Baseline

OMB No. 0930-0277

Expiration Date: 10/31/2012

CMHS Jail Diversion and Trauma Recovery Initiative

Priority to Veterans



Baseline Instrument- modified 5.7.10

Interview Date: ___ ___/ ___ ___/ ____ ____ ____ ____ MM DD YYYY
Study ID#: ____ ____- ____ - ____- ____ ____ ____ (Site Code) (Prog #) (Grp #) (Subject ID #)
Interviewer Name:		Interviewer ID: ___ ___
Interview Type _____	1. Baseline 2. Six month 3. Twelve Month

Site Code		Program Pilot	Group Code Number
01. Connecticut	09. North Carolina	1. Pilot Site 1	1. Pre-booking Diversion
02. Colorado	10. Ohio	2. Pilot Site 2	2. Post-booking Diversion
03. Georgia 04. Illinois	11. Pennsylvania 12. Rhode Island	3. Pilot Site 3	3. Probation/Parole Violation
05. Massachusetts	13. Texas
06. Vermont 07. Florida		(TBD with sites)
08. New Mexico

Location of Interview
1. Community setting (e.g. any residence, restaurant, research offices, university, outdoors)	Was anyone else present during the interview?
2. Services Site (e.g. Hospital, Treatment facility/program, Shelter, Transitional housing)	1. Yes
3. Jail	2. No
4. Court 5. Other
(specify:____________)	If Yes- who? _________________________

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 0930-0277.  Public reporting burden for this collection of information is estimated to average 3,014 hours per client 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.

TABLE OF CONTENTS

Interviewer Instructions 3

Glossary 4

Introduction 7

1. Demographics 8

2. Education, Employment and Income 9

3. Military Service Questions 12

4. Lifetime Mental Health/Substance Use Service Questions 14

5. Drug and Alcohol Use 15

6. Services 17

7. Criminal Justice Questions 18

8. Functioning 19

9. Social Connectedness 20

10. Traumatic Events 21

11. Posttraumatic Stress Disorder Checklist (PCL-C) 23

12. BASIS 24 25

13. REE: Recovery Markers –Revised 27

END OF THE INTERVIEW 29

Interviewer Observations 30

Interviewer Instructions

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

1. There is a short introductory paragraph that should be adapted to your project’s study, program, and consent process. Please take time to review it prior to beginning the interview.

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

3. Responses in capital letters should not be read to respondents. Instructions to the interviewer are in italics. Also, NEVER read ‘NA’ ‘RF’ or ‘DK” response categories.

4. If paper interview is being administered, please be sure to review the entire instrument for completeness and accuracy of recording. Specifically, review the interview for: missing data, recording errors and inconsistencies, complete cover page information, and legibility.

