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pdfAttachment 1a: Document 1 - Client Focus Group Discussion Guide
Form Approved
OMB No. ####-####
Expiration Date: ##/##/####
TARGETED CAPACITY EXPANSION PROGRAM FOR SUBSTANCE ABUSE
TREATMENT AND HIV/AIDS SERVICES (TCE-HIV)
MULTI-SITE EVALUATION PROJECT
CLIENT FOCUS GROUP DISCUSSION GUIDE
CONDUCTED BY:
JBS International, Inc., Alliance for Quality Education, Battelle Memorial Institute, and the
Oregon Health & Science University
Grantee Name:
__________________________________________
Grantee ID Number:
__________________________________________
Date Completed:
_______ /
_______ /
Month
Day
_______
Year
Notice to Respondents
Public reporting time for this collection is estimated to average 60 minutes, 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 OMB Officer, 1
Choke Cherry Road Room 7-1044, Rockville, MD 20850. 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 fo r this project is XXXX-XXXX.
1
Attachment 1a: Document 1 - Client Focus Group Discussion Guide
TCE-HIV Multi-Site Evaluation
Client Focus Group Guide
The purpose of this guide is to provide an overview of the information that will be gathered through focus
groups with clients involved in the Targeted Capacity Expansion Program for Substance Abuse Treatment
and HIV/AIDS Services (TCE-HIV) Project. A “client” refers to an individual from the Grantee
organization/program who has engaged in TCE-HIV sponsored treatment and/or program activities.
Members of the Multi-Site Evaluation Team will conduct the client focus group in a setting convenient to
the focus group participants. Up to nine clients will participate in the focus group. Those clients who have
been in the TCE-HIV program for at least 14 days will be considered for participation. The focus group
participants will reflect diversity in age and gender. The focus group discussion will last approximately
1 hour.
The goals of the client focus groups conducted during TCE-HIV Multi-Site Evaluation site visits include
discussion of:
(1) clients’ satisfaction with the treatment program.
(2) barriers and facilitators of treatment services.
(3) client-level outcomes (i.e., substance use/abuse, risk behavior, quality of life).
Final discussion guides for each Grantee will be customized based on the nature of individual Grantee’s
treatment modality (i.e., outpatient vs. residential). The information gathered from this focus group will
be used to better understand clients’ perceptions of the TCE-HIV funded program and will be synthesized
with information gathered from other TCE-HIV Grantees to inform the Multi-Site Evaluation of the TCEHIV program.
Following completion of the client focus group, the facilitator(s) should complete the post focus group
summary form to validate that each discussion section topic was covered during the focus group
discussion. Space is also provided on the form to record other germane topics discussed during the focus
group and additional notes/comments relating to the discussion.
For ease of future qualitative analysis coding and thematic content analysis, any key findings/themes that
emerged during the focus group discussion should also be recorded in the table. The associated page
number note references and a listing of respondents whose statements support reported findings should
also be noted, where applicable.
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Attachment 1a: Document 1 - Client Focus Group Discussion Guide
TCE-HIV Multi-Site Evaluation
Client Focus Group Discussion Guide
NOTE: Co-facilitator will hand out consent forms after participants have entered the room and are
seated.
Opening: Moderator’s Introduction (5 minutes):
Hello and welcome. Thank you for taking time to participate in this focus group. My name is
_______________ and I am conducting this discussion on behalf of the Center for Substance Abuse
Treatment (CSAT). CSAT has funded four organizations, JBS International, the Alliance for Quality
Education, Battelle Memorial Institute, and the Oregon Health & Science University, to conduct a MultiSite Evaluation of its national Targeted Capacity Expansion Program for Substance Abuse Treatment and
HIV/AIDS Services (TCE-HIV). (Introduce team members, give brief description of qualifications, and
describe functions during the focus group). As part of the evaluation, we are conducting several focus
groups around the country with clients of TCE-HIV programs. Although the Multi-Site Evaluation Team
is funded by CSAT, we are not part of that federal agency, any other federal agency, or this local
program. We are independent evaluators of the TCE-HIV program. I will review the consent form with
you. It describes exactly what is expected of you and you will need to sign it stating that you agreed to
participate in this discussion.
We are here today to learn about your experiences in the [INSERT PROGRAM NAME]. We are
interested in hearing about your successes, challenges, and any feedback about your involvement in the
program. The information that you provide will be extremely helpful to CSAT as it seeks to learn how
clients may be benefiting from the TCE-HIV program.
Before we begin, I would like to establish some guidelines for our discussion. During our discussion, it
would be most helpful if one person talks at a time. Please know that there are no right or wrong answers,
just different points of view, and we want to hear all of them. Everyone’s experience is important to us,
so please feel free to share your point of view even if it is different from what others have said. Also, keep
in mind that we are interested in both positive and negative comments. I mentioned earlier that my
colleagues and I are conducting this focus group on behalf of CSAT, but it’s important to let you know
that we are not CSAT employees.
The discussion will last about 1 hour.
I also want to mention to you that we are providing some refreshments for you to enjoy. Please help
yourself to these snacks during our discussion.
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Attachment 1a: Document 1 - Client Focus Group Discussion Guide
Initial Instructions (2 minutes):
A. Before we begin, so I––and you––can know who is here, I’d like to let each of you
introduce yourself (first name only) and tell us a little something about yourself.
B. May I have everyone’s permission to tape this session? (Only if everyone gives
permission will taping be allowed). Even though we are recording this session, we will
not associate your comments and experiences with your name; and the program staff
will not have access to the discussion that we share here today.
Are there any questions before we get started?
I.
Community Context (*Understand how the program is viewed in the community) (15
minutes)
Even though you are all clients in the same program, it is likely that your experiences prior to
entering the ________________ (insert name of program) as well as your experiences while in
the program are not identical.
We are here today to hear your thoughts about the program, including how satisfied or
dissatisfied you’ve been with the program services. I’d like to begin our discussion today by
talking about your overall thoughts about the program, and how it is viewed by people who live
in the community.
A. In your opinion, what do people in the community/neighborhood think about __ _______? (Note to facilitator: Be prepared to tailor context
questions based on specific setting; e.g., some clients will refer to the physical
neighborhood setting, and others may refer to a community of individuals)
PROBE 1:
What, if any, positive impressions do people in the
community/neighborhood have about
PROBE 2:
What, if any, negative impressions do people in the
community/neighborhood have about
PROBE 3:
Do people think that there is a need for this program in the
community/neighborhood? Why? Why not?
PROBE 4:
Do people think this program has changed the
community/neighborhood? If so, how has the program changed the
community/neighborhood?
B. How would you describe drug use in this community/neighborhood?
C. How would you describe the HIV problem in this community/neighborhood?
Thank you for sharing your opinions about the program’s image in the community/neighborhood
and thanks for providing your thoughts on the drug use and HIV in the community/neighborhood.
II.
Client Satisfaction (*Understand how the clients feel about the services and treatment
they received as part of the program) (10 minutes)
Now, let’s talk a little about how the program is viewed by you––the clients.
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Attachment 1a: Document 1 - Client Focus Group Discussion Guide
A. What things about this program do you like?
PROBE 1:
What is it about this program that would make you want to
continue receiving service?
B. What things can/could have been improved?
PROBE 1:
What things do/did you dislike about the program?
C. What did you like about the outreach pretreatment (i.e., how people approached you
and talked about recovery)?
D. What did you like about the treatment program?
Thank you for talking about how satisfied or not you have been with the program services.
III.
Barriers/Facilitators to Receiving Services (15 minutes)
Let’s move on to a discussion of barriers and facilitators to your treatment in this program.
A. What are some things or people that may have prevented you from receiving treatment
or program services?
B. What type of things or people may have prevented you from being successful in this
program?
PROBE 1:
Was the location of this program accessible?
PROBE 2:
Was the staff here helpful to you as you were going through
treatment? How so? How not?
PROBE 3:
Was the staff available when you needed them? Please describe
instances where you think they were available to you.
PROBE 4:
How, if at all, has the staff been sensitive to your cultural
background? Have you been assigned to counselors of the same
race? Is that important to you?
C. What could be done to make the program and services more appealing?
D. What suggestions do you have for the program staff that might help make the program
better?
Thanks for sharing how you feel about the program and for providing suggestions for
improvement in certain program areas.
IV.
Client Outcomes (15 minutes)
Now I’d like to move into a discussion of how things in your life may have changed because of
this program.
A. Has anything in your life changed as a result of your participation in this program?
PROBE 1:
How, if at all, has your alcohol use changed?
PROBE 2:
Has your injection drug use changed?
PROBE 3:
Has your sense or level of anxiety or nervousness changed?
PROBE 4:
Have you engaged in unprotected sex less frequently?
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Attachment 1a: Document 1 - Client Focus Group Discussion Guide
PROBE 5:
What, if any at all, specific program services have helped you
make the changes we’ve just discussed?
B. Have you seen changes in other aspects of your life as a result of participation in the
program?
V.
PROBE 1:
How, if at all, has your living situation changed?
PROBE 2:
Have your relationships with those close to you changed since
you’ve been in treatment? How so?
PROBE 3:
Have you had less involvement with the criminal justice system
since you’ve been in treatment?
PROBE 4:
Have you worked at a job (full or part-time)? (ask if the job is part
of an outpatient employment program)
Closing Comments (*Concluding remarks) (5 minutes)
Thank you very much for taking the time to discuss your experiences in this program. In closing, I
wanted to give you the opportunity to ask questions or make additional comments.
A. Do you have any questions, comments, or feedback regarding our discussion?
B. Are there any topic areas, issues, or concerns relating to the TCE-HIV Multi-Site
Evaluation that you would suggest?
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Attachment 1a: Document 1 - Client Focus Group Discussion Guide
CLIENT FOCUS GROUP
FACILITATOR FORM
The following form should be completed by the facilitator(s) and it is not part of the focus group
guide.
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Attachment 1a: Document 1 - Client Focus Group Discussion Guide
Post-Focus Group Summary [Completed by Facilitator]
Table: Discussion Topics Covered in Interview and Key Findings/Themes
Section
Key Interview Findings/Themes by Topic Area
Respondents
Supporting
Finding*
Supporting
Page(s) in
Notes
Community/
Contextual
Conditions
Client
Satisfaction
Barriers/
Facilitators
Client
Outcomes
* Code respondents based on Data Sheet numbering: Respondent 1 as R1, Respondent 2 as R2, etc. (e.g.,
Statements by R1 supported Key Theme 1)
Other Topic Areas Discussed
List of Documents Obtained
Observations Regarding Interview Setting (e.g., description of location, disruptions, etc.)
Observations Regarding Interview Respondents (e.g., engagement level, reluctance etc.)
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Attachment 1a: Document 1 - Client Focus Group Discussion Guide
Additional Notes and Comments
9
Attachment 1a: Document 2 - Intake/Baseline Client-Level Survey
Form Approved
OMB No. ####-####
Expiration Date: ##/##/####
TCE-HIV Multi-Site Evaluation
INTAKE/BASELINE Client-Level Survey
Funding for data collection supported by the
Center for Substance Abuse Treatment (CSAT)
Substance Abuse and Mental Health Services Administration (SAMHSA)
U.S. Department of Health and Human Services (HHS)
Instructions: These instructions are for program staff administering the TCE-HIV Multi-Site Evaluation
Client-Level Survey. The Client-Level Survey should be administered by program staff at baseline (based
on the program’s definition of baseline), discharge, and 6 months post baseline to all clients receiving
TCE-HIV services. Please note that this version of the Client-Level Survey is to be used at
INTAKE/BASELINE only.
