not at all |
RF |
DK |
1 |
2 |
3 |
4 |
5 |
8 |
9 |
[If “Not at all”, skip to 9.05a]
b. Did this happen ONLY after you drank alcohol or took drugs?
0 No
1 Yes
7 NA
8 RF
9 DK
9.05 a. In the past month, how often did you hear voices, or hear or see things that other people
didn’t think were there? [Read each response option]
At least every day |
Several times a week |
Several times during the month |
Once during the month |
Not at all |
RF |
DK |
1 |
2 |
3 |
4 |
5 |
8 |
9 |
[If “Not at all”, skip to 9.06a]
b. Did this happen ONLY after you drank alcohol or took drugs?
0 No
1 Yes
7 NA
8 RF
9 DK
9.06 a. [Interviewer Note: Omit words in brackets if respondent answered ‘Not at all’ to 9.05a]
In the past month, how often did your [voices], [things you see/hear], thoughts, or feelings
interfere with your doing things? [Read each response option]
At least every day |
Several times a week |
Several times during the month |
Once during the month |
Not at all |
RF |
DK |
1 |
2 |
3 |
4 |
5 |
8 |
9 |
[If “Not at all”, skip to 9.07]
b. Did this happen ONLY after you drank alcohol or took drugs?
0 No
1 Yes
7 NA
8 RF
9 DK
9.07 In the past month, how often did you have trouble making up your mind about something, like
deciding where you wanted to go or what you were going to do, or how to solve a problem?
[Read each response option]
At least every day |
Several times a week |
Several times during the month |
Once during the month |
Not at all |
RF |
DK |
1 |
2 |
3 |
4 |
5 |
8 |
9 |
9.08 In the past month, how often did you have trouble thinking straight or concentrating on
something you needed to do (like worrying so much or thinking about problems so much that
you can’t remember or focus on other things)? [Read each response option]
At least every day |
Several times a week |
Several times during the month |
Once during the month |
Not at all |
RF |
DK |
1 |
2 |
3 |
4 |
5 |
8 |
9 |
9.09 a. In the past month, how often did you feel that your behavior or actions were strange or
different from that of other people? [Read each response option]
At least every day |
Several times a week |
Several times during the month |
Once during the month |
Not at all |
RF |
DK |
1 |
2 |
3 |
4 |
5 |
8 |
9 |
[If “Not at all”, skip to 9.10]
b. Did this happen ONLY after you drank alcohol or took drugs?
0 No
1 Yes
7 NA
8 RF
9 DK
9.10 In the past month, how often did you feel out of place or like you did not fit in?
[Read each response option]
At least every day |
Several times a week |
Several times during the month |
Once during the month |
Not at all |
RF |
DK |
1 |
2 |
3 |
4 |
5 |
8 |
9 |
9.11 In the past month, how often did you forget important things? [Read each response option]
At least every day |
Several times a week |
Several times during the month |
Once during the month |
Not at all |
RF |
DK |
1 |
2 |
3 |
4 |
5 |
8 |
9 |
9.12 a. In the past month, how often did you have problems with thinking too fast (thoughts racing)?
[Read each response option]
At least every day |
Several times a week |
Several times during the month |
Once during the month |
Not at all |
RF |
DK |
1 |
2 |
3 |
4 |
5 |
8 |
9 |
[If “Not a all”, skip to 9.13a]
b. Did this happen ONLY after you drank alcohol or took drugs?
0 No
1 Yes
7 NA
8 RF
9 DK
9.13 a. In the past month, how often did you feel suspicious or paranoid? [Read each response option]
At least every day |
Several times a week |
Several times during the month |
Once during the month |
Not at all |
RF |
DK |
1 |
2 |
3 |
4 |
5 |
8 |
9 |
[If “Not at all”, skip to 9.14]
b. Did this happen ONLY after you drank alcohol or took drugs?
0 No
1 Yes
7 NA
8 RF
9 DK
9.14 In the past month, how often did you feel like hurting or killing yourself?
[Read each response option]
At least every day |
Several times a week |
Several times during the month |
Once during the month |
Not at all |
RF |
DK |
1 |
2 |
3 |
4 |
5 |
8 |
9 |
9.15 In the past month, how often have you felt like seriously hurting someone else?
[Read each response option]
At least every day |
Several times a week |
Several times during the month |
Once during the month |
Not at all |
RF |
DK |
1 |
2 |
3 |
4 |
5 |
8 |
9 |
Part 5: Services Used
15.01 Since the LAST interview, did you go to an emergency room for problems with your emotions, nerves, or other psychiatric problems?