Glossary

Term	Definition
Active Duty	Military members who are currently serving full time in their military capacity, with military pay and allowances in the armed forces.
Adequate	Enough or good enough.
Advocate	To support or speak in favor of something.
Alimony	An allowance that a court orders paid by one's spouse or former spouse as a part of a legal separation or divorce.
Combat Zone	A zone designated by the President by Executive order, it is a specific geographical area defined as an area of armed conflict.
Competitive Employment	Work in the competitive labor market that is performed on a full-time basis and paid no less than wages for same or similar work performed by individuals who are not disabled.
Concentrate	Focusing attention on something.
Conviction	Being found guilty of a crime.
Crisis or Respite Program--	A system that provides regular or special relief to persons or families providing care for persons unable to care for themselves.
Criticize	To judge, negatively or unfavorably, to find fault.
Deployment	Deployment is in preparation for battle or work including peace keeping or training.
Family, Partner, Significant Other Contribution	Voluntary contribution separate from court-ordered child support.
Foster Care	A situation in which a child or children are raised by people other than their biological parents or adoptive parents.
Group Home1	An institution for the care and housing of persons with mental illness &/or substance abuse problems.
Group Home2	A non-secure program in which a group of young people (under the age of 18) live and receive services at the program facility under the supervision of adult staff.
Guilty	Feelings or awareness of having done something wrong.
Hotel or Motel	An establishment that provides lodging, paid for either by the Individual or system/shelter/program.
Inpatient Treatment	Treatment that requires at least on overnight stay at a facility.
Intoxication	(Alcohol intoxication) the quantity of alcohol the person consumes exceeds the individual's tolerance for alcohol and produces behavioral or physical abnormalities. In other words, the person's mental and physical abilities are impaired. (Drug intoxication) excessive dosage (varies from individual to individual) of drug can cause undesirable side effects.
Jail/Prison/Detention Center	A state or federal confinement facility having custodial authority over adults sentenced to confinement; a confinement facility administrated by an agency of local government, typically a law enforcement agency, entered for adults but sometimes also containing juveniles, which holds persons detained pending sentencing and/or persons committed after sentencing, usually those committed on sentences of a year or less.
Job Training	Training whose main objective is to prepare people for a work.
Medicaid & Medicare	Health care programs funded by the federal and state governments that pay the medical expenses of people who are unable to pay some or all of their own expenses.
Moderate	Not great or severe - in the middle of mild and severe.
National Guard/Reserve	Civilian military recruited by stated and equipped by the government that can become part of the national army if there is war or national emergency.
Necessities	Items to meet basic needs, such as personal care items (e.g. deodorant, shampoo).
Outpatient	Treatment that takes place without the client being checked into a hospital or treatment center. This treatment may take place in an office, clinic or other type of care facility.
Probation	A punishment given out as part of a sentence where instead of jailing a person, she/he is released to the community subject to certain conditions and is under the supervision of the court
Program Staff	Employees of the housing/treatment program
Recreational Services	Services involving some form of play, amusement or relaxation.
Restraining Order/ Order of Protection	No contact and order of protection are court orders that prohibits a person from having any kind of contact with another individual usually the victim of a crime.
Self-help/ Peer Support	Self-help and peer support refers to activities organized by people with psychiatric diagnoses (or other characteristics in common) to share their strengths and help each other cope and grow. It does not include support groups led by service providers who are not peers.
Service-Connected Disability	A disability that the US VA has determined was incurred or aggravated in the line of duty during active military, naval or air service.
Sheltered Workshop	Subsidized work where an individual is paid a stipend by a program or agency, because she is unable to work in a competitive work setting.
Staff	People who are paid to provide various services to individuals.
Supported Housing or Certified Apartment Program	Services that assist individuals in finding and maintaining appropriate housing arrangements.
Tour of Duty	A period of time in which those enrolled in the armed forces spend in combat or performing operational duties for their Armed Forces branch. Tours of duty can be anywhere from 5 months or to several years.
Transitional Housing	It is a type of housing that is used to assist the movement of homeless individuals and families to permanent housing. In general, transitional housing is time-limited, provides services beyond survival services, it generally offers more privacy than a shelter, and is viewed as a step between shelter and permanent housing.
Traumatic	Painfully emotional or shocking, often producing lasting psychological effects.
V.A.	The United States Department of Veterans Affairs (VA) is a government-run military veteran benefit system. It is responsible for administering programs of veterans’ benefits for veterans, their families, and survivors.
Vocational Trade/Tech Diploma	Education, training, a school, etc. intended to prepare one for an occupation or trade, such as nurses' assistant, electrician, mechanic, etc.

Introduction

Interviewer read to respondent*

Hi, I’m (your name) and I work for the Jail Diversion Evaluation Study. This study is funded by the Center for Mental Health Services within the federal government. The findings from this study will be used to improve jail diversion programs. Thank you for agreeing to talk with me today. I appreciate your time and cooperation in participating in this interview and the study. You will receive a payment of $ XX for this interview and $XX for each of the two follow-up interviews, the first of which will be in about 6 months.

Your answers will be kept private and will in no way affect your legal status or any other services or money you receive. The information you give will only be seen by research staff.

Before we start, I want to review a few things. First, you should know that your participation is completely voluntary – you do not need to do this interview and if you decide not to, it will not affect any services you receive or your standing in the diversion program. Also, you can choose not to answer any question I ask, or stop the interview at any time. Second, this interview asks a lot of personal questions, some of which may be difficult to think about. Please let me know if you are feeling upset, or need a break. Before we start, please read and sign this consent form.

[HAND RESPONDENT INFORMED CONSENT FORM, REVIEW IT WITH THEM, AND ASK THEM TO SIGN IT]

Thank you. Do you have any questions? (If so, note questions and responses).

