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pdfTraining on TCE-HIV Multi-Site Evaluation
Client Level Survey Instrument Completion
for Pilot Test
Introduce pilot test TCE-HIV Multi-Site Evaluation
Project Client Level Survey.
Provide guidelines for completing and the Client
Level Survey for the pilot test.
Provide assistance to enhance consistency of pilot
data collected using the Client Level Survey.
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•
JBS Team
•
Background
•
TCE-HIV Client Level
Survey
JBS
International, Inc.
Alliances for Quality Education, Inc.
Battelle Memorial Institute
Oregon Health & Science University
CSAT’s TCE-HIV Program was designed to improve
access to substance abuse treatment and
HIV/AIDS services through increasing capacity
and outreach to racial and ethnic minority
populations.
The purpose of the TCE-HIV Client Level Survey
is to…
Serve as a supplemental information source that
measures content areas not covered in GPRA.
Gather data regarding client outcomes before and
after exposure to TCE-HIV services.
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Similar to administration of the GPRA, the Client Level
Survey for the pilot test can be administered at
baseline, discharge, and 6 months post-baseline.
For the pilot test, the Client Level Survey should be
administered to nine TCE-HIV enrolled clients who are
also administered the GPRA.
If possible, we are requesting that you administer the
Client Level Survey to 3 clients at baseline, 3 clients at
discharge, and 3 clients at 6-months post-baseline.
If possible, the Client Level Survey should be
administered to clients between November 12, 2009
and December 1, 2009
Please read the introduction to each section (in italics)
and then read each question to the client as it is
written.
You will read the response options to clients for some
questions. Other questions are open-ended and you will
not read the response options to clients. See the note
in italics next to each question for guidance.
If the client requests clarification, you may assist them
in understanding the question, but please do not
change the wording of the question. Do not provide the
response options unless indicated or unless the client
requests them for clarification.
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When marking answers, please mark choices with an
“X.”
For questions that require you to write the client’s
response, please record the exact statement given by
the client.
Have a calendar present to reference for questions that
ask about the past 30 days.
Have the pre-provided Response Cards available and
provide the card to clients when required during survey
administration.
We believe the Client Level Survey will take about 25
minutes to administer.
However, we would like your feedback on how long it
takes to administer each of the 9 surveys.
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CLIENT IDENTIFICATION (ID)
Client ID: The Client ID appears above Section A.
The Client ID should be the same as the GPRA ID.
The GPRA Client ID is a unique client identifier that
is determined by the program.
The GPRA Client ID can be between 1 and 15
characters and can include both numerals and
letters.
This number should be written in the space
provided next to Client ID.
EXAMPLE: RM102919
SECTION A: BACKGROUND INFORMATION
A1: Do you consider yourself a racial/ethnic
minority? Do not read response options.
Read the italicized Section A introduction above
question A1 and then read question A1 as written.
Record the client’s answer by marking the survey
response that most closely matches the client’s
answer.
If they client reports that they are uncertain or do
not know, mark the “Don’t Know” box.
If the client refuses to answer the question, mark
the “Refused” box.
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SECTION A: BACKGROUND INFORMATION
A2: What is your sexual orientation? Do not read
response options.
Read question A2 as written.
Record the client’s answer by marking the survey
response that most closely matches the client’s
answer.
If the client records a response that does not
match any of the provided responses, mark the
“Other” box and record the client’s response in
the space provided.
If the client refuses to answer the question, mark
the “Refused” box.
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SECTION A: BACKGROUND INFORMATION
A3: What is your marital status? Do not read
response options.
Read question A3 as written.
Record the client’s answer by marking the
survey response that most closely matches the
client’s answer.
If the client refuses to answer the question,
mark the “Refused” box.
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SECTION A: BACKGROUND INFORMATION
A4: In the past 30 days, with whom did you live?
You may say yes to more than one. Please read
response options.
Read question A4 as written and then read each
response option and allow the client the answer
“Yes” or “No” to each.
Record all “Yes” responses by marking the box to
the left of the response option with an “X.”
If the client answers “No” please do not mark the
box.
If the client refuses to answer the question, mark
the “Refused” box.
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SECTION B: SUBSTANCE USE/RISKY BEHAVIOR
B1: I am going to ask you about your alcohol and
drug use on a typical day during the past 30
days. In particular, I am going to ask how many
times you used alcohol and specific drugs. Do not
read response options.
Read the italicized Section B introduction above
question B1, and then read questions B1a through
B1o as written.
Use the “On a typical day during the past 30 days
how many times did you use…” question stem for
questions B1a through B1o.