The Client-Level Survey includes six sections: Background Information, Risky Behaviors, HIV Testing/HIV
Status, Social Support, Mental Health and Medical Health, and Motivation for Treatment. All questions in
Sections A – F should be asked of the client.
Please read the introduction to each section (in italics) and then read each question to the client as it is
written. For some questions, you will read the response options to clients. Other questions are openended and you will not read the response options to clients. Please see the note in italics next to each
question to determine whether you should read the response options. Some questions require the use of
response options cards. Please provide the response options card to clients when noted.
You may provide clarification to the client to help him or her understand the question, but please do not
change the wording of the questions.
The Client-Level Survey should take approximately 25 minutes to administer.
Public reporting 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, if all items are asked of a client/participant; to the extent that providers already obtain much of this
information as part of their ongoing client/participant intake or follow-up, less time will be required. Send comments regarding this
burden estimate or any other aspect of this collection of information 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 control number for this project is ####-####.
BL 1
Attachment 1a: Document 2 - Intake/Baseline Client-Level Survey
Form Approved
OMB No. ####-####
Expiration Date: ##/##/####
TCE-HIV Multi-Site Evaluation
Client-Level Survey
INTAKE/BASELINE
Funding for data collection supported by the Center for Substance Abuse Treatment (CSAT)
Substance Abuse and Mental Health Services Administration (SAMHSA)
U.S. Department of Health and Human Services (HHS)
Grantee ID
TI0 ___ ___ ___ ___ ___ ___
Partner ID (if applicable)
TI0 ___ ___ ___ ___ ___ ___ - ___ ___ ___
Client ID ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
(Please use the same Client ID that was assigned to the client for the GPRA)
Date of Administration (mm/dd/yyyy)
___ ___ / ___ ___ / ___ ___ ___ ___
PROGRAM STAFF: Please complete the following client background
questions using information collected from the Intake/Baseline GPRA.
Client’s Gender
Male
Female
Transgender
Refused
Other (specify) ________________________
Client’s Ethnicity: Is the client
Hispanic or Latino?
Client’s Race
Yes
No
Refused
Alaska Native
American Indian
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Refused
Client’s Age
___ ___
Public reporting 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, if all items are asked of a client/participant; to the extent that providers already obtain much of this
information as part of their ongoing client/participant intake or follow-up, less time will be required. Send comments regarding this
burden estimate or any other aspect of this collection of information 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 control number for this project is ####-####.
BL 2
Attachment 1a: Document 2 - Intake/Baseline Client-Level Survey
Client ID: ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
(Please use the same Client ID that was assigned to the client for the GPRA)
Program Staff: The purpose of these questions is to get more information about how best to provide
services. We are asking these questions because it is a requirement for us from the Federal government
who gave us funding to provide services to you. All your background information and survey answers will
be kept strictly confidential. All survey answers will be provided to the Federal government using only a
number for you so there will be no way they can identify who you are. If you have any questions,
comments, or concerns, please contact Resa Matthew, Ph.D. at 240-645-4608.
A. Background Information
Program Staff: First, I am going to ask you some questions about yourself.
A1. What is your marital status? Do not read response options.
1
Never Married/Single
2
Married
3
Living as Married
4
Separated
5
Divorced
6
Widowed
88
Refused
A2. In the past 30 days, have you lived...? You may say yes to more than one. Please read response
options.
88
Alone
With parents
With children alone
With other family members
With significant other alone
With friends
With significant other and children
In jail
In prison
In a hospital
In residential treatment
Other (specify) _________________
Refused
B. Risky Behaviors
Program Staff: The next set of questions asks about any behaviors that you may engage in that may put
you at risk for substance use disorders or HIV/AIDS. I realize these questions are very personal, but your
open and honest answers are very important. There are no right or wrong answers.
B1. Did you use alcohol or drugs in the past 30 days? Do not read response options.
1
Yes (specify what substances were used in past 30 days) __________
0
No
88
Refused
66
Don’t Know
Program Staff: If clients reported alcohol or drug use in Question B1 above please skip to
question B3 below. Only ask question B2 below to clients who reported no alcohol or drug
use in Question B1 above.
BL 3
Attachment 1a: Document 2 - Intake/Baseline Client-Level Survey
B2. You reported that during the past 30 days you did not use alcohol or drugs. What were your
reasons for not using any alcohol or drugs? You may say yes to more than one. Please read
response options.
1
In jail/prison
4
Medical hospitalization
2
On probation/parole
5
Inpatient mental health treatment
3
Lack of money
6
Residential substance use treatment
7
Other (specify) ___________________________
77
Not applicable – used alcohol and/or drugs in the past 30 days.
88
Refused
Program Staff: The next set of questions asks about your sexual behaviors. Again, I realize these
questions are very personal, but your open and honest answers are very important.
B3. In the past 30 days, did you engage in unprotected sexual activity with a male partner?
1
Yes
0
No
66
Don’t Know
Refused
88
B4. In the past 30 days, did you engage in unprotected sexual activity with a female partner?
1
Yes
0
No
66
Don’t Know
Refused
88
B5. In the past 30 days, did you engage in unprotected sexual activity with both a male partner and a
female partner?
1
Yes
0
No
66
Don’t Know
Refused
88
Program Staff: Only ask questions B6a – B6j of those clients who reported having unprotected
sexual contact during the past 30 days. If the client did not report having unprotected sexual
contact during the past 30 days, please skip to Question C1 below.
If the client reported having unprotected sexual contact ONLY with a male partner, please ask only
questions B6a, B6c, B6e, B6g, and B6i.
If the client reported having unprotected sexual contact ONLY with a female partner, please ask
questions B6b, B6d, B6f, B6h, and B6j.
If the client reported having unprotected sexual contact with BOTH a male partner and a female
partner please answer all questions in B6a – B6j.
B6. In the past 30 days, did you have…
Oral Sex
a. Unprotected
sexual
contact with
a male
partner?
1#
of times ___
0 No
66 Don’t
Vaginal Sex
1#
of times ___
0 No
Know
66 Don’t
Anal Sex
1#
of times ___
0 No
Know
66 Don’t
Did you use any of
the following before
or during… (check all
that apply)
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
BL 4
Attachment 1a: Document 2 - Intake/Baseline Client-Level Survey
Oral Sex
Vaginal Sex
Anal Sex
Did you use any of
the following before
or during… (check all
that apply)
77 N/A
88 Refused
b. Unprotected
sexual
contact with
a female
partner?
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
c.
Unprotected
sex with a
male
partner in
exchange for
money,
drugs, or
shelter?
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
d. Unprotected
sex with a
female
partner in
exchange for
money,
drugs, or
shelter?
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
e. Unprotected
sex with a
male
partner you
know has, or
might have a
sexually
transmitted
disease
(STD)?
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
f.
Unprotected
sex with a
female
partner you
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
BL 5
Attachment 1a: Document 2 - Intake/Baseline Client-Level Survey
Oral Sex
know has, or
might have
sexually
transmitted
disease
(STD)?
g. Unprotected
sex with a
male
partner you
know has, or
might have
HIV/AIDS?
Vaginal Sex
Anal Sex
77 N/A
77 N/A
77 N/A
88 Refused
88 Refused
88 Refused
Did you use any of
the following before
or during… (check all
that apply)
4 Cocaine/ Crack
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
h. Unprotected
sex with a
female
partner you
know has, or
might have,
HIV/AIDS?
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
i.
Unprotected
sex with a
male
partner you
know iss, or
might be an
injection
drug user?
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
j.
Unprotected
sex with a
female
partner you
know is, or
might be an
injection
drug user?
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
BL 6
Attachment 1a: Document 2 - Intake/Baseline Client-Level Survey
C. HIV Testing/HIV Status
Program Staff: These questions about whether you have ever been tested for HIV and your HIV status
as well as other sexually transmitted infections (STIs).
C1. In that past 12 months, have you been diagnosed with a sexually transmitted infection (STI) other
than HIV? Do not read response options.
1
Yes
0
No
66
Don’t Know
88
Refused
C2. Have you ever tested positive for HIV? Do not read response options.
1
Yes
0
No
66
Don’t Know
88
Refused
Program Staff: If client answered No, Don’t Know, or Refused to Question C2, please skip to
Question D1
C3. How long have you known you were HIV positive? Do not read response options.
1
30 days or less
2
Greater than 30 days
66
Don’t Know
77
Not applicable – Not HIV positive.
88
Refused
Program Staff: Next, I am going to ask you some questions about whether you have changed your
behavior since you found out you were HIV positive. I am going to read each answer option and please
use Response Card A to tell me how much you have changed your behavior. Please select only one
choice for each statement. [Please read response options].
Since you found out you were HIV
positive, how much have you changed
the following behaviors…
Not at
all
A little
bit
Moderately
Quite
a bit
Extremely
N/A
Refused
C4.
Sharing drug injection equipment
(needles/syringes) without first
cleaning it with anything?
1
2
3
4
5
77
88
C5.
Sharing drug injection equipment
(needles/syringes) with someone
you know has, or might have
HIV/AIDS?
1
2
3
4
5
77
88
C6.
Having unprotected sexual
contact?
1
2
3
4
5
77
88
C7.
Having unprotected sex with
someone in exchange for money,
drugs, or shelter?
1
2
3
4
5
77
88
C8.
Having unprotected sex with a
partner you know has, or might
have a sexually transmitted
disease (STD)?
1
2
3
4
5
77
88
C9.
Having unprotected sex with a
partner you know has or might
have HIV/AIDS?
1
2
3
4
5
77
88
C10.
Having unprotected sex with
1
2
3
4
5
77
88
BL 7
Attachment 1a: Document 2 - Intake/Baseline Client-Level Survey
Since you found out you were HIV
positive, how much have you changed
the following behaviors…
Not at
all
A little
bit
1
2
Moderately
Quite
a bit
Extremely
N/A
Refused
someone you knew is or might be
an injection drug user?
C11.
Having unprotected sex while you
were under the influence of drugs
or alcohol?
3
4
5
77
88
D. Social Support
Program Staff: Next, I am going to ask you some questions about the important people in your life. I am
going to read each answer option and please indicate how much you agree or disagree with each
statement below using Response Card B. Please select only one choice for each statement. [Please read
response options].
Disagree
Strongly
Disagree
Uncertain
Agree
Agree
Strongly
Refused
D1.
You have people close to you who
motivate and encourage your recovery.
1
2
3
4
5
88
D2.
You have close family members who
help you stay away from drugs.
1
2
3
4
5
88
D3.
You have good friends who do not
use drugs.
1
2
3
4
5
88
D4.
You have people close to you who
can always be trusted.
1
2
3
4
5
88
D5.
You have people close to you who
understand your situation and
problems.
1
2
3
4
5
88
D6.
You work in situations where drug
use is common.
1
2
3
4
5
88
D7.
You have people close to you who
expect you to make positive changes
in your life.
1
2
3
4
5
88
D8.
You have people close to you who
help you develop confidence in
yourself.
1
2
3
4
5
88
D9.
You have people close to you who
respect you and your efforts in this
program.
1
2
3
4
5
88
BL 8
Attachment 1a: Document 2 - Intake/Baseline Client-Level Survey
D10. In the past 30 days, did you attend any self-help groups for recovery (e.g., NA, AA, SMART
Recovery)? Do not read response options.