Okay, let’s start. I’m going to read you a set of questions exactly as they are worded so that each person is asked the same questions. In some cases, you’ll be asked to answer questions in your own words and I’ll write down your answers. In other cases, you’ll be given a list of answers and asked to choose the one that is best for you. We are interested in your personal opinions about these questions. There are no right or wrong answers. Please take your time. Feel free to ask me questions if you are not sure what is wanted. Some of the questions I will ask you may sound repetitive or may not apply to you, but I have to ask them anyway. Remember that your answers are private.

This interview will last about 45 minutes. I will need to keep things moving along so I hope that I do not sound rude if I tell you we need to move on to the next question.

If at any time you feel you need to take a break or stop the interview. Please let me know.

Now, I think we are ready to begin. I am going to ask you some questions about yourself. Sometimes I will ask you about a specific time frame, like the past week or the last 30 days, and sometimes I will ask you about things that have happened during your lifetime. I’ll try to be clear, but please ask me if you are not sure about the time period involved. Do you have any questions before we begin?

1. Demographics

For the first few questions, I am going to ask you some basic questions about yourself.

1. What is your gender?

1. Male

2. Female

3. Other (Specify:_______________)

7. REFUSED

8. DK

2. Are you Hispanic or Latino?

1. YES

2. NO- SKIP TO QD4.

7. REFUSED

8. DK

3. If yes, what ethnic group do you consider yourself?

	Yes	No	REFUSED	DK
Central American	1	2	-7	-9
Cuban	1	2	-7	-9
Dominican	1	2	-7	-9
Mexican	1	2	-7	-9
Puerto Rican	1	2	-7	-9
South American	1	2	-7	-9
Other: specify_________	1	2	-7	-9

4. What is your race? (Select one or more)

	Yes	No	REFUSED	DK
American Indian	1	2	-7	-9
Alaska Native	1	2	-7	-9
Asian	1	2	-7	-9
Black or African American	1	2	-7	-9
Native Hawaiian or other Pacific Islander	1	2	-7	-9
White	1	2	-7	-9

5. What is your date of birth?

Please provide the Month, day and year.

___ ___ /___ ___ / ___ ___ ___ ___

M M D D Y Y Y Y

2. Education, Employment and Income

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 calendar to orient respondent to this time frame].

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

1. Not Enrolled

2. Enrolled Full Time

3. Enrolled Part-time

4. Other (Specify:_____________)

7. REFUSED

8. DK

2. What is the highest level of education you have finished, whether or not you received a degree?

1. less than 12^th grade

2. 12^th grade/High School diploma/ Equivalent (GED)

3. VOC/Tech Diploma

4. Some College or University

5. Bachelor’s Degree (BA, BS)

6. Graduate Work/Graduate Degree

7. REFUSED

8. DK

3. 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 worked at all or had a regular job but was off of work]

1. EMPLOYED FULL TIME (35 HOURS PER WEEK)

2. EMPLOYED PART TIME

3. UNEMPLOYED, LOOKING FOR WORK

4. UNEMPLOYED, DISABLED

5. UNEMPLOYED, VOLUNTEER WORK

6. UMEMPLOYED, RETIRED

7. OTHER, SPECIFY___________________

77. REFUSED

99. MISSING

4. IF EMPLOYED,

	YES	NO	RF	DK
a. Are you paid at or above minimum wage?	1	2	7	8
b. Are your wages paid directly to you by your employer?	1	2	7	8
c. Could anyone have applied for this job?	1	2	7	8

I am going to read you a list of possible sources of money that you may have 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 private 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…	YES	NO	RF	DK	(If YES, ask) How much?
a. Wages or money from paid employment. This includes any wages or money received from legal AND “under the table” employment.	1	2	7	8	__________
b. SSI, SSDI, or Disability (Non-Veteran)	1	2	7	8	__________
c. Social Security Income (SSA)	1	2	7	8	__________
d. Food Stamps	1	2	7	8	__________
e. Public assistance or other benefits, such as welfare, general assistance, or TANF (Temporary Assistance to Needy Families)	1	2	7	8	__________
f. Veteran’s benefits (including disability or other compensation)	1	2	7	8	__________
g. Unemployment or Worker’s Compensation	1	2	7	8	__________
h. Child support or alimony	1	2	7	8	__________
i. Income from a spouse or partner’s wages or other money	1	2	7	8	__________
j. Money from family members or friends to buy food, pay rent, get medical care or anything else	1	2	7	8	__________
k. Retirement	1	2	7	8	__________
l. Income from other sources that I did not mention [If YES, specify source(s)______________________ ________________________________]	1	2	7	8	__________