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SECTION B: SUBSTANCE USE/RISKY BEHAVIOR
B1a through B1n: On a typical day during the past
30 days how many times did you use…? Do not
read response options.
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SECTION B: SUBSTANCE USE/RISKY BEHAVIOR
B1a through B1n: On a typical day during the
past 30 days how many times did you use…? Do
not read response options.
In the space provided, record the client’s response
to the number of times they used the substance(s)
in question on a typical day during the past 30
days.
If the client answers that they did not use the
substance on a typical day, mark the box “No Past
30 Day Use.”
If they client reports that they are uncertain or do
not know, mark the “Don’t Know” box.
If the client refuses to answer the question, mark
the “Refused” box.
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SECTION B: SUBSTANCE USE/RISKY BEHAVIOR
B1o: On a typical day during the past 30 days how
many times did you use…other drugs (specify)? Do
not read response options.
If the client reports that they used other drugs on a
typical day during the past 30 days, request that they
specify and record the client’s response in the space
provided beneath “Other (specify).”
If the client answers that they did not use other drugs
on a typical day during the past 30 days, mark the “No
Past 30 Day Use” box.
If they client reports that they are uncertain or do not
know, mark the “Don’t Know” box.
If the client refuses to answer the question, mark the
“Refused” box.
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SECTION B: SUBSTANCE USE/RISKY BEHAVIOR
If the client reports no drug or alcohol use in
questions B1a through B1o, move to question
B2 of the survey.
If the client reports any drug or alcohol use in
questions B1a through B1o, skip to question B4
of the survey
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SECTION B: SUBSTANCE USE/RISKY BEHAVIOR
B2: You reported that you did not use alcohol or
drugs in the past 30 days. What were your reasons
for not using in the past 30 days? You may say yes to
more than one. Please read response options.
Read question B2 as written and then read each
response option and allow the client the answer “Yes”
or “No” to each.
Record all “Yes” responses by marking the box to the
left of the response option with an “X.”
If the client answers “No” please do not mark the box.
Mark the “Not Applicable…” box if the client used
alcohol and/or drugs in the past 30 days.
If the client refuses to answer the question, mark the
“Refused” box.
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SECTION B: SUBSTANCE USE/RISKY BEHAVIOR
B3: Did you use alcohol or drugs in the past 60
days? Do not read response options.
Read question B3 as written.
If the client responds “Yes,” request that they
specify what substances they have used in the past
60 days and record the client’s response in the
space provided.
If they client reports that they are uncertain or do
not know, mark the “Don’t Know” box.
If the client refuses to answer the question, mark
the “Refused” box.
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SECTION B: SUBSTANCE USE/RISKY BEHAVIOR
B4: In the past 30 days, have you shared drug
injection equipment (needles/syringes, cotton,
cooker, water without first cleaning it with
anything? Do not read response options.
If questions B2 and B3 were completed, skip to
question B6 in the survey. If questions B2 and B3 were
not completed, read question B4 as written.
If the client responds “Yes,” request that they specify
the number of times and record the client’s response in
the space provided.
Mark the “Not Applicable…” box if the client did not
use drug injection equipment in the past 30 days.
If the client refuses to answer the question, mark the
“Refused” box.
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SECTION B: SUBSTANCE USE/RISKY BEHAVIOR
B5: In the past 30 days, did you share drug injection
equipment (needles/syringes) with someone you
know had, or suspected of having HIV/AIDS? Do not
read response options.
Read question B5 as written.
If the client responds “Yes,” request that they specify
the number of times and record the client’s response in
the space provided.
Mark the “Not Applicable…” box if the client did not
use drug injection equipment in the past 30 days.
If the client refuses to answer the question, mark the
“Refused” box.
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SECTION B: SUBSTANCE USE/RISKY BEHAVIOR
B6: In the past 30 days, did you have….
Read the italicized introduction above question
B6, and then read question B6a through B6e as
written.
Use the “In the past 30 days, did you have…”
question stem for questions B6a through B6e.
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SECTION B: SUBSTANCE USE/RISKY BEHAVIOR
B6a through B6e: In the past 30 days, did you have
…?
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SECTION B: SUBSTANCE USE/RISKY BEHAVIOR
B6a through B6e: In the past 30 days, did you have …?
If the client reports that they have engaged in this behavior,
ask the number of times they engaged in oral sex, vaginal
sex, and anal sex and record the client’s response in the
space provided.
Next, ask the client whether they used any of the substances
listed in the far right column before or during engaging in
this behavior.