1
Yes (specify how many times) __________
0
No
88
Refused
E. Mental Health and Medical Health
Program Staff: These questions ask about different areas of your life such as your emotional and
physical health.
Mental Health
Program Staff: Next I have a list of problems people sometimes have. As I read each one to you, I want
you to tell me how much that problem has distressed or bothered you during the past 30 days including
today using Response Card A. [Please read response options].
During the past 30 days, how much were you
distressed by…
Not at
all
A little
bit
Moderately
Quite
a bit
Extremely
Refused
E1.
Nervousness or shakiness inside
1
2
3
4
5
88
E2.
Thoughts of ending your life
1
2
3
4
5
88
E3.
Suddenly scared for no reason
1
2
3
4
5
88
E4.
Feeling lonely
1
2
3
4
5
88
E5.
Feeling blue
1
2
3
4
5
88
E6.
Feeling no interest in things
1
2
3
4
5
88
E7.
Feeling fearful
1
2
3
4
5
88
E8.
Feeling hopeless about the future
1
2
3
4
5
88
E9.
Feeling tense or keyed up
1
2
3
4
5
88
E10.
Spells of terror or panic
1
2
3
4
5
88
E11.
Feeling so restless you couldn’t sit still
1
2
3
4
5
88
E12.
Feelings of worthlessness
1
2
3
4
5
88
E13.
E14.
In the past 30 days, how often have you used drugs (including prescription drugs) or alcohol to
help you cope with stressful life events? I am going to read each answer option and please use
Response Card A to provide your answer. [Please read response options].
1
Not at all
2
A little bit
3
Moderately
4
Quite a bit
5
Extremely
88
Refused
During the past 3 months, did you receive services for mental or emotional difficulties (i.e.,
inpatient, outpatient, emergency room)? Do not read response options.
1
Yes (specify how many times) __________
88
Refused
0
No
BL 9
Attachment 1a: Document 2 - Intake/Baseline Client-Level Survey
E15.
E16.
During the past 3 months, were you prescribed a medication for mental or emotional difficulties
(e.g., Prozac, Cymbalta)?
1
Yes (specify medications) __________
88
Refused
0
No
Is this your first time in a substance abuse treatment program? Do not read response options.
1
Yes
0
No
88
Refused
Program Staff: If client answered Yes to Question E16, please skip to Question E19
E17.
E18.
E19.
E20.
How many times have you been in substance abuse treatment before coming to this program?
Please read response options.
1
One time
2
2 – 4 times
3
5 – 7 times
4
> than 7 times
77
Not Applicable
88
Refused
What type of substance abuse treatment program were you in before coming to this program? Do
not read response options.
1
Outpatient
2
Residential
77
Not Applicable
88
Refused
3
Both
4
Opioid Treatment
Why are you enrolling in this treatment program? Do not read response options.
1
Self-admitted
88
Refused
2
Court Mandated
3
Other (specify) _____________
Which drug(s) do you want to address in this treatment program?
Specify: ______________________________________________________________________
66
E21.
Don’t Know
88
Refused
If you are receiving other substance abuse treatment services, how much of your care is
provided by this agency/organization? Please read response options.
0
I do not receive other substance abuse treatment services
1
I receive most of my care from this agency/organization
2
I receive about half of my care from this agency/organization and half from another
agency/organization
3
I receive most of my care from another agency/organization
BL 10
Attachment 1a: Document 2 - Intake/Baseline Client-Level Survey
Medical Health
E22.
In the past 30 days, did you have any type of health insurance for yourself? Please read
response options.
Yes, private health insurance (e.g., through an employer/union, privately purchased)
Yes, Medicare
Yes, other Government health insurance
Yes, Medicaid
E23.
E24.
0
No
Refused
88
During the past 30 days, did you receive medical treatment (not including substance abuse
treatment) for physical illness or injury (i.e., inpatient, outpatient, emergency room)? Do not read
response options.
1
Yes (specify how many times) __________
88
Refused
0
No
During the past 30 days, for about how many days did poor physical health keep you from doing
your usual activities, such as self-care, work, or recreation? Do not read response options.
Number of days __________
88
Refused
F. Motivation for Treatment
Program Staff: The following questions ask about your attitudes toward substance abuse treatment.
Each of the following statements describes a way that you might (or might not) feel about your drug use.
For each statement, I am going to read each answer option and please use Response Card C to indicate
how much you agree or disagree with each statement right now. [Please read response options].
Note: If the client’s primary substance of choice is alcohol, please replace underlined words with the
wording changes suggested in [ ] below.
Strongly
Disagree
1
Disagree
Undecided
or Unsure
3
Agree
Strongly
Agree
5
Refused
F1.
I have already started making
some changes in my use of
drugs [drinking].
F2.
I was using drugs [drinking] too
much at one time, but I’ve
managed to change that [my
drinking].
1
2
3
4
5
88
F3.
I’m not just thinking about
changing my drug use [drinking],
I’m already doing something
about it.
1
2
3
4
5
88
F4.
I have already changed my drug
use [drinking], and I am looking
for ways to keep from slipping
back to my old pattern.
1
2
3
4
5
88
F5.
I am actively doing things now to
cut down or stop my use of drugs
[drinking].
1
2
3
4
5
88
2
4
88
BL 11
Attachment 1a: Document 2 - Intake/Baseline Client-Level Survey
Strongly
Disagree
1
Disagree
Undecided
or Unsure
3
Agree
Strongly
Agree
5
Refused
F6.
I want help to keep from going
back to the drug [drinking]
problems that I had before.
F7.
I am working hard to change my
drug use [drinking].
1
2
3
4
5
88
F8.
I have made some changes in
my drug use [drinking], and I
want some help to keep from
going back to the way I used [to
drink] before.
1
2
3
4
5
88
2
4
88
End of INTAKE/BASELINE Client-Level Survey
Thank you for your time!
BL 12
Attachment 1a: Document 2 - Intake/Baseline Client-Level Survey
Program Staff: Please complete the following section on client drug testing after administration of
the INTAKE/BASELINE Client-Level Survey. Please consult the client’s medical record as
necessary to complete this section.
1. How frequently does your program conduct drug testing? Mark all that apply.
1
Intake
2
At each session
3
Randomly
4
Discharge
5
Post-discharge
6
Never
3
Other (specify) ____________
2. For what reason(s) does your program conduct drug testing? Mark all that apply.
1
Scheduled
4
At the request of the legal system (e.g., parole officer, court mandated)
2
For Cause
3
Other (specify) ____________
3. Has the client received a drug test in the past 90 days?
1
Yes (specify how many times) __________
0
No
66
Unknown
Program Staff: Only complete the following questions if the client has received a drug test in the
past 90 days
4. When did the client last receive a drug test?
Month, Day, Year: __________________________
66
Unknown
5. What method was used to conduct the client’s most recent drug test?
1
Saliva
2
Blood
3
Urine
Hair
4
5
Sweat
6
Breath
6. Was the sample collection directly observed?
1
Yes (specify how many times) __________
0
No
7. The client’s most recent drug test checked for the presence of which substances and/or drug
groups? Mark all that apply.
Alcohol
Amphetamines
Barbiturates
Benzodiazepines
Cocaine/Crack
Marijuana
Methamphetamine
Opiates
Phencyclidine (PCP)
Other (specify) ____________________________
66
Unknown
8. What were the results of the client’s most recent drug test?
1
Negative for all drugs tested
2
Positive (specify for which substances) ______________________________
3
Other outcome (i.e., neither negative nor positive), specify ________________________
9. If the test was positive for recent use of alcohol or other drugs, what actions were taken as a result
of the positive test?
Client counseled not to use drugs and/or alcohol
More frequent visits required (specify frequency) _________________________
More frequent drug testing required (specify frequency) _______________________
Other action(s) (specify) ________________________________________________
BL 13
Attachment 1a: Document 2 - Intake/Baseline Client-Level Survey
RESPONSE CARD A
RESPONSE CARD B
RESPONSE CARD C
1 = Not at all
1 = Disagree Strongly
1 = Strongly Disagree
2 = A little bit
2 = Disagree
2 = Disagree
3 = Moderately
3 = Uncertain
3 = Undecided or Unsure
4 = Quite a bit
4 = Agree
4 = Agree
5 = Extremely
5 = Agree Strongly
5 = Strongly Agree
BL 14
Attachment 1a: Document 3 - Discharge Client-Level Survey
Form Approved
OMB No. ####-####
Expiration Date: ##/##/####
TCE-HIV Multi-Site Evaluation
DISCHARGE Client-Level Survey
Funding for data collection supported by the
Center for Substance Abuse Treatment (CSAT)
Substance Abuse and Mental Health Services Administration (SAMHSA)
U.S. Department of Health and Human Services (HHS)
Instructions: These instructions are for program staff administering the TCE-HIV Multi-Site Evaluation
Client-Level Survey. The Client-Level Survey should be administered by program staff at baseline (based
on the program’s definition of baseline), discharge, and 6 months post baseline to all clients receiving
TCE-HIV services. Please note that this version of the Client-Level Survey is to be used at the
DISCHARGE only.
The Client-Level Survey includes six sections: Background Information, Risky Behaviors, HIV Testing/HIV
Status, Social Support, Mental Health and Medical Health, and Motivation for Treatment. All questions in
Sections A – F should be asked of the client.
Please read the introduction to each section (in italics) and then read each question to the client as it is
written. For some questions, you will read the response options to clients. Other questions are openended and you will not read the response options to clients. Please see the note in italics next to each
question to determine whether you should read the response options. Some questions require the use of
response options cards. Please provide the response options card to clients when noted.
You may provide clarification to the client to help them understand the question, but please do not change
the wording of the questions.
The Client-Level Survey should take approximately 25 minutes to administer.
Public reporting 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, if all items are asked of a client/participant; to the extent that providers already obtain much of this
information as part of their ongoing client/participant intake or follow-up, less time will be required. Send comments regarding this
burden estimate or any other aspect of this collection of information 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 control number for this project is ####-####.
D/C 1
Attachment 1a: Document 3 - Discharge Client-Level Survey
Form Approved
OMB No. ####-####
Expiration Date: ##/##/####
TCE-HIV Multi-Site Evaluation
Client-Level Survey
DISCHARGE
Funding for data collection supported by the Center for Substance Abuse Treatment (CSAT)
Substance Abuse and Mental Health Services Administration (SAMHSA)
U.S. Department of Health and Human Services (HHS)
Grantee ID
TI0 ___ ___ ___ ___ ___ ___
Partner ID (if applicable)
TI0 ___ ___ ___ ___ ___ ___ - ___ ___ ___
Client ID ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
(Please use the same Client ID that was assigned to the client for the GPRA)
Date of Administration (mm/dd/yyyy)
___ ___ / ___ ___ / ___ ___ ___ ___
PROGRAM STAFF: Please complete the following client background questions
using information collected from the Discharge GPRA.
Client’s Gender
Male
Female
Transgender
Refused
Other (specify) ________________________
Client’s Ethnicity: Is the client
Hispanic or Latino?
Client’s Race
Yes
No
Refused
Alaska Native
American Indian
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Refused
Client’s Age
___ ___
Public reporting 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, if all items are asked of a client/participant; to the extent that providers already obtain much of this
information as part of their ongoing client/participant intake or follow-up, less time will be required. Send comments regarding this
burden estimate or any other aspect of this collection of information 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 control number for this project is ####-####.