E6A. In the past 30 days, how many:

	Number of nights/times?	RF	DK	MISSING
i. nights you have been homeless	_______ nights/times	7	8	9
ii. nights you have spent in a hospital for mental health care?	_______ nights/times	7	8	9
iii. nights you have spent in a facility for detox/inpatient or residential treatment?	________ nights/times	7	8	9
iv. nights you have spent in a correctional facility, including jail or prison	________ nights/times	7	8	9
ITEMS i-iv cannot add up to more 30 nights.
v. times you have gone to an emergency room for a psychiatric or emotional problems	________ nights/times	7	8	9

6. In the past 30 days, where have you been living most of the time?

Circle one only

1. Owned or Rented house, apartment, trailer, room

2. Someone else’s house, apartment, trailer, room

3. Homeless (Shelter, Street/Outdoors, Park)

4. Group Home¹

5. Adult Foster Care

6. Transitional Living Facility

7. Hospital (Medical)

8. Hospital (Psychiatric)

9. Correctional Facility (Jail/Prison)

10. VA Hospital

11. Nursing Home

12. Veteran’s Home

13. Military Base

14. Other Housed, Specify:_______________

15. Detox/Inpatient or residential substance abuse treatment facility

77. REFUSED

88. DK

6. If Homeless, is that…

1. In a homeless shelter

2. On the street or some place like an abandoned building, park or car

7.REFUSED

8. DK/Missing

6. Did you ever live in foster care or a group home² before you became 18?

1. YES

2. NO

7. REFUSED

8. DK/Missing

3. Military Service Questions

Now I am going to ask you some questions about your military service.

Did you serve in the US Armed Forces?	1. YES 2. NO (SKIP TO SECTION 4, page 13) 7. REFUSED 8. DK
In what branch(es) of the US Armed Forces did you serve? Select all that apply	1. Army (include Army National Guard/ Reserve) 2. Navy (include Reserve) 3. Marine Corps (include Reserve) 4. Air Force (include Air Natnl Guard/Reserve) 5. Coast Guard (include Reserve) 6. Other (Specify: ____________________) 7. REFUSED 8. DK
When did you first enter the Armed Forces? Please provide the month and year.	___ ___ (Month) ___ ___ ___ ___ (Year)
Now I am going to ask you about your current status in the military.
Are you… (read choices)	1. Still in the Military 2. Separated from service -SKIP TO M7 7. REFUSED 8. DK
If you are still in the military, which of the following best describes your current status?	1. Active Duty -SKIP TO M10 2. Guard/Reserve 7. REFUSED 8. DK
If Guard/Reserve, is that…. SKIP TO QUESTION M10	1. Traditional/part-time guard reserve 2. Currently Activated/Full-time/Reserve 7. REFUSED 8. DK
If separated from service, which best describes your current military status?	1. Retired 2. Discharged with Severance or Military Disability Payments 3. Discharged without severance or Payment 4. Other specify: _________________________ 7. REFUSED 8. DK
When were you last discharged from the military? Please provide the month and year.	___ ___ (Month) ___ ___ ___ ___ (Year)
What type of discharge did you receive?	1. Honorable (includes discharges that have been converted to honorable since leaving the military) 2. General (honorable conditions) 3. General (other than honorable) 4. Undesirable 5. Bad conduct 6. Dishonorable 7. Medical (including Section 8) 97. REFUSED 98. DK
Please indicate which of the following eras you have served? Please indicate all that apply.	1. Pre WWII (11/18-11/41) 2. WWII (12/41-12/46) 3. Pre-Korean War (1/47-6/50) 4. Korean War (7/50-1/55) 5. Between Korean -Vietnam Eras (2/55-7/64) 6. Vietnam Era (8/64-4/75) 7. Post-Vietnam (5/75-7/90) 8. Persian Gulf-Middle East Era (8/90-9/01) 9. Afghanistan/Iraq (1/02-present) 97. REFUSED 98. DK
Has your military service caused or contributed to any medical problems you may have?	1. YES 2. NO 7. REFUSED 8. DK
Has your military service caused or contributed to any mental health or emotional problems you may have?	1. YES 2. NO 7. REFUSED 8. DK
Do you have a VA determined Service-Connected Disability?	1. YES 2. NO 7. REFUSED 8. DK
Have you ever served in a combat theater/zone?	1. YES 2. NO- (SKIP TO SECTION 4, page 13) 7. REFUSED 8. DK
How many tours of duty have you served?	_________ # tours 97. REFUSED 98. DK
Have you been deployed in the past 12 months?	1. YES 2. NO 7. REFUSED 8. DK

