Form Attachment B9 - Mi Attachment B9 - Mi Attachment B9 - Mini-N-SSATS 2010 CATI

Attachment B9
Mini-N-SSATS 2010 CATI questionnaire

Attachment B9 (Mini-N-SSATS 2010 CATI questionnaire)
FORM APPROVED: OMB No. 0930-xxxx
APPROVAL EXPIRES: xx/xx/xxxx
See OMB burden statement on last page

NATIONAL SURVEY OF SUBSTANCE ABUSE TREATMENT SERVICES
2010 Mini N-SSATS
>Hello<

Hello, my name is [fill interview name]. I am calling
concerning SAMHSA's Substance Abuse and Mental Health Services
Administration online Locator for drug and alcohol abuse treatment
facilities.

>GetDir<

May I speak with [fill Director] about including this facility in
SAMHSA’s online Locator?
<1> SPEAKING WITH FACILITY DIRECTOR/APPROPRIATE PERSON
<2> CONNECTED TO FACILITY DIRECTOR/APPROPRIATE PERSON [goto
Hello2_Mini]
<3> FACILITY DIRECTOR NOT AVAILABLE
<4> ANSWERING MACHINE
<5> WRONG NUMBER

>Received
Mini<
Recently you were sent a letter signed by Dr. Peter J. Delany of
SAMHSA explaining that this facility has been approved to be listed
in the online Treatment Facility Locator for drug and alcohol abuse
treatment facilities. The letter also explains that this
facility can be added to the Locator by answering a few questions
about the services that this facility provides. Did you receive
that letter?
<1> Yes [goto Intro_Mini]
<2> No [goto ReadLetter]
>Read
Letter<

Would you like me to read you the letter, or perhaps fax it to you?
IF READ LETTER, THEN READ THE LETTER AND THEN ENTER CONTINUE
IF RESPONDENT REQUESTS A FAX, CONFIRM FAX NUMBER LISTED ON THE
UPDATEINFO TAB.
<1> CONTINUE [goto Intro_Mini]
<2> FAX THE LETTER

>Fax
Letter<

I will fax the letter today. You can visit the Locator at the Web
address listed on the letter. If you decide to participate, please
call us at the toll-free number given on the letter.
<1>Continue [goto Thanks]

>Intro
Mini<

If you would like to be included in the Locator, we can ask you the
questions now.
<1> YES, CONTINUE [goto Confirm2]
<2> SCHEDULE CALLBACK AT CONVENIENT TIME
<4> NO LONGER PROVIDES SUBSTANCE ABUSE TREATMENT [goto a1_1]
<5> NEVER PROVIDED SUBSTANCE ABUSE SERVICES [
goto a1_1]
<6> DUPLICATE FACILITY [goto Duplicate]
<7> MERGED WITH ANOTHER FACILITY [goto Merged]
<8> FACILITY CLOSED/NO LONGER EXISTS [goto Thanks]
<9> SATELLITE FACILITY [goto Satellite]
<10> DOES NOT WANT TO BE INCLUDED IN THE LOCATOR [goto Thanks]

>Confirm2<

I will be asking you questions about
[fill UFA@NAM1]
[fill UFA@NAM2]
[FILL LOC@UAD1]
[FILL LOC@UAD2]
[FILL LOC@UCTY], [FILL LOC@UST] [FILL LOC@UZP5:0][FILL LOC@UZP4]
IF NOT CORRECT USE THE UpdateInfo TAB TO UPDATE FACILITY
INFORMATION
<1> Continue

>Duplicate<
Fill2 Which facility is a duplicate to this one? PRESS ENTER TO
CHOOSE FROM LIST OR TO ENTER FACILITY INFO

>Merged<

Fill2 Which facility was this one merged with? PRESS ENTER TO
CHOOSE FROM LIST OR TO ENTER FACILITY INFO

>Satellite<
Which facility is this one associated with?
For the purpose of this survey a satellite facility is one that
does not have permanent staff on location. Often times staff will
travel from another location to provide treatment on a limited
schedule.
PRESS ENTER TO CHOOSE FROM LIST OR TO ENTER FACILITY INFO

>Thanks
Mini<

Thank you so much for your time.