D/C 2
Attachment 1a: Document 3 - Discharge Client-Level Survey
Client ID: ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
(Please use the same Client ID that was assigned to the client for the GPRA)
Program Staff: The purpose of these questions is to get more information about how best to provide
services. We are asking these questions because it is a requirement for us from the Federal government
who gave us funding to provide services to you. All your background information and survey answers will
be kept strictly confidential. All survey answers will be provided to the Federal government using only a
number for you so there will be no way they can identify who you are. If you have any questions,
comments, or concerns please contact Resa Matthew, Ph.D. at 240-645-4608.
A. Background Information
Program Staff: First, I am going to ask you some questions about yourself.
A1. What is your marital status? Do not read response options.
1
Never Married/Single
2
Married
3
Living as Married
4
Separated
5
Divorced
6
Widowed
88
Refused
A2. In the past 30 days, have you lived...? You may say yes to more than one. Please read response
options.
88
Alone
With parents
With children alone
With other family members
With significant other alone
With friends
With significant other and children
In jail
In prison
In a hospital
In residential treatment
Other (specify) _________________
Refused
B. Risky Behaviors
Program Staff: The next set of questions asks about any behaviors that you may engage in that may put
you at risk for substance use disorders or HIV/AIDS. I realize these questions are very personal, but your
open and honest answers are very important. There are no right or wrong answers.
B1. Did you use alcohol or drugs since entering treatment? Do not read response options.
1
Yes (specify what substances were used since entering treatment) __________
0
No
88
Refused
66
Don’t Know
Program Staff: If clients reported alcohol or drug use in Question B1 above please skip to
question B3 below. Only ask question B2 below to clients who reported no alcohol or drug
use in Question B1 above.
D/C 3
Attachment 1a: Document 3 - Discharge Client-Level Survey
B2. You reported that since entering treatment you did not use alcohol or drugs. What were your
reasons for not using any alcohol or drugs? You may say yes to more than one. Please read
response options.
1
In jail/prison
4
Medical hospitalization
2
On probation/parole
5
Inpatient mental health treatment
3
Lack of money
6
Residential substance use treatment
7
Other (specify) ___________________________
77
Not applicable – used alcohol and/or drugs since entering treatment.
88
Refused
Program Staff: The next set of questions asks about your sexual behaviors. Again, I realize these
questions are very personal, but your open and honest answers are very important.
B3. In the past 30 days, did you engage in unprotected sexual activity with a male partner?
1
Yes
0
No
66
Don’t Know
Refused
88
B4. In the past 30 days, did you engage in unprotected sexual activity with a female partner?
1
Yes
0
No
66
Don’t Know
Refused
88
B5. In the past 30 days, did you engage in unprotected sexual activity with both a male partner and a
female partner?
1
Yes
0
No
66
Don’t Know
Refused
88
***Program Staff: Only ask questions B6a – B6j of those clients who reported having unprotected
sexual contact during the past 30 days. If the client did not report having unprotected sexual
contact during the past 30 days, please skip to Question C1 below.
If the client reported having unprotected sexual contact ONLY with a male partner, please ask only
questions B6a, B6c, B6e, B6g, and B6i.
If the client reported having unprotected sexual contact ONLY with a female partner, please ask
questions B6b, B6d, B6f, B6h, and B6j.
If the client reported having unprotected sexual contact with BOTH a male partner and a female
partner please answer all questions in B6a – B6j. ***
B6. In the past 30 days, did you have…
Oral Sex
a. Unprotected
sexual
contact with
a male
partner?
1#
of times ___
0 No
66 Don’t
Vaginal Sex
1#
of times ___
0 No
Know
66 Don’t
Anal Sex
1#
of times ___
0 No
Know
66 Don’t
Did you use any of
the following before
or during… (check all
that apply)
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
D/C 4
Attachment 1a: Document 3 - Discharge Client-Level Survey
Oral Sex
b. Unprotected
sexual
contact with
a female
partner?
1#
of times ___
0 No
66 Don’t
Vaginal Sex
1#
of times ___
0 No
Know
66 Don’t
Anal Sex
1#
of times ___
0 No
Know
66 Don’t
Did you use any of
the following before
or during… (check all
that apply)
88 Refused
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
c.
Unprotected
sex with a
male
partner in
exchange for
money,
drugs, or
shelter?
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
d. Unprotected
sex with a
female
partner in
exchange for
money,
drugs, or
shelter?
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
e. Unprotected
sex with a
male
partner you
know had, or
suspected of
having a
sexually
transmitted
disease
(STD)?
f. Unprotected
sex with a
female
partner you
know had, or
suspected of
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
1#
of times ___
0 No
66 Don’t
77 N/A
1#
of times ___
0 No
Know
66 Don’t
77 N/A
1#
of times ___
0 No
Know
66 Don’t
77 N/A
1 Alcohol
2 Marijuana
Know
3 Heroin
4 Cocaine/ Crack
D/C 5
Attachment 1a: Document 3 - Discharge Client-Level Survey
Oral Sex
having a
sexually
transmitted
disease
(STD)?
g. Unprotected
sex with a
male
partner you
know had, or
suspected of
having
HIV/AIDS?
88 Refused
Vaginal Sex
88 Refused
Anal Sex
88 Refused
Did you use any of
the following before
or during… (check all
that apply)
5 Other ______
66 Don’t
Know
77 N/A
88 Refused
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
h. Unprotected
sex with a
female
partner you
know had, or
suspected of
having
HIV/AIDS?
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
i.
Unprotected
sex with a
male
partner you
knew was, or
suspected of
being an
injection
drug user?
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
j.
Unprotected
sex with a
female
partner you
knew was, or
suspected of
being an
injection
drug user?
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
D/C 6
Attachment 1a: Document 3 - Discharge Client-Level Survey
C. HIV Testing/HIV Status
Program Staff: These questions about whether you have ever been tested for HIV and your HIV status
as well as other sexually transmitted infections (STIs).
C1. In that past 12 months, have you been diagnosed with a sexually transmitted infection (STI) other
than HIV? Do not read response options.
1
Yes
0
No
66
Don’t Know
88
Refused
C2. Have you ever tested positive for HIV? Do not read response options.
1
Yes
0
No
66
Don’t Know
88
Refused
****Program Staff: If client answered No, Don’t Know, or Refused to Question C2, please skip to
Question D1****
C3. How long have you known you were HIV positive? Do not read response options.
1
30 days or less
2
Greater than 30 days
66
Don’t Know
77
Not applicable – Not HIV positive.
88
Refused
Program Staff: Next, I am going to ask you some questions about whether you have changed your
behavior since you found out you were HIV positive. I am going to read each answer option and please
use Response Card A to tell me how much you have changed your behavior. Please select only one
choice for each statement. [Please read response options].
Since you found out you were HIV
positive, how much have you changed
the following behaviors…
Not at
all
A little
bit
Moderately
Quite
a bit
Extremely
N/A
Refused
C4.
Sharing drug injection equipment
(needles/syringes) without first
cleaning it with anything?
1
2
3
4
5
77
88
C5.
Sharing drug injection equipment
(needles/syringes) with someone
you know had, or suspected of
having HIV/AIDS?
1
2
3
4
5
77
88
C6.
Having unprotected sexual
contact?
1
2
3
4
5
77
88
C7.
Having unprotected sex with
someone in exchange for money,
drugs, or shelter?
1
2
3
4
5
77
88
C8.
Having unprotected sex with a
partner you know had, or
suspected of having a sexually
transmitted disease (STD)?
1
2
3
4
5
77
88
C9.
Having unprotected sex with a
partner you know had, or
suspected of having HIV/AIDS?
1
2
3
4
5
77
88
C10.
Having unprotected sex with
1
2
3
4
5
77
88
D/C 7
Attachment 1a: Document 3 - Discharge Client-Level Survey
Since you found out you were HIV
positive, how much have you changed
the following behaviors…
Not at
all
A little
bit
1
2
Moderately
Quite
a bit
Extremely
N/A
Refused
someone you knew was, or
suspected of being an injection
drug user?
C11.
Having unprotected sex while you
were under the influence of drugs
or alcohol?
3
4
5
77
88
D. Social Support
Program Staff: Next, I am going to ask you some questions about the important people in your life. I am
going to read each answer option and please indicate how much you agree or disagree with each
statement below using Response Card B. Please select only one choice for each statement. [Please read
response options].
Disagree
Strongly
Disagree
Uncertain
Agree
Agree
Strongly
Refused
D1.
You have people close to you who
motivate and encourage your recovery.
1
2
3
4
5
88
D2.
You have close family members who
help you stay away from drugs.
1
2
3
4
5
88
D3.
You have good friends who do not
use drugs.
1
2
3
4
5
88
D4.
You have people close to you who
can always be trusted.
1
2
3
4
5
88
D5.
You have people close to you who
understand your situation and
problems.
1
2
3
4
5
88
D6.
You work in situations where drug
use is common.
1
2
3
4
5
88
D7.
You have people close to you who
expect you to make positive changes
in your life.
1
2
3
4
5
88
D8.
You have people close to you who
help you develop confidence in
yourself.
1
2
3
4
5
88
D9.
You have people close to you who
respect you and your efforts in this
program.
1
2
3
4
5
88
D10. In the past 30 days, did you attend any self-help groups for recovery (e.g., NA, AA, SMART
Recovery)? Do not read response options.
1
Yes (specify how many times) __________
0
No
88
Refused
D/C 8
Attachment 1a: Document 3 - Discharge Client-Level Survey
E. Mental Health and Medical Health
Program Staff: These questions ask about different areas of your life such as your emotional and
physical health.
Mental Health
Program Staff: Next I have a list of problems people sometimes have. As I read each one to you, I want
you to tell me how much that problem has distressed or bothered you during the past 30 days including
today using Response Card A. [Please read response options].
During the past 30 days, how much were you
distressed by…
Not at
all
A little
bit
Moderately
Quite
a bit
Extremely
Refused
E1.
Nervousness or shakiness inside
1
2
3
4
5
88
E2.
Thoughts of ending your life
1
2
3
4
5
88
E3.
Suddenly scared for no reason
1
2
3
4
5
88
E4.
Feeling lonely
1
2
3
4
5
88
E5.
Feeling blue
1
2
3
4
5
88
E6.
Feeling no interest in things
1
2
3
4
5
88
E7.
Feeling fearful
1
2
3
4
5
88
E8.
Feeling hopeless about the future
1
2
3
4
5
88
E9.
Feeling tense or keyed up
1
2
3
4
5
88
E10.
Spells of terror or panic
1
2
3
4
5
88
E11.
Feeling so restless you couldn’t sit still
1
2
3
4
5
88
E12.
Feelings of worthlessness
1
2
3
4
5
88
E13.
E14.
In the past 30 days, how often have you used drugs (including prescription drugs) or alcohol to
help you cope with stressful life events? I am going to read each answer option and please use
Response Card A to provide your answer. [Please read response options].
1
Not at all
2
A little bit
3
Moderately
4
Quite a bit
5
Extremely
88
Refused
During the past 3 months, did you receive services for mental or emotional difficulties (i.e.,
inpatient, outpatient, emergency room)? Do not read response options.
1
E15.
Yes (specify how many times) __________
0
No
88
Refused
During the past 3 months, were you prescribed a medication for mental or emotional difficulties
(e.g., Prozac, Cymbalta)?