4. Lifetime Mental Health/Substance Use Service Questions

Have you ever received outpatient mental health services, including counseling or therapy?	1. YES 2. NO 7. REFUSED 8. DK
Have you ever received mental health inpatient care or been hospitalized for psychiatric or emotional problems?	1. YES 2. NO 7. REFUSED 8. DK
Have you ever participated in mental health self-help or peer support services?	1. YES 2. NO 7. REFUSED 8. DK
At what age did you have your first contact with mental health services?	___ ___ years old 97. REFUSED 98. DK 99. NOT APPLICABLE
Have you ever received outpatient substance abuse services, including substance abuse counseling or therapy?	1. YES 2. NO 7. REFUSED 8. DK
Have you ever received inpatient treatment for substance abuse, including detox?	1. YES 2. NO 7. REFUSED 8. DK
Have you ever participated in any voluntary self help groups for recovery such as Alcoholics Anonymous, Narcotics Anonymous?	1. YES 2. NO 7. REFUSED 8. DK
At what age did you have your first contact with substance abuse services?	___ ___ years old 97. REFUSED 98. DK 99. NOT APPLICABLE

I am now going to ask you some questions about mental health and substance abuse services.

5. Drug and Alcohol Use

The following questions refer to your feelings and behavior over your whole life. Please listen to each statement and indicate with a ‘yes’ or ‘no’. Please give the answer that is right most of the time.
Have you ever felt you should cut down on drinking?	1. YES 2. NO 7. REFUSED 8. DK
Have people annoyed you by criticizing your drinking?	1. YES 2. NO 7. REFUSED 8. DK
Have you ever felt guilty about your drinking?	1. YES 2. NO 7. REFUSED 8. DK
Have you ever taken a drink in the morning to steady your nerves or get rid of a hangover, or as an eye opener?	1. YES 2. NO 7. REFUSED 8. DK
The following questions relate to your experience with alcohol, cigarettes, and other drugs. Some of the substances we’ll talk about are prescribed by a doctor (like pain medications). But I will only record those if you have taken them for reasons or does other than prescribed.

In the past 30 days, how often have you used…..	Never	Once or Twice	Weekly	Daily or almost daily	DK	RF
tobacco products (cigarettes, chewing tobacco, cigars, etc)	0	1	2	3	7	8
Alcoholic beverages (beer, wine, liquor)	0	1	2	3	7	8
IF SA6>= ONCE OR TWICE AND RESPONDENT IS MALE, ask SA7. IF SA5>= ONCE OR TWICE AND RESPONDENT IS NOT MALE, ask SA8
.How many times in the past 30 days have you had five or more drinks in a day?	0	1	2	3	7	8
How many times in the past 30 days have you had four or more drinks?	0	1	2	3	7	8
Cannabis (marijiuana, pot, grass, hash, etc)	0	1	2	3	7	8
Cocaine (coke, crack, etc)?	0	1	2	3	7	8
Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)	0	1	2	3	7	8
Methamphetamine (speed, crystal meth, ice, etc).	0	1	2	3	7	8
Inhalants (nitrous oxide, glue, gas, paint thinner, etc)	0	1	2	3	7	8
Sedatives or sleeping pills (Valium, Serepax, Ativan, Librium, Xanax, Rohypnol, GHB, etc)	0	1	2	3	7	8
Hallucinogens (LSD, acid, mushroom, PCP, Special K, ecstasy, etc)	0	1	2	3	7	8
Street opioids (heroin, opium, etc)	0	1	2	3	7	8
Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocone [Vicodin], methadone, buprenorphine, etc)?	0	1	2	3	7	8
Other- specify:	0	1	2	3	7	8

6. Services

In this next section, I am going to ask you about services that you may have received 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.