Read each substance listed in the column and allow the
client to respond “Yes” or “No.”
If the client reports that they used a substance other than
those listed, request that they specify and record their
response in the space provided.
Mark the “Not Applicable…” box if the client did not have
unprotected sexual contact in the past 30 days.
If the client refuses to answer the question, mark the
“Refused” box.
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SECTION C: HIV TESTING / HIV STATUS
C1: Have you ever tested positive for HIV? Do not
read response options.
Read the italicized Section C introduction above
question C1 and then read question C1 as written.
Record the client’s answer by marking the survey
response that most closely matches the client’s
answer.
If they client reports that they are uncertain or do
not know, mark the “Don’t Know” box.
If the client refuses to answer the question, mark
the “Refused” box.
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SECTION C: HIV TESTING / HIV STATUS
C2: How long have you known you were HIV positive?
Do not read response options.
If the client answered “No” to question C1, skip to
Section D. If the client answered “Yes” to question C1,
read question C2 as written.
Record the client’s answer by marking the survey
response that most closely matches the client’s answer.
If they client reports that they are uncertain or do not
know, mark the “Don’t Know” box.
Mark the “Not Applicable…” box if the client reported
that they are not HIV positive.
If the client refuses to answer the question, mark the
“Refused” box.
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SECTION C: HIV TESTING / HIV STATUS
C3 through C10: Since you found out you were
HIV positive, how much have you changed the
following behaviors…
Read the italicized introduction above question C3.
Provide the client with Response Card A.
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SECTION C: HIV TESTING / HIV STATUS
C3 through C10: Since you found out you were
HIV positive, how much have you changed the
following behaviors…?
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SECTION C: HIV TESTING / HIV STATUS
C3 through C10: Since you found out you were HIV
positive, how much have you changed the following
behaviors…?
Read questions C3 through C10 as written.
Using Response Card A, clients will be able to respond
“Not at all,” “A little bit,” “Moderately,” “Quite a bit,”
or “Extremely” to each question in the series
Only one choice should be selected for each question.
Mark the “Not Applicable…” box if the client reported
that they are not HIV positive.
If the client refuses to answer the question, mark the
“Refused” box.
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SECTION D: SOCIAL SUPPORT
D1 through D9: Social Support Questions
Read the italicized introduction above question
D1.
Provide the client with Response Card B.
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SECTION D: SOCIAL SUPPORT
D1 through D9: Social Support Questions
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SECTION D: SOCIAL SUPPORT
D1 through D9: Social Support Questions
Read questions D1 through D9 as written.
Using Response Card B, clients will be able to
respond “Disagree Strongly,” “Disagree,” “Uncertain,”
“Agree,” or “Agree Strongly” to each question in the
series.
Only one choice should be selected for each
question.
If the client refuses to answer the question, mark
the “Refused” box.
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SECTION D: SOCIAL SUPPORT
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.
Read question D10 as written.
If the client responds “Yes,” request that they
specify the number of times and record the
client’s response in the space provided.
If the client refuses to answer the question, mark
the “Refused” box.
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SECTION E: MENTAL HEALTH AND MEDICAL HEALTH
E1 through E12: During the past 30 days, how
much were you distressed by…
Read the italicized introduction above question
E1.
Provide the client with Response Card A.
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SECTION E: MENTAL HEALTH AND MEDICAL HEALTH
E1 through E12: During the past 30 days, how much
were you distressed by…?
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SECTION E: MENTAL HEALTH AND MEDICAL HEALTH
E1 through E12: During the past 30 days, how
much were you distressed by…?
Read questions E1 through E12 as written.
Using Response Card A, clients will be able to respond
“Not at all,” “A little bit,” “Moderately,” “Quite a
bit,” or “Extremely” to each question in the series.
Only one choice should be selected for each question.
If the client refuses to answer the question, mark the
“Refused” box.
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SECTION E: MENTAL HEALTH AND MEDICAL HEALTH
E13: In the past 30 days, how often have you used
drugs (including prescription drugs) or alcohol in
response to stressful life events? Please use
Response Card A to provide your answer.
Read question E13 as written.
Using Response Card A, clients will be able to respond
“Not at all,” “A little bit,” “Moderately,” “Quite a bit,”
or “Extremely” to each question in the series.
Only one choice should be selected for each question.
If the client refuses to answer the question, mark the
“Refused” box.
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SECTION E: MENTAL HEALTH AND MEDICAL HEALTH
E14: In the past 30 days, on how many days did you
use drugs or alcohol to help you cope with stressful
life events? Please use Response Card A to provide
your answer.
Read questions E14 as written.