1
Yes (specify medications) __________
88
Refused
0
No
D/C 9
Attachment 1a: Document 3 - Discharge Client-Level Survey
E16.
E17.
Why did you enroll in this treatment program? Do not read response options.
1
Self-admitted
88
Refused
2
Court Mandated
3
Other (specify) _____________
Which drug(s) did you want to address in this treatment program?
Specify: ______________________________________________________________________
66
E18.
Don’t Know
88
Refused
If you are receiving other substance abuse treatment services, how much of your care is
provided by this agency/organization? Please read response options.
0
I do not receive other substance abuse treatment services
1
I receive most of my care from this agency/organization
2
I receive about half of my care from this agency/organization and half from another
agency/organization
3
I receive most of my care from another agency/organization
Medical Health
E19.
In the past 30 days, did you have any type of health insurance for yourself? Please read
response options.
Yes, private health insurance (e.g., through an employer/union, privately purchased)
Yes, Medicare
Yes, Medicaid
88
E20.
E21.
Yes, other Government health insurance
0
No
Refused
During the past 30 days, did you receive medical treatment (not including substance abuse
treatment) for physical illness or injury (i.e., inpatient, outpatient, emergency room)? Do not read
response options.
1
Yes (specify how many times) __________
88
Refused
0
No
During the past 30 days, for about how many days did poor physical health keep you from doing
your usual activities, such as self-care, work, or recreation? Do not read response options.
Number of days __________
88
Refused
D/C 10
Attachment 1a: Document 3 - Discharge Client-Level Survey
F. Motivation for Treatment
Program Staff: The following questions ask about your attitudes toward substance abuse treatment.
Each of the following statements describes a way that you might (or might not) feel about your drug use.
For each statement, I am going to read each answer option and please use Response Card C to indicate
how much you agree or disagree with each statement right now. [Please read response options].
Note: If the client’s primary substance of choice is alcohol, please replace underlined words with the
wording changes suggested in [ ] below.
Strongly
Disagree
1
Disagree
Undecided
or Unsure
3
Agree
Strongly
Agree
5
Refused
F1.
I have already started making
some changes in my use of
drugs [drinking].
F2.
I was using drugs [drinking] too
much at one time, but I’ve
managed to change that [my
drinking].
1
2
3
4
5
88
F3.
I’m not just thinking about
changing my drug use [drinking],
I’m already doing something
about it.
1
2
3
4
5
88
F4.
I have already changed my drug
use [drinking], and I am looking
for ways to keep from slipping
back to my old pattern.
1
2
3
4
5
88
F5.
I am actively doing things now to
cut down or stop my use of drugs
[drinking].
1
2
3
4
5
88
F6.
I want help to keep from going
back to the drug [drinking]
problems that I had before.
1
2
3
4
5
88
F7.
I am working hard to change my
drug use [drinking].
1
2
3
4
5
88
F8.
I have made some changes in
my drug use [drinking], and I
want some help to keep from
going back to the way I used [to
drink] before.
1
2
3
4
5
88
2
4
88
End of DISCHARGE Client Level Survey
Thank you for your time!
D/C 11
Attachment 1a: Document 3 - Discharge Client-Level Survey
Program Staff: Please complete the following section on client drug testing after administration of
the DISCHARGE Client Level Survey. Please consult the client’s medical record as necessary to
complete this section.
1. How frequently does your program conduct drug testing? Mark all that apply.
1
Intake
2
At each session
3
Randomly
4
Discharge
5
Post-discharge
6
Never
3
Other (specify) ____________
2. For what reason(s) does your program conduct drug testing? Mark all that apply.
1
Scheduled
4
At the request of the legal system (e.g., parole officer, court mandated)
2
For Cause
3
Other (specify) ____________
3. Has the client received a drug test in the past 90 days?
1
Yes (specify how many times) __________
0
No
66
Unknown
****Program Staff: Only complete the following questions if the client has received a drug test in
the past 90 days ****
4. When did the client last receive a drug test?
Month, Day, Year: __________________________
66
Unknown
5. What method was used to conduct the client’s most recent drug test?
1
Saliva
2
Blood
3
Urine
Hair
4
5
Sweat
6
Breath
6. Was the sample collection directly observed?
1
Yes (specify how many times) __________
0
No
7. The client’s most recent drug test checked for the presence of which substances and/or drug
groups? Mark all that apply.
Alcohol
Amphetamines
Barbiturates
Benzodiazepines
Cocaine/Crack
Marijuana
Methamphetamine
Opiates
Phencyclidine (PCP)
Other (specify) ____________________________
66
Unknown
8. What were the results of the client’s most recent drug test?
1
Negative for all drugs tested
2
Positive (specify for which substances) ______________________________
3
Other outcome (i.e., neither negative nor positive), specify ________________________
9. If the test was positive for recent use of alcohol or other drugs, what actions were taken as a result
of the positive test?
Client counseled not to use drugs and/or alcohol
More frequent visits required
More frequent drug testing required (specify frequency) _______________________
Other action(s) (specify) _______________________________
D/C 12
Attachment 1a: Document 3 - Discharge Client-Level Survey
RESPONSE CARD A
RESPONSE CARD B
RESPONSE CARD C
1 = Not at all
1 = Disagree Strongly
1 = Strongly Disagree
2 = A little bit
2 = Disagree
2 = Disagree
3 = Moderately
3 = Uncertain
3 = Undecided or Unsure
4 = Quite a bit
4 = Agree
4 = Agree
5 = Extremely
5 = Agree Strongly
5 = Strongly Agree
D/C 13
Attachment 1b: Document 1 – Six Month Follow-Up Client-Level Survey
Form Approved
OMB No. ####-####
Expiration Date: ##/##/####
TCE-HIV Multi-Site Evaluation
6-MONTH FOLLOW-UP Client-Level Survey
Funding for data collection supported by the
Center for Substance Abuse Treatment (CSAT)
Substance Abuse and Mental Health Services Administration (SAMHSA)
U.S. Department of Health and Human Services (HHS)
Instructions: These instructions are for program staff administering the TCE-HIV Multi-Site Evaluation
Client-Level Survey. The Client-Level Survey should be administered by program staff at baseline (based
on the program’s definition of baseline), discharge, and 6-months post-baseline to all clients receiving
TCE-HIV services. Please note that this version of the Client-Level Survey is to be used at the 6MONTH FOLLOW-UP (i.e., 6-months post-intake/baseline) only.
The Client-Level Survey includes six sections: Background Information, Risky Behaviors, HIV Testing/HIV
Status, Social Support, Mental Health and Medical Health, and Motivation for Treatment. All questions in
Sections A – F should be asked of the client.
Please read the introduction to each section (in italics) and then read each question to the client as it is
written. For some questions, you will read the response options to clients. Other questions are openended and you will not read the response options to clients. Please see the note in italics next to each
question to determine whether you should read the response options. Some questions require the use of
response options cards. Please provide the response options card to clients when noted.
You may provide clarification to the client to help them in understanding the question, but please do not
change the wording of the questions.
The Client-Level Survey should take approximately 25 minutes to administer.
Public reporting 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, if all items are asked of a client/participant; to the extent that providers already obtain much of this
information as part of their ongoing client/participant intake or follow-up, less time will be required. Send comments regarding this
burden estimate or any other aspect of this collection of information 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 control number for this project is ####-####.
F/U 1
Attachment 1b: Document 1 – Six Month Follow-Up Client-Level Survey
Form Approved
OMB No. ####-####
Expiration Date: ##/##/####
TCE-HIV Multi-Site Evaluation
Client-Level Survey
6-MONTH FOLLOW-UP
Funding for data collection supported by the Center for Substance Abuse Treatment (CSAT)
Substance Abuse and Mental Health Services Administration (SAMHSA)
U.S. Department of Health and Human Services (HHS)
Grantee ID
TI0 ___ ___ ___ ___ ___ ___
Partner ID (if applicable)
TI0 ___ ___ ___ ___ ___ ___ - ___ ___ ___
Client ID ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
(Please use the same Client ID that was assigned to the client for the GPRA)
Date of Administration (mm/dd/yyyy)
___ ___ / ___ ___ / ___ ___ ___ ___
PROGRAM STAFF: Please complete the following client background questions
using information collected from the 6-months post-intake/baseline GPRA.
Client’s Gender
Male
Female
Transgender
Refused
Other (specify) ________________________
Client’s Ethnicity: Is the client
Hispanic or Latino?
Client’s Race
Yes
No
Refused
Alaska Native
American Indian
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Refused
Client’s Age
___ ___
Public reporting 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, if all items are asked of a client/participant; to the extent that providers already obtain much of this
information as part of their ongoing client/participant intake or follow-up, less time will be required. Send comments regarding this
burden estimate or any other aspect of this collection of information 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 control number for this project is ####-####.
F/U 2
Attachment 1b: Document 1 – Six Month Follow-Up Client-Level Survey
Client ID: ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
(Please use the same Client ID that was assigned to the client for the GPRA)
Program Staff: The purpose of these questions is to get more information about how best to provide
services. We are asking these questions because it is a requirement for us from the Federal government
who gave us funding to provide services to you. All your background information and survey answers will
be kept strictly confidential. All survey answers will be provided to the Federal government using only a
number for you so there will be no way they can identify who you are. If you have any questions,
comments, or concerns they can be directed to Resa Matthew, Ph.D. at 240-645-4608.
A. Background Information
Program Staff: First, I am going to ask you some questions about yourself.
A1. What is your marital status? Do not read response options.
1
Never Married/Single
2
Married
3
Living as Married
4
Separated
5
Divorced
6
Widowed
88
Refused
A2. In the past 30 days, have you lived...? You may say yes to more than one. Please read response
options.
88
Alone
With parents
With children alone
With other family members
With significant other alone
With friends
With significant other and children
In jail
In prison
In a hospital
In residential treatment
Other (specify) _________________
Refused
B. Risky Behaviors
Program Staff: The next set of questions asks about any behaviors that you may engage in that may put
you at risk for substance use disorders or HIV/AIDS. I realize these questions are very personal, but your
open and honest answers are very important. There are no right or wrong answers.
B1. Did you use alcohol or drugs since leaving treatment? Do not read response options.
1
Yes (specify what substances were used since leaving treatment) __________
0
No
88
Refused
66
Don’t Know
Program Staff: If clients reported alcohol or drug use in Question B1 above please skip to
question B3 below. Only ask question B2 below to clients who reported no alcohol or drug
use in Question B1 above.
F/U 3
Attachment 1b: Document 1 – Six Month Follow-Up Client-Level Survey
B2. You reported that since leaving treatment you did not use alcohol or drugs. What were your
reasons for not using any alcohol or drugs? You may say yes to more than one. Please read
response options.
1
In jail/prison
4
Medical hospitalization
2
On probation/parole
5
Inpatient mental health treatment
3
Lack of money
6
Residential substance use treatment
7
Other (specify) ___________________________
77
Not applicable – used alcohol and/or drugs since leaving treatment.
88
Refused
Program Staff: The next set of questions asks about your sexual behaviors. Again, I realize these
questions are very personal, but your open and honest answers are very important.
B3. In the past 30 days, did you engage in unprotected sexual activity with a male partner?
1
Yes
0
No
66
Don’t Know
Refused
88
B4. In the past 30 days, did you engage in unprotected sexual activity with a female partner?
1
Yes
0
No
66
Don’t Know
Refused
88
B5. In the past 30 days, did you engage in unprotected sexual activity with both a male partner and a
female partner?