>a1<

[missing ]
First, I will ask you about the characteristics of the individual
facility, [fill UFA@NAM1] [fill UFA@NAM2].
Please answer the following questions referring only to this
substance abuse facility.
Which of the following substance abuse services are offered by
this facility [r]at this location[n], that is,
[fill LOCATION ADDRESS]?
1
2
3

Intake, assessment, or referral
Detoxification
Substance abuse treatment, by that we mean services that
focus on initiating and maintaining an individual’s
recovery from substance abuse and on averting relapse

(1) YES
[@1] <1,0,d,r>
[@2] <1,0,d,r>
[@3] <1,0,d,r>

>a2<

(0) NO

(d) DON’T KNOW

(r) REFUSED

[missing ]
DID RESPONDENT ANSWER “YES” TO [r]DETOXIFICATION[n] IN
OPTION 2 OF a1?
<1> YES [goto a4]
<0> NO

>a3<

[missing ]
DID RESPONDENT ANSWER “YES” TO [r]SUBSTANCE ABUSE TREATMENT[n]
IN OPTION 3 OF a1?
<1> YES [goto a4]
<0> NO [goto a37]
DON’T KNOW [goto a37]
REFUSED [goto a37]

>a4<

[missing ]
What is the [r]primary[n] focus of facility
[at this location[n], that is, [fill LOCATION ADDRESS]?
INTERVIEWER: IF RESPONDENT GIVES MORE THAN ONE RESPONSE, Which do
you consider the [r]primary[n] focus of this facility?
INTERVIEWER:

CODE ONE ONLY

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

>a8<

[missing ]
Is this facility a jail, prison, or other organization that
provides treatment [r]exclusively[n] for incarcerated persons
or juvenile detainees?
<1> YES
<0> NO [goto a10]
DON’T KNOW [goto a10]
REFUSED [goto a10]

>a8a<

[missing ]
Just to confirm, this facility provides substance abuse
treatment services [r]only[n] to incarcerated persons or juvenile
detainees.
Is that correct?
<1> YES, THAT IS CORRECT [goto uloc5]
<0> NO, THAT IS NOT CORRECT
DON’T KNOW
REFUSED

>a10<

[missing ]
What telephone number(or numbers) should a potential client call
to schedule an [r]intake[n] appointment?
INTERVIEWER:

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

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

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

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

OR
ENTER
ENTER
ENTER
ENTER

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

>V10<

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

>V10b<

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

>V10c<

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

>V10d<

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

>a11e<

[missing ]
Which of the following pharmacotherapies services are provided by
this facility [r]at this location[n], [fill UFA@NAM1] [fill
UFA@NAM2]?
INTERVIEWER:
@38
@39
@40

CODE ALL THAT APPLY

Methadone
Buprenorphine, with the brand name Subutex [goto a12a]
Buprenorphine, with the brand name Suboxone [goto a12a]

(d) DON’T KNOW
(r) REFUSED
[@38] <1,0,d,r>
[@39] <1,0,d,r>
[@40] <1,0,d,r>

>a12<

[missing ]
DID RESPONDENT ANSWER “YES” TO METHADONE, BUPRENORPHINE –
SUBUTEX, OR BUPRENORPHINE – SUBOXONE?
<1>
<0>

>a12x<

YES [goto a12x]
NO [goto a19]
DON’T KNOW [goto a19]
REFUSED [goto a19]

[missing ]
Does this facility operate a methadone maintenance or
buprenorphine maintenance program [r]at this location[n]?
<1> Yes [goto a12a]
<0> NO [goto a12y]

>a12a<

[missing ]
Does this facility operate…
INTERVIEWER:

MARK ONE ONLY

<1> A methadone maintenance program,
<2> A buprenorphine maintenance program
(Subutex and/or Suboxone),
<3> Both a methadone maintenance and a
buprenorphine maintenance program
DON’T KNOW
REFUSED

>a12b<

[missing ]
Does this facility serve [r]only[n] opiate-dependent clients [r]at
this location[n]?
<1>
<0>

YES
NO
DON’T KNOW
REFUSED

>a12y<

[missing ]
Does this facility operate an opiate detox program [r]at this
location[n] that uses methadone or buprenorphine to detoxify
clients?
<1> YES [goto a12c]
<2> NO [goto a19]