	YES	[IF YES] Altogether for how many nights/times?	NO	RF	DK	MISSING
SV1. Inpatient Treatment for:
i. Physical complaint	1	_______ nights/times	2	7	8	9
SV2. Outpatient Treatment for:
i. Physical complaint	1	_______ nights/times	2	7	8	9
ii. Mental or emotional difficulties	1	_______ nights/times	2	7	8	9
iii. Alcohol or substance abuse	1	________ nights/times	2	7	8	9
SV3. Emergency Room Treatment for:
i. Physical complaint	1	_______ nights/times	2	7	8	9
iii. Alcohol or substance abuse	1	________ nights/times	2	7	8	9

7. Criminal Justice Questions

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.

In the past 30 days, how many times have you been arrested?	___ ___ # times arrested 97. REFUSED 98. DK
Now I am going to ask you about your involvement with the criminal justice during your lifetime.
At what age were you first arrested, booked, or taken into custody by the police?	___ ___ years old 97. REFUSED 98. DK
Have you ever been on probation?	1. YES 2. NO 7. REFUSED 8. DK
Have you ever spent time in jail or prison because of a conviction?	1. YES 2. NO (SKIP TO Question CJ7) 7. REFUSED 8. DK
How many times have you been in jail or prison in your life?	___ ___ # times incarcerated 97. REFUSED 98. DK
Has someone ever had a restraining order, no contact order or an order of protection against you?	1. YES 2. NO (SKIP TO NEXT SECTION) 7. REFUSED 8. DK
Does someone currently have a restraining order, no contact order or an order of protection against you?	1. YES 2. NO 7. REFUSED 8. DK

8. Functioning

F1A. How would you rate your overall health right now?

1. Excellent 2. Very Good 3. Good 4. Fair 5. Poor 7. REFUSED 8. DK

In order to provide the best possible mental health services, we need to know what you think about how well you were able to deal with your everyday life during the last 30 days.

Statement	Strongly Disagree	Disagree	Undecided	Agree	Strongly Agree	Refuse
I deal with problems effectively.	1	2	3	4	5	7
I am able to control my life.	1	2	3	4	5	7
I am able to deal with crisis	1	2	3	4	5	7
I am getting along with my family	1	2	3	4	5	7
I do well in social situations.	1	2	3	4	5	7
I do well in school and/or work.	1	2	3	4	5	7
My housing situation is satisfactory	1	2	3	4	5	7
My symptoms are not bothering me	1	2	3	4	5	7

The following questions ask about how you have been feeling during the past 30 days. For each question, please indicate how often you had this feeling.

In the past 30 days, how often did you feel…..	All of the time	Most of the time	Some of the Time	A Little of the Time	None of the Time	DK	RF
F9. nervous?	0	1	2	3	4	7	8
F10. hopeless?	0	1	2	3	4	7	8
F11. restless or fidgety	0	1	2	3	4	7	8
F12. so depressed that nothing could cheer you up?	0	1	2	3	4	7	8
F13. that everything was an effort	0	1	2	3	4	7	8
F14. worthless	0	1	2	3	4	7	8

9. Social Connectedness

Please indicate your disagreement/agreement with each of the following statements. Please answer for relationships with persons other than your mental health provider in the past 30 days.

Statement	Strongly Disagree	Disagree	Undecided	Agree	Strongly Agree	Refuse
I am happy with the friendships I have.	1	2	3	4	5	7
I have people with whom I can do enjoyable things.	1	2	3	4	5	7
I feel I belong in my community.	1	2	3	4	5	7
In a crisis, I would have the support I need from family or friends.	1	2	3	4	5	7

10. Traumatic Events

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- but do not include your experiences in military combat situations. 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 private and will be used only for research purposes.