1
Yes
0
No
66
Don’t Know
Refused
88
***Program Staff: Only ask questions B6a – B6j of those clients who reported having unprotected
sexual contact during the past 30 days. If the client did not report having unprotected sexual
contact during the past 30 days, please skip to Question C1 below.
If the client reported having unprotected sexual contact ONLY with a male partner, please ask only
questions B6a, B6c, B6e, B6g, and B6i.
If the client reported having unprotected sexual contact ONLY with a female partner, please ask
questions B6b, B6d, B6f, B6h, and B6j.
If the client reported having unprotected sexual contact with BOTH a male partner and a female
partner please answer all questions in B6a – B6j. ***
B6. In the past 30 days, did you have…
Oral Sex
a. Unprotected
sexual
contact with
a male
partner?
1#
of times ___
0 No
66 Don’t
Vaginal Sex
1#
of times ___
0 No
Know
66 Don’t
Anal Sex
1#
of times ___
0 No
Know
66 Don’t
Did you use any of
the following before
or during… (check all
that apply)
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
F/U 4
Attachment 1b: Document 1 – Six Month Follow-Up Client-Level Survey
Oral Sex
Vaginal Sex
Anal Sex
Did you use any of
the following before
or during… (check all
that apply)
77 N/A
88 Refused
b. Unprotected
sexual
contact with
a female
partner?
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
c.
Unprotected
sex with a
male
partner in
exchange for
money,
drugs, or
shelter?
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
d. Unprotected
sex with a
female
partner in
exchange for
money,
drugs, or
shelter?
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
e. Unprotected
sex with a
male
partner you
know had, or
suspected of
having a
sexually
transmitted
disease
(STD)?
f. Unprotected
sex with a
female
partner you
know had, or
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
F/U 5
Attachment 1b: Document 1 – Six Month Follow-Up Client-Level Survey
Oral Sex
suspected of
having a
sexually
transmitted
disease
(STD)?
g. Unprotected
sex with a
male
partner you
know had, or
suspected of
having
HIV/AIDS?
Vaginal Sex
Anal Sex
77 N/A
77 N/A
77 N/A
88 Refused
88 Refused
88 Refused
Did you use any of
the following before
or during… (check all
that apply)
4 Cocaine/ Crack
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
h. Unprotected
sex with a
female
partner you
know had, or
suspected of
having
HIV/AIDS?
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
i.
Unprotected
sex with a
male
partner you
knew was, or
suspected of
being an
injection
drug user?
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
j.
Unprotected
sex with a
female
partner you
knew was, or
suspected of
being an
injection
drug user?
1#
of times ___
0 No
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1#
of times ___
0 No
Know
66 Don’t
1 Alcohol
2 Marijuana
Know
3 Heroin
77 N/A
77 N/A
77 N/A
4 Cocaine/ Crack
88 Refused
88 Refused
88 Refused
5 Other
______
66 Don’t
Know
77 N/A
88 Refused
F/U 6
Attachment 1b: Document 1 – Six Month Follow-Up Client-Level Survey
C. HIV Testing/HIV Status
Program Staff: These questions about whether you have ever been tested for HIV and your HIV status
as well as other sexually transmitted infections (STIs).
C1. In that past 12 months, have you been diagnosed with a sexually transmitted infection (STI) other
than HIV? Do not read response options.
1
Yes
0
No
66
Don’t Know
88
Refused
C2. Have you ever tested positive for HIV? Do not read response options.
1
Yes
0
No
66
Don’t Know
88
Refused
****Program Staff: If client answered No, Don’t Know, or Refused to Question C2, please skip to
Question D1****
C3. How long have you known you were HIV positive? Do not read response options.
1
30 days or less
2
Greater than 30 days
66
Don’t Know
77
Not applicable – Not HIV positive.
88
Refused
Program Staff: Next, I am going to ask you some questions about whether you have changed your
behavior since you found out you were HIV positive. I am going to read each answer option and please
use Response Card A to tell me how much you have changed your behavior. Please select only one
choice for each statement. [Please read response options].
Since you found out you were HIV
positive, how much have you changed
the following behaviors…
Not at
all
A little
bit
Moderately
Quite
a bit
Extremely
N/A
Refused
C4.
Sharing drug injection equipment
(needles/syringes) without first
cleaning it with anything?
1
2
3
4
5
77
88
C5.
Sharing drug injection equipment
(needles/syringes) with someone
you know had, or suspected of
having HIV/AIDS?
1
2
3
4
5
77
88
C6.
Having unprotected sexual
contact?
1
2
3
4
5
77
88
C7.
Having unprotected sex with
someone in exchange for money,
drugs, or shelter?
1
2
3
4
5
77
88
C8.
Having unprotected sex with a
partner you know had, or
suspected of having a sexually
transmitted disease (STD)?
1
2
3
4
5
77
88
C9.
Having unprotected sex with a
partner you know had, or
suspected of having HIV/AIDS?
1
2
3
4
5
77
88
C10.
Having unprotected sex with
1
2
3
4
5
77
88
F/U 7
Attachment 1b: Document 1 – Six Month Follow-Up Client-Level Survey
Since you found out you were HIV
positive, how much have you changed
the following behaviors…
Not at
all
A little
bit
1
2
Moderately
Quite
a bit
Extremely
N/A
Refused
someone you knew was, or
suspected of being an injection
drug user?
C11.
Having unprotected sex while you
were under the influence of drugs
or alcohol?
3
4
5
77
88
D. Social Support
Program Staff: Next, I am going to ask you some questions about the important people in your life. I am
going to read each answer option and please indicate how much you agree or disagree with each
statement below using Response Card B. Please select only one choice for each statement. [Please read
response options].
Disagree
Strongly
Disagree
Uncertain
Agree
Agree
Strongly
Refused
D1.
You have people close to you who
motivate and encourage your recovery.
1
2
3
4
5
88
D2.
You have close family members who
help you stay away from drugs.
1
2
3
4
5
88
D3.
You have good friends who do not
use drugs.
1
2
3
4
5
88
D4.
You have people close to you who
can always be trusted.
1
2
3
4
5
88
D5.
You have people close to you who
understand your situation and
problems.
1
2
3
4
5
88
D6.
You work in situations where drug
use is common.
1
2
3
4
5
88
D7.
You have people close to you who
expect you to make positive changes
in your life.
1
2
3
4
5
88
D8.
You have people close to you who
help you develop confidence in
yourself.
1
2
3
4
5
88
D9.
You have people close to you who
respect you and your efforts in this
program.
1
2
3
4
5
88
D10. In the past 30 days, did you attend any self-help groups for recovery (e.g., NA, AA, SMART
Recovery)? Do not read response options.
1
Yes (specify how many times) __________
0
No
88
Refused
F/U 8
Attachment 1b: Document 1 – Six Month Follow-Up Client-Level Survey
E. Mental Health and Medical Health
Program Staff: These questions ask about different areas of your life such as your emotional and
physical health.
Mental Health
Program Staff: Next I have a list of problems people sometimes have. As I read each one to you, I want
you to tell me how much that problem has distressed or bothered you during the past 30 days including
today using Response Card A. [Please read response options].
During the past 30 days, how much were you
distressed by…
Not at
all
A little
bit
Moderately
Quite
a bit
Extremely
Refused
E1.
Nervousness or shakiness inside
1
2
3
4
5
88
E2.
Thoughts of ending your life
1
2
3
4
5
88
E3.
Suddenly scared for no reason
1
2
3
4
5
88
E4.
Feeling lonely
1
2
3
4
5
88
E5.
Feeling blue
1
2
3
4
5
88
E6.
Feeling no interest in things
1
2
3
4
5
88
E7.
Feeling fearful
1
2
3
4
5
88
E8.
Feeling hopeless about the future
1
2
3
4
5
88
E9.
Feeling tense or keyed up
1
2
3
4
5
88
E10.
Spells of terror or panic
1
2
3
4
5
88
E11.
Feeling so restless you couldn’t sit still
1
2
3
4
5
88
E12.
Feelings of worthlessness
1
2
3
4
5
88
E13.
E14.
E15.
In the past 30 days, how often have you used drugs (including prescription drugs) or alcohol to
help you cope with stressful life events? I am going to read each answer option and please use
Response Card A to provide your answer. [Please read response options].
1
Not at all
2
A little bit
3
Moderately
4
Quite a bit
5
Extremely
88
Refused
During the past 3 months, did you receive services for mental or emotional difficulties (i.e.,
inpatient, outpatient, emergency room)? Do not read response options.
1
Yes (specify how many times) __________
88
Refused
0
No
During the past 3 months, were you prescribed a medication for mental or emotional difficulties
(e.g., Prozac, Cymbalta)?
1
Yes (specify medications) __________
88
Refused
0
No
F/U 9
Attachment 1b: Document 1 – Six Month Follow-Up Client-Level Survey
E16.
E17.
Why did you enroll in this treatment program? Do not read response options.
1
Self-admitted
88
Refused
2
Court Mandated
3
Other (specify) _____________
Which drug(s) did you want to address in this treatment program?
Specify: ______________________________________________________________________
66
E18.
Don’t Know
88
Refused
If you are receiving other substance abuse treatment services, how much of your care is
provided by this agency/organization? Please read response options.
0
I do not receive other substance abuse treatment services
1
I receive most of my care from this agency/organization
2
I receive about half of my care from this agency/organization and half from another
agency/organization
3
I receive most of my care from another agency/organization
Medical Health
E19.
In the past 30 days, did you have any type of health insurance for yourself? Please read
response options.
Yes, private health insurance (e.g., through an employer/union, privately purchased)
Yes, Medicare
Yes, Medicaid
88
E20.
E21.
Yes, other Government health insurance
0
No
Refused
During the past 30 days, did you receive medical treatment (not including substance abuse
treatment) for physical illness or injury (i.e., inpatient, outpatient, emergency room)? Do not read
response options.
1
Yes (specify how many times) __________
88
Refused
0
No
During the past 30 days, for about how many days did poor physical health keep you from doing
your usual activities, such as self-care, work, or recreation? Do not read response options.
Number of days __________
88
Refused
F/U 10
Attachment 1b: Document 1 – Six Month Follow-Up Client-Level Survey
F. Motivation for Treatment
Program Staff: The following questions ask about your attitudes toward substance abuse treatment.
Each of the following statements describes a way that you might (or might not) feel about your drug use.
For each statement, I am going to read each answer option and please use Response Card C to indicate
how much you agree or disagree with each statement right now. [Please read response options].
Note: If the client’s primary substance of choice is alcohol, please replace underlined words with the
wording changes suggested in [ ] below.
Strongly
Disagree
1
Disagree
Undecided
or Unsure
3
Agree
Strongly
Agree
5
Refused
F1.
I have already started making
some changes in my use of
drugs [drinking].
F2.
I was using drugs [drinking] too
much at one time, but I’ve
managed to change that [my
drinking].
1
2
3
4
5
88
F3.
I’m not just thinking about
changing my drug use [drinking],
I’m already doing something
about it.
1
2
3
4
5
88
F4.
I have already changed my drug
use [drinking], and I am looking
for ways to keep from slipping
back to my old pattern.
1
2
3
4
5
88
F5.
I am actively doing things now to
cut down or stop my use of drugs
[drinking].
1
2
3
4
5
88
F6.
I want help to keep from going
back to the drug [drinking]
problems that I had before.
1
2
3
4
5
88
F7.