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
[If NO, skip to 15.02]
[If YES to 15.01] a. Where did you go to the emergency room? [Record facility name, city and state]
FOR MULTIPLE ER VISITS TO THE SAME FACILITY, LIST EACH FACILITY ONLY ONE TIME. |
b. How many times did you go to this emergency room? [Code # of times]
98 = Refused 99 = Don’t Know |
Facility name, city and state |
Number of times |
1.
|
_____ _____
|
2.
|
_____ _____
|
3.
|
_____ _____
|
4.
|
_____ _____
|
Since the LAST interview, did you receive other crisis services, such as mobile crisis, crisis stabilization,
or crisis residential/respite care?
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
[If NO, skip to 15.03]
[If YES to 15.02] a. What is the name of the provider and where did you receive those crisis services? [Record provider, agency name, city and state]
|
Provider, agency name, city and state |
1.
|
2.
|
3.
|
4.
|
Since the LAST interview, have you been hospitalized overnight or did you receive any type of inpatient
care for your emotions, nerves or other psychiatric problems?
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
[If NO, skip to 15.04]
[If YES to 15.03] a. Where were you hospitalized or where did you receive inpatient psychiatric care? [Record facility name, city and state]
FOR MULTIPLE ADMISSIONS TO THE SAME FACILITY, LIST EACH FACILITY ONLY ONE TIME. |
b. How many times were you in this hospital or inpatient facility? [Code # of times]
98 = Refused 99 = Don’t Know |
Facility name, city and state |
Number of times |
1.
|
_____ _____
|
2.
|
_____ _____
|
3.
|
_____ _____
|
4.
|
_____ _____
|
Since the LAST interview, did you receive any outpatient treatment, such as individual or family therapy,
group therapy, day treatment, or other outpatient treatment? [EXCLUDE Case Management services here and record in 15.05]
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
[If NO, skip to 15.05]
[If YES to 15.04] a. Where did you receive outpatient treatment? [Record facility name, city and state]
[Interviewer: Probe by saying: “Did you see any other providers that you haven’t mentioned?”]
|
Facility name, city and state |
1.
|
2.
|
3.
|
4.
|
Since the LAST interview, did you receive any type of case management services? [If respondent asks,
say: “Case management refers to a person or team that helps you obtain or coordinate services, entitlements (such as Medicaid or SSI), housing, and advocates on your behalf.”]
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
[If NO, skip to 15.06]
[If YES to 15.05] a. What is the name of the provider and where did you receive the case management services? [Record provider, agency name, city and state]
[Interviewer: Probe by saying: “Did you see any other providers that you haven’t mentioned?”]
|
Provider, agency name, city and state |
1.
|
2.
|
3.
|
4.
|
Since the LAST interview, did you see a doctor or nurse about psychiatric medications that you are taking
or are planning to take?
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
[If NO, skip to 15.07]
[If YES to 15.06] a. What is the name of the doctor or nurse and where did you go to see this provider to discuss psychiatric medications? [Record provider, agency name, city and state]
|
Provider, agency name, city and state |
1.
|
2.
|
3.
|
4.
|
Since the LAST interview, did you live in a residential treatment facility, group home, adult home, halfway house, or other community living setting? [Interviewer Note: This question refers to treatment at a place where the respondent spent the night, but not a hospital, crisis stabilization unit, crisis residential/respite care setting, detox, or jail.]
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
[If NO, skip to 15.08]
[If YES to 15.07] a. Where were you in residential treatment or other community living setting? [Record facility name, city and state]
FOR MULTIPLE ADMISSIONS TO THE SAME FACILITY, LIST EACH FACILITY ONLY ONE TIME. |
b. How many times were you in this residential treatment facility or community living setting? [Code # of times]
98 = Refused; 99 = Don’t Know |
Facility name, city and state |
Number of times |
1.
|
_____ _____
|
2.
|
_____ _____
|
3.
|
_____ _____
|
4.
|
_____ _____
|
15.08 Since the LAST interview, did you receive detoxification services for an alcohol or drug problem?
[If respondent asks or appears unsure as to what “detoxification services” are, say: “Detoxification services, or detox, usually takes place in an inpatient hospital or similar setting. In detox, a person who is physically dependent on and/or addicted to a substance is withdrawn from it. Often times, medications are taken to lessen the short-term withdrawal symptoms.”
[Interviewer Note: Support groups such as AA, NA, etc. should NOT be included here. Include in question 11.08 on p.7.]
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
[If NO, skip to 15.09]
[If YES to 15.08] a. Where did you receive detox? [Record facility name, city and state]
FOR MULTIPLE ADMISSIONS TO THE SAME FACILITY, LIST EACH FACILITY ONLY ONE TIME. |
b. How many times were you in this detox program? [Code # of times]
98 = Refused; 99 = Don’t Know
|
Facility name, city and state |
Number of times |
1.
|
_____ _____
|
2.
|
_____ _____
|
3.
|
_____ _____
|
4.
|
_____ _____
|
15.09 Since the LAST interview, did you receive any vocational or rehabilitation services, such as psychosocial
rehabilitation, consumer-operated services, supported employment, vocational counseling, or supported education?