>a12c<

[missing ]
Does this facility operate…
INTERVIEWER:

MARK ONE ONLY

<1> A program that uses methadone to detox clients
<2> A program that uses buprenorphine to detox clients
(Subutex and/or Suboxone), or
<3> Both a program that uses methadone and a program that uses
buprenorphine to detox clients
DON’T KNOW
REFUSED

>a19<

[missing ]
Does this facility, at this location, offer a
[r]specially designed[n] program or group intended
[r]exclusively[n] for DUI/DWI or other drunk driver
offenders?
<1> YES [goto a19a]
<0> NO [goto a20]
DON’T KNOW [goto a20]
REFUSED [goto a20]

>a19a<

[missing ]
Does this facility serve [r]only[n] DUI/DWI clients?
<1> YES
<0> NO
DON’T KNOW
REFUSED

>a20<

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

>a21<

[missing ]
Does this facility provide substance abuse treatment services in
a language other than English at this location?
<1> YES [goto a21a]
<0> NO [goto a22a1]
DON’T KNOW [goto a22a1]
REFUSED [goto a22a1]

>a21a<

[missing ]
At this facility, who provides substance abuse treatment
services in a language other than English? Is it…
<1> A staff counselor who speaks a language
other than English, [goto a21a1]
<2> An on-call interpreter, in person or by phone,
brought in when needed, or [goto a22a1]
<3> [r]BOTH[n] staff counselor and on-call
interpreter? [goto a21a1]
DON’T KNOW
REFUSED

>a22a1<

[missing ]
Do [r]staff counselors[n] provide substance abuse treatment
in Spanish at this facility?
<1> YES [goto a21a2]
<0> NO [goto a21b]
DON’T KNOW [goto a21b]
REFUSED [goto a21b]

>a21a2<

[missing ]
Do [r]staff counselors[n] at this facility provide substance
abuse treatment in any other languages?
<1> YES [goto a21b]
<0> NO [goto a22_1]
DON’T KNOW [goto a22_1]
REFUSED [goto a22_1]

>a22b<

[missing ]
In what other languages do [r]staff counselors[n] provide
substance abuse treatment?
@1
@2
@3
@4
@5
@6
@7
@8
@9
@10
@11
@12
@13
@14
@15
@16
@18
@19
@20

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

(d) DON’T KNOW
(r) REFUSED

>a21ck<

[missing ]
IF TREATMENT IS OFFERED IN MORE THAN THREE LANGUAGES, ASK:
Are all of these languages spoken by a [r]staff counselor[n]? (READ
LIST)
INTERVIEWER:

YOU MAY HAVE TO SCROLL DOWN TO SEE ALL OPTIONS.

<1> YES [goto a22_1]
<0> NO [RETURN TO FIX LIST]

>a22_1<

[missing ]
The next series of questions asks if specific types of clients are
accepted into treatment [r]at this location[n]. For each type of
client accepted at this facility, I will ask if this facility
offers [r]specially designed[n] substance abuse treatment program
or group [r]exclusively[n] for that type of client.
Does [fill UFA@NAM1] [fill UFA@NAM2] accept (READ CATEGORY) into
treatment [r]at this location[n]?
@1 Adolescents READ IF NECESSARY: Adolescents could be described
as “youths” or “teens.”
@2 Clients with co-occurring mental and
substance abuse disorders
@3 Criminal justice clients other than DUI/DWI
@4 Persons with HIV OR AIDS
@5 Gays or lesbians
@6 Seniors or older adults
@7 Adult women
@8 Pregnant or postpartum women
@9 Adult men
(1) YES

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

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

(0) NO

(d) DON’T KNOW

(r) REFUSED

>a22_2<

[missing ]
[PROGRAMMER: For all “yes” responses at a22_1 ASK:]
Does this facility offer a [r]specially designed[n] substance abuse
treatment program or group [r]exclusively[n] for (READ CATEGORY)?
@1 Adolescents
@2 Clients with co-occurring mental and
substance abuse disorders
@3 Criminal justice clients (other than DUI/DWI)
@4 Persons with HIV or AIDS
@5 Gays or lesbians
@6 Seniors or older adults
@7 Adult women
@8 Pregnant or postpartum women
@9 Adult men
@10 [r]Specially designed[n] substance abuse treatment programs
or groups for any other types of clients at this location?
(SPECIFY AND END WITH //)
(1) YES