I am working hard to change my
drug use [drinking].
1
2
3
4
5
88
F8.
I have made some changes in
my drug use [drinking], and I
want some help to keep from
going back to the way I used [to
drink] before.
1
2
3
4
5
88
2
4
88
End of 6-MONTH FOLLOW-UP Client Level Survey
Thank you for your time!
F/U 11
Attachment 1b: Document 1 – Six Month Follow-Up Client-Level Survey
RESPONSE CARD A
RESPONSE CARD B
RESPONSE CARD C
1 = Not at all
1 = Disagree Strongly
1 = Strongly Disagree
2 = A little bit
2 = Disagree
2 = Disagree
3 = Moderately
3 = Uncertain
3 = Undecided or Unsure
4 = Quite a bit
4 = Agree
4 = Agree
5 = Extremely
5 = Agree Strongly
5 = Strongly Agree
F/U 12
Attachment 1b: Document 2 - Client Dosage Form
Form Approved
OMB No. ####-####
Expiration Date: ##/##/####
TARGETED CAPACITY EXPANSION PROGRAM FOR
SUBSTANCE ABUSE TREATMENT AND HIV/AIDS
SERVICES (TCE-HIV)
MULTI-SITE EVALUATION PROJECT
CLIENT DOSAGE FORM
Grantee Name:
__________________________________________
Grantee ID Number:
__________________________________________
Client ID Number:
(same as GPRA ID)
__________________________________________
Date Completed:
_______ /
_______ /
Month
Day
_________
Year
Notice to Respondents
Public reporting burden for this collection of information is estimated to average 15 minutes per response; including the time
for reviewing instructions, searching existing data sources 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 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 control number for this project is XXXX-XXXX.
1
Attachment 1b: Document 2 - Client Dosage Form
Dosage Instructions and Client Dosage Form
DOSAGE MEASUREMENT
Individual clients in a program can have very different types and amounts of contact (i.e., dosage) due to
absences, participation in different components, or dropping out; thus it is critical to have dosage
information to accurately assess program effects. Dosage is a measure of the type and amount of contact
that a client has with the program.
The documentation of client exposure to program services is an important feature of the CSAT TCE-HIV
multi-site evaluation. The dosage measurement developed for this evaluation study is designed to meet
several criteria. First, the client dosage form must reflect the actual services and treatment activities of the
funded programs. Second, the client dosage form must be simple enough to implement across all
treatment grantees. Third, the client dosage form should be completed only at client discharge.
TCE-HIV EVALUATION DOSAGE GENERAL INSTRUCTIONS
Multi-site dosage measurement applies only to those services that directly involve TCE-HIV clients.
Dosage data will not be collected on services for which the client is not individually involved, such as
case management review meetings or referral calls made on behalf of the client. Most direct services will
involve face-to-face contact between the client and service provider, but there may be direct services
provided over the telephone such as crises intervention or case management counseling. Program
services and treatment activities included are only those provided directly by the grantee or through
contractual arrangements. Services that clients receive outside of the program will not be measured for
multi-site purposes, even if the services were received through referrals from the program. Because
dosage is a measurement of program exposure to services and treatment activities, dosage data will be
collected on TCE-HIV clients only.
There is no expectation that a program would conduct activities in all of the service/treatment activities
categories listed in the client dosage form. However, for the purposes of dosage recording, it is important
that each program activity conducted at the local level be attached to one of these intervention types.
Some program encounters will involve only one intervention type, e.g., a family counseling session.
However, clients can receive more than one type of service or treatment activity during a daily encounter.
For example, as part of a daily program encounter, clients may learn about the harmful effects of alcohol,
tobacco, and drugs (Substance Abuse Education) during the first hour and then during the second hour
participate in a group substance abuse counseling (Group Substance Abuse Treatment Counseling)
session and spend a third hour working on exercises to improve parent-child communication (Parenting
Skills Education). Two tables provided below contain definitions to assist in completing the client dosage
form. Table 1 has definitions of the treatment modalities for completing the first section of the client
dosage form and Table 2 has definitions on various service and treatment activities for the completion of
the second section of the client dosage form.
COMPLETING THE CLIENT DOSAGE FORM
Below are some suggestions that will facilitate your completion of the Client Dosage Form. Please
complete one form for each TCE-HIV client in your program.
1. Complete a Client Dosage Form for each TCE-HIV client at discharge. The definition of discharge
should follow your program definition. If your program does not have a definition of discharge, the
Client Dosage Form should be completed when the client has had no contact with the program for 30
days.
2. It is critical that you are familiar with the form and have the client’s chart/records (or other records of
the client’s services received and activities) available prior to completing the form. Give yourself
about 15 minutes to complete the form when you have the client’s records.
2
Attachment 1b: Document 2 - Client Dosage Form
INSTRUCTIONS FOR COMPLETION
DATE: Please fill in the date you complete the form.
CLIENT IDENTIFICATION: Enter the client’s program identification number. The client’s ID number
should be the same number assigned to the client for his/her GPRA administration.
PERSON COMPLETING FORM: Fill in your name as the person completing the form.
GRANT NUMBER: Enter your grant identification number starting with TI0.
QUESTION 1[LENGTH OF STAY]: To complete this question you will need to refer to the client’s
treatment records to assess how many days the client spent in your treatment program and place an “X” in
the box next to the corresponding number of days the client spent in treatment.
QUESTION 2 [TYPE OF TREATMENT]: For this question you will need to indicate the type of
treatment the client engaged in while in your program. Please refer to Table 1 for clarification if you are
uncertain of the type of treatment. Please place an “X” in the appropriate box(es) for the type of
treatment the client engaged in while in your program.
Table 1: Dosage Treatment Modalities
TREATMENT MODALITY
Outpatient: This modality is for clients who require treatment that entails group education, activity therapy, etc.,
lasting more than 4 continuous hours in a supportive environment.
Intensive Outpatient: This modality consists of intense multimodal treatment for clients who require frequent
treatment in order to improve, while still maintaining family, student, or work responsibilities in the community.
Intensive outpatient services differ from outpatient by the intensity and number of hours per week. Intensive
outpatient services are provided 2 or more hours per day for 3 or more days per week.
Methadone: This modality includes the provision of methadone maintenance for opioid-addicted clients.
Residential: This modality is for a residential facility that provides onsite structured therapeutic and supportive
services specifically for alcohol and other drugs.
SERVICE/TREATMENT ACTIVITIES: These series of statements refer to the services and treatment
activities a client received or in which he or she participated. Please refer to Table 2 if you need a
definition for the service/treatment activity. Begin with the first service/treatment activity and look across
to the column labeled “A Services Received.” Choose the response category (i.e., 1 = yes, 0 = no, -1 =
N/A, -8 = Don’t know) for the service or treatment activity and record the number in column A. If you
record a N/A (-1) for receiving a service in Column A, then it is anticipated that the client will also
receive N/A in Columns B–C. Repeat the same process for Columns B and C. Go through each of the
service/treatment activity and repeat the process until you are finished.
Table 2: Dosage Service/Treatment Activities
SERVICE/TREATMENT ACTIVITIES
Case Management Services: These services involve direct services between the client and the case manager,
including individual assessments, service plan development and evaluation, arranging for and monitoring needed
services, making and following up on referrals, and other case management services as defined by the program.
Routine telephone calls are not included.
3
Attachment 1b: Document 2 - Client Dosage Form
Parenting Skills Education: Activities included in this category include instruction on developmental expectations
parents should have given their child’s age, provision of information about positive parenting practices and forms of
discipline, lessons on parent-child communication, and other parenting-related information.
Family Counseling: Activities included in this category include relationship-building activities conducted with the
client and family members together, family mediation, family counseling (individual family or multi-family),
parenting counseling (individual or group), and self-help/support groups for clients.
Physical Exam: The category includes any physical examination by a licensed professional such as a medical
doctor, nurse practitioner, or physician’s assistant that includes assessment of height, weight, vital signs, body mass
index, or body systems such as respiratory, cardiac, gastrointestinal, genitourinary, skin, and neurological.
Educational Services: This category includes activities such as tutoring assistance to improve reading, literacy,
and math skills or other educational activities leading to a high school diploma, GED, or higher education.
Employment Placement/Vocational Support: Vocational support activities are included in this category, such as
career counseling, job training, resources provided to clients to assist in finding employment, and job placement.
Life Skills Training: Activities in this category focus on training on specific personal or interpersonal skills that
have been identified as important to successful individual and social development. This category includes skills
development training that targets competencies, such as communication, decision making, problem solving, conflict
resolution, refusal skills, as well as more general life skills (e.g., budgeting, cooking). Also included in this category
are program sessions that specifically address self-esteem, self-concept, and self-confidence building.
Positive Recreation and Enrichment: This category includes a broad range of program activities that share a
primary concern about leisure time activities that take place in a drug-free environment, are appealing to clients, and
may contribute to enrichment or skills development by providing an opportunity to engage in stimulating and
rewarding activities. Activities in this category may be loosely structured, e.g., self-care time and group meals, or
more structured activities such as crafts courses or art classes.
Substance Abuse Education: This category includes education, training, or discussion sessions that focus directly
or indirectly on information concerning Alcohol, Tobacco, or Other Drugs (ATOD) awareness, knowledge, or use.
The category also includes training or education on risk situations specifically related to ATOD use, such as
HIV/AIDS, and preventing and controlling violent impulses, especially those resulting from substance abuse.
Rapid HIV Testing and Counseling: Included in this category are the private pre and post test counseling sessions
associated with each rapid HIV testing session.
HIV Prevention Education: Activities in this category focus on training on specific personal or interpersonal
skills that have been identified as important to prevent or reduce the risk for HIV infection. This category includes
skills for condom negotiation, practicing safer sex, and awareness of barrier methods and microbicides.
Childcare: This category includes care provided to children for a period of time so clients can participate in
individual and group activities or receive services.
Relapse Prevention: This category includes the activities and processes for identifying each client’s current stage
of recovery and establishing a recovery plan to identify and manage the relapse warning signs.
Social Support Groups: Included in this category are the sessions clients engage in to help or improve themselves
with assistance from others; and/or an assemblage of persons who have similar experiences and assist in
encouraging and keeping individuals from relapsing.
Spiritual Activity: Included in this category is spiritual/religion-based support for the clients’ recovery process
(meditational activities/use of media, attendance at services.
4
Attachment 1b: Document 2 - Client Dosage Form
Form Approved
OMB No. XXXX-XXXX
Expiration Date XX-XX-XX
DATE:
2 0
|__|__| |__|__| |__|__|__|__|
DF_MO DF_DY DF_YR
CLIENT’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
DF_CLIENT
PERSON COMPLETING |_______________|
DF_INTERVIEWER
GRANT# TI0|__|__|__|__|__|
DF_SITE
CLIENT DOSAGE FORM
At the time a client is discharged from treatment, this form is to be completed by project staff based on review of each
client’s treatment records.
1.
Length of stay
2.
Treatment modality (check all that apply)
DF_LENGTH_STAY
DF_TREATMENT_MODALITY
Less than 30 days .............
30 days ..............................
31 – 45 days ......................
46 – 60 days ......................
61 – 90 days ......................
91 – 120 days ....................
121 – 180 days ..................
181 – 270 days ..................
More than 270 days...........
COLUMN ‘A’ RESPONSES
SERVICES RECEIVED
1 = Yes
0 = No
-1 = N/A
-8 = Don’t know
Outpatient ......................