[If respondent seems unsure ask: Would you like me to clarify what I mean by vocational or rehabilitation services?]
Vocational/rehabilitation services:
Psychosocial rehabilitation:
…means services and activities in a supportive and flexible atmosphere which lead to the development of functional skills, basic vocational and educational skills, community-based social supports and informed life and work choices.
Consumer-operated services:
…means a provider of services or supports operated by consumers. May include clubhouse/transitional employment programs, peer support programs, peer case management, drop-in centers and social clubs. Staff and management are consumers. This does not include AA or NA support groups.
Supported employment:
…means on-the-job support in community-based employment paying competitive wages, including working with employers to develop jobs, individual job placement, on-the-job skills training, and work-site support.
Vocational counseling:
…means the comprehensive assessment of an individual’s vocational skills, attitudes, behaviors and interests and may include helping people make choices about work or training opportunities.
Supported education:
…means assistance in locating or providing a range of educational services including basic literacy, GED (general Equivalency Diploma), study skills, and educational counseling for college, technical or other courses.
[Interviewer Note: Support groups such as AA, NA, etc. should NOT be included here. Include in question 11.08 on p.7.]
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
[If NO, skip to 15.10]
[If YES to 15.09] a. Where did you receive vocational or rehabilitation services? [Record facility name, city and state]
|
Facility name, city and state |
1.
|
2.
|
3.
|
4.
|
5.
|
15.10 Since the LAST interview, did you receive any community support services, such as outreach to you when you were homeless, legal or consumer advocacy services, representative payee services or family psychoeducation services? [If respondent seems unsure ask, Would you like me to clarify what I mean by community support services?]
Community support services:
Homeless outreach:
…means making contact with persons who are homeless to encourage them to engage in treatment, either to provide support where they are or to help them access treatment services.
Legal advocacy:
…means assisting consumers in legal matters related to their mental health service needs and rights.
Consumer advocacy:
…means a program offering consumer staff/volunteers who provide advocacy around issues related to receiving mental health services and community living, including obtaining entitlements, rights in treatment and residential settings, etc.
Representative payee services:
…means services provided by a services provider or advocacy organization to assume responsibility for being a representative payee for a person who qualifies for and is receiving SSI or SSDI.
Family psychoeducation:
…means consultation and education to families (usually in groups) about the nature, consequences and treatment of mental illness.
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
[If NO, skip to 15.11]
[If YES to 15.10] a. Where did you receive community support services? [Record facility name, city and state]
|
Facility name, city and state |
1.
|
2.
|
3.
|
4.
|
5.
|
6.
|
15.11 Since the LAST interview, did you receive any mental health or substance abuse services IN JAIL OR PRISON?
No |
Yes |
RF |
DK |
0 |
1 |
8 |
9 |
[If NO, skip to 10.01]
[If YES to 15.11] a. What is the name of the jail or prison where you received mental health or substance abuse services?[Record facility name, city and state]
|
Facility name, city and state |
1.
|
2.
|
3.
|
4.
|
5.
|
6.
|
END OF INTERVIEW This
is the end of the interview. I want to thank you very much for your
time and participation.
INTERVIEWER REMINDER:
BE SURE TO GO BACK AND
REVIEW THE INSTRUMENT FOR COMPLETENESS AND ACCURACY OF RECORDING
RESPONSES.
COMPLETE THE INTERVIEWER
OBSERVATION QUESTIONS
ON THE NEXT PAGE.
INTERVIEWER OBSERVATION QUESTIONS
10.01 Estimate the respondent’s understanding of the interview.
1 No difficulty – no language or comprehension problems
2 Just a little difficulty – few language or comprehension problems
3 A fair amount of difficulty – some language or comprehension problems
4 A lot of difficulty – considerable language or comprehension problems
10.02 How cooperative has the respondent been?
1 Very cooperative
2 Fairly cooperative
3 Not very cooperative
4 Openly hostile
10.03 How accurate do you think the respondent’s answers were?
1 Very accurate
2 Fairly accurate
3 Not very accurate
4 Not accurate at all
Version 3 12-Month - May 2006 - DRAFT The TAPA Center
| File Type | application/msword |
| File Title | The CMHS Jail Diversion TCE Initiative |
| Author | PRA EMPLOYEES |
| Last Modified By | Preferred Customer |
| File Modified | 2006-11-15 |
| File Created | 2003-02-11 |