(0) NO

(d) DON’T KNOW

(r) REFUSED

[@1] <1,0,d,r>
[@2] <1,0,d,r>
[@3] <1,0,d,r>
[@4] <1,0,d,r>
[@5] <1,0,d,r>
[@6] <1,0,d,r>
[@7] <1,0,d,r>
[@8] <1,0,d,r>
[@9] <1,0,d,r>
[@10] <1,0,d,r>
>a23<

[missing ]
Does this facility offer [r]Hospital Inpatient[n] substance
abuse services at this location?
<1> YES [goto a23a]
<0> NO [goto a24]
DON’T KNOW [goto a24]
REFUSED [goto a24]

>a23a<

[missing ]
Which of the following [r]Hospital Inpatient[n] services are
offered by this facility?
@1 Hospital Inpatient detoxification, which is similar to
ASAM Levels IV-D and III.7-D. (Medically managed or
monitored inpatient detoxification)
READ IF NECESSARY:

ASAM is the American Society of Addiction
Medicine. ASAM developed guidelines regarding
levels of care that are now widely used.

@2 Hospital Inpatient treatment, which is similar to ASAM Levels
IV and III.7. (Medically managed or monitored intensive
inpatient treatment)
[@1] <1,0,d,r>
[@2] <1,0,d,r>

>a24<

[missing ]
Does this facility offer [r]Residential[n], non-hospital,
substance abuse services at this location?
<1> YES [goto a24a]
<0> NO [goto a25]
DON’T KNOW [goto a25]
REFUSED [goto a25]

>a24a<

[missing ]
Which of the following [r]Residential [n] services are offered
by this facility?
@1 Residential detoxification, which is similar to ASAM Level
III.2-D. (Clinically managed residential detoxification or
social detoxification)
READ IF NECESSARY:

ASAM is the American Society of Addiction
Medicine. ASAM developed guidelines regarding
levels of care that are now widely used.

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

[PROGRAMMER:
>a11.31<

IF Q24a_1 OR 24a_2 OR 24a_3 EQUALS “YES,” GOTO a11.31]

[missing ]
Does this facility provide residential beds for clients’
children?
<1> YES
<0> NO
DON’T KNOW
REFUSED

>a25<

[missing ]
Does this facility offer [r]Outpatient[n] substance abuse
services at this location?
<1> YES [goto a25a]
<0> NO [goto a26]
DON’T KNOW [goto a26]
REFUSED [goto a26]

>a25a<

[missing ]
Which of the following [r]Outpatient[n] services are offered
by this facility?
@1 Outpatient detoxification, which is similar to ASAM
Levels I-D and II-D. (Ambulatory detoxification)
READ IF NECESSARY:

ASAM is the American Society of Addiction
Medicine. ASAM developed guidelines regarding
levels of care that are now widely used.

@2 Outpatient methadone/buprenorphine maintenance.
(Opioid maintenance therapy)
@3 Outpatient day treatment or partial hospitalization, which is
similar to ASAM Level II.5. (20 or more hours per week)
@4 Intensive outpatient treatment, which is similar to
ASAM Level II.1. (9 or more hours per week)

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

@5 Regular outpatient treatment, which is similar to ASAM
Level I. (Outpatient treatment, non-intensive)
<1,0,d,r>
<1,0,d,r>
<1,0,d,r>
<1,0,d,r>
<1,0,d,r>

>va23_a25_1<
[PROGRAMMER: IF a23 AND a24 AND a25 EQUAL “NO,” GOTO
va23_a25_1]
So,this facility does not offer Hospital Inpatient,
Residential,or Outpatient substance abuse services. Is that
correct?
<1> YES, THAT IS CORRECT
<0> NO, CHANGE a23, a24, or a25

>va23_a25_2<
What type of substance abuse treatment does this facility
Offer?
<1> TO RECORD VERBATIM
<2> DOES NOT OFFER SUBSTANCE ABUSE TREATMENT SERVICES