Intensive Outpatient .......
Methadone .....................
Residential .....................
1
2
3
4
1
2
3
4
5
6
7
8
9
COLUMN ‘B’ RESPONSES
NUMBER OF SESSIONS
0 = No sessions
1 = Once
2 = Monthly
3 = 2–3 x/month
4 = Weekly
5 = 2–4 x/week
6 = 5–6 x/week
7 = Daily
-1 = N/A
1
2
3
4
5
6
-1
=
=
=
=
=
=
=
COLUMN ‘C’ RESPONSE
WHERE AND BY WHOM
On-site by TCE-HIV project staff
On-site by another agency
Off-site by TCE-HIV project staff
Off-site by another agency
On-site by TCE-HIV parent organization staff
Off-site by TCE-HIV parent organization staff
N/A
In the following section, choose the response category that most closely describes the services received by this client.
Record the corresponding value in the box for each column: A – Services Received, B – Number of Sessions, and
C – Where and by Whom. Please note for Column C you can enter more than one number as appropriate for where
services were received.
If a client is given a N/A for receiving a service in Column A, then it is anticipated that the client will also receive N/A or
NONE in Columns B and C.
Public reporting burden for this collection of information is estimated to average 15 minutes per response; including the time for
reviewing instructions, searching existing data sources 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 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 control number for this project is XXXX-XXXX.
Attachment 1b: Document 2 - Client Dosage Form
SERVICE/TREATMENT ACTIVITY
A
Services
Received
1.
2.
3.
4.
Pretreatment Services..................................................................................
Rapid HIV Testing and Counseling ..............................................................
Substance Abuse Education ........................................................................
HIV Prevention Education, including prevention education for:....................
a. Safe sex practices ....................................................................................
b. Condom negotiation skills .........................................................................
c. Barrier protection methods .......................................................................
d. Peer education .........................................................................................
e. HIV risk in pregnancy & childbirth ............................................................
5.
Sexually Transmitted Infections Screening and Treatment ..........................
6.
Medical Diagnosing and Follow-up Treatment .............................................
7.
Physical Exam by Healthcare Providers (including height, weight,
vital signs, body mass index, and body systems such as
respiratory, cardiac, gastrointestinal, genitourinary, skin,
neurological).................................................................................................
8.
9.
10.
11.
12.
Laboratory Testing (urinalysis, complete blood count, electrolytes) .............
Substance Abuse Treatment Planning ..........................................................
Mental Health Assessment ..........................................................................
Mental Health Treatment..............................................................................
Group Psychiatric Therapy (based on psychiatric diagnosis).......................
B
Sessions
C
Where and
by Whom
|___|
|___|
|___|
DF_STA01_A
DF_STA01_B
DF_STA01_C
|___|
|___|
|___|
DF_STA02_A
DF_STA02_B
DF_STA02_C
|___|
|___|
|___|
DF_STA03_A
DF_STA03_B
DF_STA03_C
|___|
|___|
|___|
DF_STA04_A
DF_STA04_B
DF_STA04_C
|___|
|___|
|___|
DF_STA04a_
DF_STA04a_
DF_STA04a_
SAFE_A
SAFE_B
SAFE_C
|___|
|___|
|___|
DF_STA04b_
DF_STA04b_
DF_STA04b_
CONDOM_A
CONDOM_B
CONDOM_C
|___|
|___|
|___|
DF_STA04c_
DF_STA04c_
DF_STA04c_
BARRIER_A
BARRIER_B
BARRIER_C
|___|
|___|
|___|
DF_STA04d_
DF_STA04d_
DF_STA04d_
PEER_A
PEER_B
PEER_C
|___|
|___|
|___|
DF_STA04e_
DF_STA04e_
DF_STA04e_
PREGNANT_A
PREGNANT_B
PREGNANT_C
|___|
|___|
|___|
DF_STA05_A
DF_STA05_B
DF_STA05_C
|___|
|___|
|___|
DF_STA06_A
DF_STA06_B
DF_STA06_C
|___|
|___|
|___|
DF_STA07_A
DF_STA07_B
DF_STA07_C
|___|
|___|
|___|
DF_STA08_A
DF_STA08_B
DF_STA08_C
|___|
|___|
|___|
DF_STA09_A
DF_STA09_B
DF_STA09_C
|___|
|___|
|___|
DF_STA10_A
DF_STA10_B
DF_STA10_C
|___|
|___|
|___|
DF_STA11_A
DF_STA11_B
DF_STA11_C
|___|
|___|
|___|
DF_STA12_A
DF_STA12_B
DF_STA12_C
Attachment 1b: Document 2 - Client Dosage Form
SERVICE/TREATMENT ACTIVITY (continued)
A
Services
Received
13.
14.
15.
16.
17.
Individual Psychiatric Therapy (based on psychiatric diagnosis)..................
Individual Substance Abuse Treatment Counseling .....................................
Group Substance Abuse Treatment Counseling ..........................................
Gender Specific Sessions ............................................................................
Trauma-informed services, including assessment and interventions for:
a.
b.
c.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
Emotional abuse ...................................................................................
Sexual abuse ........................................................................................
Physical abuse .......................................................................................
Case Management Services ........................................................................
Social Support Groups .................................................................................
Aftercare Planning........................................................................................
Life Skills Training ........................................................................................
Employment Readiness Training .................................................................
Employment Placement ...............................................................................
Recreational Activity (field trips, movies, team sports, cultural
experiences, picnics)....................................................................................
Spiritual Activity (meditational activities/use of media, attendance
at services)...................................................................................................
Transitional Housing ....................................................................................
Permanent Housing Arrangements ...............................................................
Educational Services (for GED and other educational needs) .....................
B
Sessions
C
Where and
by Whom
|___|
|___|
|___|
DF_STA13_A
DF_STA13_B
DF_STA13_C
|___|
|___|
|___|
DF_STA14_A
DF_STA14_B
DF_STA14_C
|___|
|___|
|___|
DF_STA15_A
DF_STA15_B
DF_STA15_C
|___|
|___|
|___|
DF_STA16_A
DF_STA16_B
DF_STA16_C
|___|
|___|
|___|
DF_STA17_A
DF_STA17_B
DF_STA17_C
|___|
|___|
|___|
DF_STA17a_
EMOTIONAL_A
DF_STA17a
EMOTIONAL_B
DF_STA17a_
EMOTIONAL_C
|___|
|___|
|___|
DF_STA17b_
SEXUAL_A
DF_STA17b_
SEXUAL_B
DF_STA17b_
SEXUAL_C
|___|
|___|
|___|
DF_STA17c_
PHYSICAL_A
DF_STA17c_
PHYSICAL_B
DF_STA17c_
PHYSICAL_C
|___|
|___|
|___|
DF_STA18_A
DF_STA18_B
DF_STA18_C
|___|
|___|
|___|
DF_STA19_A
DF_STA19_B
DF_STA19_C
|___|
|___|
|___|
DF_STA20_A
DF_STA20_B
DF_STA20_C
|___|
|___|
|___|
DF_STA21_A
DF_STA21_B
DF_STA21_C
|___|
|___|
|___|
DF_STA22_A
DF_STA22_B
DF_STA22_C
|___|
|___|
|___|
DF_STA23_A
DF_STA23_B
DF_STA23_C
|___|
|___|
|___|
DF_STA24_A
DF_STA24_B
DF_STA24_C
|___|
|___|
|___|
DF_STA25_A
DF_STA25_B
DF_STA25_C
|___|
|___|
|___|
DF_STA26_A
DF_STA26_B
DF_STA26_C
|___|
|___|
|___|
DF_STA27_A
DF_STA27_B
DF_STA27_C
|___|
|___|
|___|
DF_STA28_A
DF_STA28_B
DF_STA28_C
Attachment 1b: Document 2 - Client Dosage Form
SERVICE/TREATMENT ACTIVITY (continued)
A
Services
Received
29.
30.
31.
32.
33.
34.
35.
Vocational Services......................................................................................
Childcare ......................................................................................................
Transportation ..............................................................................................
Parenting Skills Education............................................................................
Family Counseling........................................................................................
Discharge Planning (including community reintegration, socioeconomic support at State and Federal level if eligible) ...............................
Planned or Arranged Post Treatment Continuing Care ................................
B
Sessions
C
Where and
by Whom
|___|
|___|
|___|
DF_STA29_A
DF_STA29_B
DF_STA29_C
|___|
|___|
|___|
DF_STA30_A
DF_STA30_B
DF_STA30_C
|___|
|___|
|___|
DF_STA31_A
DF_STA31_B
DF_STA31_C
|___|
|___|
|___|
DF_STA32_A
DF_STA32_B
DF_STA32_C
|___|
|___|
|___|
DF_STA33_A
DF_STA33_B
DF_STA33_C
|___|
|___|
|___|
DF_STA34_A
DF_STA34_B
DF_STA34_C
|___|
|___|
|___|
DF_STA35_A
DF_STA35_B
DF_STA35_C
Attachment 1b: Document 3 - Client Data Sheet
Form Approved
OMB No. ####-####
Expiration Date: ##/##/####
TCE-HIV Multi-Site Evaluation
Client Focus Group Participant Information
CSAT would like to learn more about you and your involvement with this organization/program. Please
take a few minutes to answer these questions before the focus group begins. Your help in answering
these questions is greatly appreciated and your answers will be held in confidence.
Grantee ID Number: _______________________
Date: ____________________
1. How long have you been a client of the program? _________________
2. Is this your first time in a substance abuse treatment program?
Yes
No
If no, how many times have you been in treatment? __________________
3. What is your gender?
Male
Female
Transgender
4. What is your age? _____________ years old
5. Are you Hispanic or Latino?
Yes
No
6. If yes, what ethnic group do you consider yourself? Please answer yes or no for each of
the following. You may say yes to more than one.
Central American
Yes
No
Cuban
Yes
No
Dominican
Yes
No
Mexican
Yes
No
Puerto Rican
Yes
No
South American
Yes
No
Other
Yes
No
(If Yes in “Other”, please specify)_______________________________
7. What is your race? Please answer yes or no for each of the following. You may check all
that apply.
Alaska Native
Yes
No
American Indian
Yes
No
Asian
Yes
No
Black or African American
Yes
No
Native Hawaiian
Yes
No
Other Pacific Islander
Yes
No
White
Yes
No
Other
Yes
No
(If Yes in “Other”, please specify)_____________________
8. Education (Highest Completed):
Some High School
High School Diploma/GED
Some vocational/technical training
Vocational technical diploma
Associate’s Degree
Bachelor’s Degree
Other (please specify) ___________
1
Attachment 1b: Document 3 - Client Data Sheet
Satisfaction with TCE-HIV Program Services
Please indicate how much you agree or disagree with each statement below. Please select the
one that best describes how you feel about each statement.
Disagree
1.
2.
3.
4.
5.
6.
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.
Somewhat
Agree
Agree
Strongly
Agree
Does
Not
Apply
THANK YOU!
Notice to Respondents
Public reporting time for this collection is estimated to average 60 minutes, 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 OMB Officer, 1
Choke Cherry Road Room 7-1044, Rockville, MD 20850. 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 XXXX-XXXX.
2
| File Type | application/pdf |
| File Title | TCE-HIV SITE VISIT CONSENT FORM AND DATA COLLECTION INSTRUMENT |
| Author | Administrator |
| File Modified | 2010-07-30 |
| File Created | 2010-07-30 |