Form Modular Survey - O Modular Survey - O Modular Survey - OTP Questions

Voluntary Customer Satisfaction Surveys to Implement Executive Order 12862 in the Substance Abuse and Mental Health Services Administration (SAMHSA)

Attachment 1 - Modular Survey Instrument with OTP Questions 12-18-09 ag

Pilot Testing in Opioid Treatment Programs (OTPs) of Modular Survey with OTP-Speicfic Questions

OMB: 0930-0197

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OMB No. 0930-0197

Expiration Date 01/31/2011










Month


Day


Year

ID Number: Date


Form Completed By: Client Other



I. Background Information


1. Your age: ____________


2. Gender: Male Female


3. Are you Hispanic or Latino?

 No Yes


4. Which of the following best describes your racial/ethnic background?

Select one or more

 American Indian/Alaska Native

 Asian

 Black or African-American

 Native Hawaiian or Other Pacific Islander

 White



  1. What is the primary reason for which you are currently receiving services?

 Mental health Substance abuse

 Both mental health and substance abuse Other (Please Specify) _______________________


  1. How long have you been receiving services here for your current problem(s)?

 Less than 1 month 1 to 2 months 3 to 5 months

 6 to 11 months 1 to 2 years More than two years (Specify) ____


­­­­­­­­­­­­­­­­­­­_____________________________________________________________________________________­­­­­­­­­­­­­­­­­­­­­­____________________

Public Burden Statement: 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 0930-0197. Public reporting burden for this collection of information is estimated to average .25 hours per respondent per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.



  1. Have you ever received treatment for this problem or a similar problem anywhere prior to coming here?


 No Yes


If YES, where – select all that apply

 Hospital, residential treatment

 Outpatient, Day treatment

 Detox

 Crisis intervention / emergency room

 Half-way house

 Peer-support / self-help

 Other ­­­­­­­­­­­­­­­________________________________________

(Please Specify)


  1. Did you voluntarily come for services? (Select ALL that apply)

Yes

 No, my treatment was court ordered

 No, I was pressured by family to come for services

 No, I was pressured by friends to come for services

 No, I was pressured by my work/school to come for services

 Other (Please Specify) ________________________



  1. Did someone (counselor, therapist, or doctor) from this agency recommend or prescribe medication that was related to your treatment?


 No Yes


9a. If someone from this agency recommended or prescribed medication, were you told about the side effects of this medication.


 No Yes


  1. When you came for services, were you given information about your rights as a client?


 No Yes

II. Survey Items


Please read each statement below and think about the services you have received. Fill in the circle that best describes how you feel.



Disagree

Somewhat Agree

Agree

Strongly Agree

Does Not Apply

When I needed services right away, I was able to see someone as soon as I wanted.

The people I went to for services spent enough time with me.

I helped to develop my service/treatment goals.

The people I went to for services were sensitive to my cultural background (race, religion, language, sexual orientation, etc.).

I was given information about different services that were available to me.

I was given enough information to effectively handle my problems.

As a result of the services (treatment) I have received . . .

I am less bothered by my symptoms.

I am better able to cope when things go wrong.

I am better able to accomplish the things I want to do.

I am not likely to use alcohol and/or other drugs.

I am doing better at work/school.

I get along with my teachers/boss.

There is someone who cares about whether I am doing better.

I have someone who will help when I have a problem.

I have people in my life who are a positive influence.

The people I care about are supportive of my recovery.

People count on me to help them when they have a problem.

I have friends who are clean and sober.

I have someone who will listen to me when I need to talk.

Using alcohol and/or drugs is a problem for me.

I need to work on my problems with alcohol and/or drugs.


OTP-Specific Questions



Disagree

Somewhat Agree

Agree

Strongly Agree

Does Not Apply

My program helps me take charge of my recovery.

My program is fair and flexible.

My program helps me lead a healthier lifestyle.

My program works with me to meet my dosage needs.

My program tells the public about what is good about medications like mine.

I am able to speak with medical staff if I need to.

My program tells the public about the benefits of treatment like mine.

My program has medication hours that are convenient for me.

Because I am in treatment, I commit fewer (or no) crimes.

My program helps me learn the skills I need to stand up for myself.

My program helps me deal with other agencies that impact my life.

My program helps me mend relations with family and friends.

My program explains my rights and obligations as a client.

I feel OK asking staff about program rules.

My program helps me be an active member of my community.

My program helps me see that I need more than medication to recover.

My program stands up for me with outside agencies and others.

My program knows how to help me meet my needs.

My program helps me find ways to pay for treatment.

Program staff works with me to ensure that my treatment goals are met.

I feel safe at my treatment program.

The place where I go for my treatment is clean and neat.

My program values my concerns about my dose.

My program helps me get access to medical care when I need it.

My program helps me lead a less risky lifestyle.

I use alcohol and/or other drugs, but I just want help for my opiate use.

My program includes peer leadership as part of my treatment.

I am able to speak with program staff about my treatment.


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File Typeapplication/msword
File TitleAttachment 9 Modular Survey
AuthorAngela Screen
Last Modified BySKING
File Modified2010-01-07
File Created2009-12-18

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