	YES	NO	RF	DK	NA
TE1. Have you ever witnessed someone seriously injured or killed due to an unnatural event such as a shooting, stabbing, or hit-and-run accident?	1	2	7	8	9
a. [IF YES] Did this occur before the age 18?	1	2	7	8	9
b. Did this occur in the past 12 months?	1	2	7	8	9
TE2. Have you ever witnessed a physical or sexual assault against a family member, friend, or other significant person?	1	2	7	8	9
a. [IF YES] Did this occur before the age 18?	1	2	7	8	9
b. Did this occur in the past 12 months?	1	2	7	8	9
TE3. Has an immediate family member, partner, or very close friend died as a result of an accident, homicide, suicide, or in a war?	1	2	7	8	9
a. [IF YES] Did this occur before the age 18?	1	2	7	8	9
b. Did this occur in the past 12 months?	1	2	7	8	9
TE4. Have you ever been stripped searched, forcibly restrained, or held against your will, including in a jail or hospital, by a provider of mental health or substance abuse services or by someone else?	1	2	7	8	9
a. [IF YES] Did this occur before the age 18?	1	2	7	8	9
b. Did this occur in the past 12 months?	1	2	7	8	9
TE5. Have you ever experienced physical violence, such as being slapped, kicked, bitten, hit, choked, strangled, smothered, or being threatened or assaulted with a weapon by someone you did not know?	1	2	7	8	9
a.[IF YES] Did this occur before the age 18?	1	2	7	8	9
b. Did this occur in the past 12 months?	1	2	7	8	9
TE6.Have you ever experienced physical violence, such as being slapped, kicked, bitten, hit, choked, strangled, smothered, or being threatened or assaulted with a weapon by someone you knew?	1	2	7	8	9
a. [IF YES] Did this occur before the age 18?	1	2	7	8	9
b. Did this occur in the past 12 months?	1	2	7	8	9
TE7. Have you ever experienced sexual assault or sexual molestation, such as being forced to touch your or someone else’s private parts, forced to have sex or any other sexual molestation by someone you did not know?	1	2	7	8	9
a. [IF YES] Did this occur before the age 18?	1	2	7	8	9
b. Did this occur in the past 12 months?	1	2	7	8	9
TE8. Have you ever experienced sexual assault or sexual molestation, such as being forced to touch your or someone else’s private parts, forced to have sex or any other sexual molestation by someone you knew?	1	2	7	8	9
a. [IF YES] Did this occur before the age 18?	1	2	7	8	9
b. Did this occur in the past 12 months?	1	2	7	8	9

Thank you for answering these questions.

<Interviewer: Conduct Safety Assessment>

11. Posttraumatic Stress Disorder Checklist (PCL-C)¹

I’m going to read a list of problems and complaints people sometimes have in response to stressful life experiences. For each item, please tell me how much you’ve been bothered by that problem in the past month.

In the past month how much have you been bothered by…	Not at all	A little bit	Moderately	Quite a bit	Extremely	RF	DK
Repeated disturbing memories, thoughts, or images of a stressful experience from the past?	1	2	3	4	5	7	8
Repeated, disturbing dreams of a stressful experience from the past?	1	2	3	4	5	7	8
Suddenly acting or feeling as if a stressful experience from the past were happening again (as if you were reliving it)?	1	2	3	4	5	7	8
Feeling very upset when something reminded you of a stressful experience from the past?	1	2	3	4	5	7	8
Having physical reactions (e.g heart pounding, trouble breathing, sweating) when something reminded you of a stressful experience from the past?	1	2	3	4	5	7	8
Avoiding thinking about or talking about a stressful experience from the past?	1	2	3	4	5	7	8
Avoiding activities or situations because they reminded you of a stressful experience from the past?	1	2	3	4	5	7	8
Trouble remembering important parts of a stressful experience from the past?	1	2	3	4	5	7	8
Loss of interest in activities that you used to enjoy?	1	2	3	4	5	7	8
Feeling distant or cut off from other people?	1	2	3	4	5	7	8
Feeling emotionally numb or being unable to have loving feelings for those close to you?	1	2	3	4	5	7	8
Feeling as if your future will somehow be cut short?	1	2	3	4	5	7	8
Trouble falling or staying asleep?	1	2	3	4	5	7	8
Feeling irritable or having angry outbursts?	1	2	3	4	5	7	8
Having difficulty concentrating?	1	2	3	4	5	7	8
Being “super-alert” or watchful or on guard?	1	2	3	4	5	7	8
Feeling jumpy or easily startled?	1	2	3	4	5	7	8

12. BASIS 24²

This section of the interview asks about how you are feeling and doing in different areas of life. Please indicate which response describes your self in the PAST WEEK. If you are unsure about how to answer, please give the best answer you can.