>a26<

[missing ]
Does this facility use a sliding fee scale?
READ IF NECESSARY: A sliding fee scale adjusts the fee for services
based on income and other factors.
<1> YES [goto a26a]
<0> NO [goto a27]
DON’T KNOW [goto a27]
REFUSED [goto a27]

>a26a<

[missing ]
Do you want the availability of a sliding fee scale
published in SAMHSA’s online Treatment Facility
Locator?
READ IF NECESSARY: The Locator is an online directory of substance
abuse treatment facilities in the United States and the services
they offer. It also has a mapping feature so clients can find
facilities easily.
READ IF NECESSARY: The Locator will explain
that sliding fee scales are based on income and other factors.
<1> YES
<0> NO
DON’T KNOW
REFUSED

>a27<

[missing ]
Does this facility offer treatment at no charge to clients who
cannot afford to pay?
<1> YES [goto a27a]
<0> NO [goto a29]
DON’T KNOW [goto a29]
REFUSED [goto a29]

>a27a<

[missing ]
Do you want the availability of free care for eligible clients
published in SAMHSA’s online Treatment Facility Locator?
READ IF NECESSARY: The Locator is an online directory of substance
abuse treatment facilities in the United States and the services
they offer. It also has a mapping feature so clients can find
facilities easily.
READ IF NECESSARY: The Locator will explain
that potential clients should call the facility for information
on eligibility.
<1> YES
<0> NO
DON’T KNOW
REFUSED

>a29<

[missing ]
Which of the following types of client payments or insurance are
accepted by this facility for [r]substance abuse treatment[n]?
@1 No payment accepted, free treatment for [r]all[n] clients
@2 Cash or self-payment
@3 Medicare
READ IF NECESSARY: [r]Medicare[n] is the federal health insurance
program for people age 65 and older and people with
disabilities.
@4 Medicaid
READ IF NECESSARY: [r]Medicaid[n] is a joint federal and state
program that helps with medical costs for some people with
low incomes and limited resources. Medicaid programs vary
from state to state.
@5
@6
@7
@8

[@1]
[@2]
[@3]
[@4]
[@5]
[@6]
[@7]
[@8]
[@9]
>a37<

A state-financed health insurance plan other than Medicaid
Federal military insurance such as TRICARE or Champ-VA
Private health insurance
Access to Recovery (ATR) vouchers
READ IF NECESSARY: Access to Recovery (ATR) is a competitive,
discretionary, grant program funded by the Substance Abuse and
Mental Health Services Administration, Center for Substance
Abuse Treatment, which provides vouchers to clients for the
purchase of substance abuse, clinical treatment, and recovery
support services.
@9 Other [specify]
<1,0,d,r>
<1,0,d,r>
<1,0,d,r>
<1,0,d,r>
<1,0,d,r>
<1,0,d,r>
<1,0,d,r>
<1,0,d,r>
<1,0,d,r>
[missing ]
Does this facility operate a halfway house or other transitional
housing for substance abuse clients at this location, that is,
[fill UFA@NAM1][fill UFA@NAM2] located at [FILL LOC@UAD1]
[FILL LOC@UAD2]?
<1> YES
<0> NO
DON’T KNOW
REFUSED

>a40<

[missing ]
Does this facility have a website or web page with information
about the facility’s substance abuse treatment programs?
<1> YES
<0> NO [goto a41]
DON’T KNOW [goto a41]
REFUSED [goto a41]

>a40x<

[missing ]
The website address for this facility will appear in the
Locator. Please give me the website address exactly as
it should be entered in order to reach your website.
INTERVIEWER:
1) DO NOT RECORD “http://” AT THE BEGINNING OF A WEB ADDRESS.
2) IF “WWW” IS NOT REPORTED AT THE BEGINNING OF THE WEB ADDRESS,
ASK IF IT IS NEEDED AND CHANGE IF NECESSARY.
3) IF AN “AT” SIGN IS REPORTED IN THE WEB ADDRESS, ASK IF THIS
IS REALLY AN E-MAIL ADDRESS. IF SO, DO NOT RECORD HERE.
(1) TO RECORD WEB SITE ADDRESS
(d) DON’T KNOW
(r) REFUSED
[if @an eq <1>]RECORD WEB SITE ADDRESS @web [endif]

>a41<

[missing ]
Does this facility want to be listed in SAMHSA’s online
Treatment Facility Locator?
READ IF NECESSARY: The Locator is an online directory of
substance abuse treatment facilities in the United
States and the services they offer. It also has a
mapping feature so clients can find facilities easily.
<1> YES
<0> NO
DON’T KNOW
REFUSED

>aM1<

[missing ]
Is this facility part of an organization with multiple
facilities or sites that provide substance abuse treatment?
<1> YES [goto aM2]
<0> NO [goto uloc]
DON’T KNOW [goto uloc]
REFUSED [goto uloc]

>aM2<

[missing ]
What is the name, address, and phone number of the facility that
is the parent, or master site, of the organization?
FACILITY NAME:
@nam1
FACILITY NAME (CONT): @nam2
ADDRESS 1:
@ad1
ADDRESS 2:
@ad2
CITY/STATE/ZIP: @cit @st @zip5 - @zip4
FACILITY PHONE: @phn
Extension: @

>uloc<

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

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

Extension:

>other_1<

[missing ][fill NFRi]

MPRID = [fill csid]

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

Is that correct?

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

[fill NFRi]

MPRID = [fill csid]

Is there another substance abuse treatment facility in your
organization that is currently located at [fill LOC@UAD1]
fill LOC@UAD2] [fill LOC@UCTY], [fill LOC@UST]
[fill LOC@UZP5:0]-[fill LOC@UZP4:0]
<1> YES
<0> NO
<3> The location address has been edited but it is
the same address
>uloc2<

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

Our

<1> YES, FAX NUMBER IS CORRECT [goto uloc5]
<0> NO, FAX NUMBER IS NOT CORRECT, MAKE CHANGES [goto uloc4]
<2> NO LONGER HAVE FAX MACHINE [goto uloc5]
DON’T KNOW [goto uloc5]
REFUSED [goto uloc5]
>uloc3<

[missing ][fill NFRi]
MPRID = [fill csid]
Does this facility have a fax machine?
<1> YES
<0> NO [goto uloc5]
DON’T KNOW [goto uloc5]
REFUSED [goto uloc5]

>uloc4<

[fill NFRi]
MPRID = [fill csid]
What is your fax number:
ENTER FAX NUMBER:

>other_3<

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

>uloc5<

[fill NFRi]
INTERVIEWER:

MPRID = [fill csid]
ENTER RESPONDENT’S NAME.

>uloc1a2<

[fill NFRi]

MPRID = [fill csid]

IF NOT KNOWN, ASK.

I may need to call you back regarding your new address.
A note on my computer indicates there may be duplicate
information in our database.
ENTER <1> TO CONTINUE
ENTER CALL BACK DATE AND TIME IN SUPERVISOR NOTES
<2> SUPERVISOR APPROVED
INTERVIEWER: ARE THERE ANY REASONS/PROBLEMS WITH THIS CASE THAT
A SUPERVISOR SHOULD REVIEW BEFORE IT IS FINAL STATUS?
<1> YES, SUPERVISOR REVIEW
<0> NO PROBLEMS, FINAL STATUS
>a47<

[missing ]
INTERVIEWER: ENTER RESPONDENT’S NAME.

IF NOT KNOWN, ASK.

NAME: @nam1

>a47_1<

[missing ]
INTERVIEWER: WAS THIS A . . .
<1> CATI CALLOUT
<2> WEB INTERVIEW

<3> HARD COPY INTERVIEW

Public burden for this collection of information is estimated to average 25 minutes per response including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden to SAMHSA Reports Clearance Officer, Room 7-1044, 1 Choke Cherry Road, Rockville, MD
20857. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The OMB number for this project is
0930-xxxx.

Pledge to Respondents
The information you provide will be protected to the fullest extent allowable under the Public Health
Service Act, 42 USC Sec 501(n). This law permits the public release of identifiable information about an
establishment only with the consent of that establishment and limits the use of the information to the
purposes for which it was supplied. With the explicit consent of eligible treatment facilities, information
provided in response to survey questions marked with an asterisk will be published in SAMHSA’ s
National Directory of Drug and Alcohol Abuse Treatment Programs and the Substance Abuse Treatment
Facility Locator. Responses to non-asterisked questions will be published only in statistical summaries so
that individual treatment facilities cannot be identified.