During the PAST WEEK, how much difficulty did you have…..	No difficulty	A little difficulty	Moderate Difficulty	Quite a bit of difficulty	Extreme difficulty	DK	RF
Managing your day- to-day life?	0	1	2	3	4	7	8
Coping with problems in your life?	0	1	2	3	4	7	8
Concentrating?	0	1	2	3	4	7	8

During the PAST WEEK, how much of the time did you….	None of the Time	A little of the time	Half of the Time	Most of the time	All of the time	DK	RF
Get along with people in your family?	0	1	2	3	4	7	8
Get along with people outside of your family?	0	1	2	3	4	7	8
Get along in social situations?	0	1	2	3	4	7	8
Feel close to another person?	0	1	2	3	4	7	8
Feel like you had someone to turn to if you needed help?	0	1	2	3	4	7	8
Feel confident in yourself?	0	1	2	3	4	7	8
Feel sad or depressed?	0	1	2	3	4	7	8
Think about ending your life	0	1	2	3	4	7	8
Feel nervous?	0	1	2	3	4	7	8

During the PAST WEEK, how much of the time did you……	Never	Rarely	Some-times	Often	Always	DK	RF
Have thoughts racing through your head?	0	1	2	3	4	7	8
Think you have special powers?	0	1	2	3	4	7	8
Hear voices or see things?	0	1	2	3	4	7	8
Think people are watching you?
Think people are against you?	0	1	2	3	4	7	8
Have mood swings?	0	1	2	3	4	7	8
Feel short-tempered?	0	1	2	3	4	7	8
Think about hurting yourself?	0	1	2	3	4	7	8
Did you have the urge to drink alcohol or take street drugs?	0	1	2	3	4	7	8
Did anyone talk to you about your drinking or drug use?	0	1	2	3	4	7	8
Did you try to hide your drinking or drug use?	0	1	2	3	4	7	8
Did you have problems from your drinking or drug use?	0	1	2	3	4	7	8

13. REE: Recovery Markers –Revised³

For each of the following questions, circle the one answer that is most true for you right now. Please indicate if you Strongly Agree, Agree, Disagree or Strongly Disagree with each statement.

	Strongly Agree	Agree	Disagree	Strongly Disagree	DK	RF
My living situation feels like a safe home to me.	1	2	3	4	7	8
I have people I trust whom I can turn to for help.	1	2	3	4	7	8
I have at least one close mutual (give-and-take) relationship.	1	2	3	4	7	8
I am involved in activities I find meaningful.	1	2	3	4	7	8
My psychiatric symptoms are under control.	1	2	3	4	7	8
I have enough income to meet my needs.	1	2	3	4	7	8
I am learning new things that are important to me.	1	2	3	4	7	8
I am in good physical health.	1	2	3	4	7	8
I have a positive spiritual life/connection to a higher power.	1	2	3	4	7	8
I like and respect myself.	1	2	3	4	7	8
I'm using my personal strengths, skills or talents.	1	2	3	4	7	8
I have goals I'm working to achieve.	1	2	3	4	7	8
I have reasons to get out of bed in the morning.	1	2	3	4	7	8
I have more good days than bad.	1	2	3	4	7	8
I have a decent quality of life.	1	2	3	4	7	8
I control the important decisions in my life.	1	2	3	4	7	8
I contribute to my community.	1	2	3	4	7	8
I am growing as a person.	1	2	3	4	7	8
I have a sense of belonging.	1	2	3	4	7	8
I feel alert and alive.	1	2	3	4	7	8
I feel hopeful about my future.	1	2	3	4	7	8
I am able to deal with stress.	1	2	3	4	7	8
I believe I can make positive changes in my life.	1	2	3	4	7	8

END OF THE INTERVIEW

This is the end of the interview. I want to remind you that all of your answers will be kept private; we will not share them with anyone outside of the research team.

Thank you for your time and participation.

Pay respondent and have them sign the receipt.

We will be contacting you in about 5 months to conduct another interview, and then again for the 12-month interview. Before we end the interview, I want to review some of the ways we might get in contact with you.

Interviewer- Complete Locator Information and information releases.

Interviewer Observations

Please 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
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

1 Weathers, Litz, Huska, & Keane; National Center for PTSD - Behavioral Science Division.

2 BASIS 24, McLean Hospital, 2001©

3 Priscilla Ridgway, 2004, 2009. Recovery Enhancing Environment measure (REE), ©

31

Baseline

Revised 5.7.10