Using Response Card A, clients will be able to respond
“Not at all,” “A little bit,” “Moderately,” “Quite a bit,”
or “Extremely” to each question in the series.
Only one choice should be selected for each question.
If the client refuses to answer the question, mark the
“Refused” box.
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SECTION E: MENTAL HEALTH AND MEDICAL HEALTH
E15: 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.
Read question E15 as written.
If the client responds “Yes,” request that they
specify the number of times and record the client’s
response in the space provided.
If the client refuses to answer the question, mark
the “Refused” box.
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SECTION E: MENTAL HEALTH AND MEDICAL HEALTH
E16: During the past 3 months, were you prescribed
a medication for mental or emotional difficulties
(e.g., Prozac, Cymbalta)? Do not read response
options.
Read question E16 as written.
If the client responds “Yes,” request that they
specify the medication(s) and record the client’s
response in the space provided.
If the client refuses to answer the question, mark
the “Refused” box.
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SECTION E: MENTAL HEALTH AND MEDICAL HEALTH
E17: Is this your first time in a substance abuse
treatment program? Do not read response options.
Read question E17 as written and allow the client
to answer “Yes” or “No.”.
If the client refuses to answer the question, mark
the “Refused” box.
If the client answers “Yes” to question E17, skip to
question E20 in the survey.
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SECTION E: MENTAL HEALTH AND MEDICAL HEALTH
E18: How many times have you been in substance
abuse treatment before coming to this program?
Please read response options.
This question should only be read if the client answered
“No” to question E17.
Read question E18 as written and then read each
response option and allow the client the response
option that best fits their prior substance abuse
treatment history.
Mark the “Not Applicable…” box if the client not been
in substance abuse treatment before.
If the client refuses to answer the question, mark the
“Refused” box.
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SECTION E: MENTAL HEALTH AND MEDICAL HEALTH
E19: What type of substance abuse treatment
program were you in before coming to this program?
Do not read response options.
This question should only be read if the client answered
“No” to question E17.
Record the client’s answer by marking the survey
response that most closely matches the client’s answer.
Mark the “Not Applicable…” box if the client not been
in substance abuse treatment before.
If the client refuses to answer the question, mark the
“Refused” box.
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SECTION E: MENTAL HEALTH AND MEDICAL HEALTH
E20: Why are you enrolling in this treatment
program? Do not read response options.
Read question E20 as written.
Record the client’s answer by marking the survey
response that most closely matches the client’s
answer.
If the client reports a reason for enrolling not
provided among the response options, mark the
“Other” box and record the client’s response in the
space provided.
If the client refuses to answer the question, mark
the “Refused” box.
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SECTION E: MENTAL HEALTH AND MEDICAL HEALTH
E21: Which drug(s) do you want to address in
this treatment program?
Read question E21 as written.
Record all substances that the client reports that
they wish to address through the course of their
treatment program in the space provided.
If they client reports that they are uncertain or do
not know, mark the “Don’t Know” box.
If the client refuses to answer the question, mark
the “Refused” box.
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SECTION E: MENTAL HEALTH AND MEDICAL HEALTH
E22: In the past 30 days, did you have any type
of health insurance for yourself? Please read
response options.
Read question E22 as written and then read each
response option and allow the client the answer
“Yes” or “No” to each.
Record all “Yes” responses by marking the box to
the left of the response option with an “X.”
If the client refuses to answer the question, mark
the “Refused” box.
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SECTION E: MENTAL HEALTH AND MEDICAL
HEALTH
E23: 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.
Read question E23 as written.
If the client responds “Yes,” request that they
specify the number of times and record the
client’s response in the space provided.
If the client refuses to answer the question,
mark the “Refused” box.
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SECTION E: MENTAL HEALTH AND MEDICAL HEALTH
E24: During the past 30 days, for about how
many days did poor physical health keep you
from doing your usual activities, such as selfcare, work, or recreation? Do not read response
options.
Read question E24 as written.
Record the client’s reported number of days that
poor physical health kept them from doing their
usual activities over the past 30 days in the space
provided.
If the client reports no days of impairment, record
“0” in the space provided.
If the client refuses to answer the question, mark
the “Refused” box.
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SECTION F: MOTIVATION FOR TREATMENT
F1 through F8: Motivation For Treatment Questions
Read the italicized introduction above question
F1.
Provide the client with Response Card C.
Note: If the client’s primary substance of choice is
alcohol, please replace underlined words with the
wording changes suggested in [ ] for questions F1
through F8.
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SECTION F: MOTIVATION FOR TREATMENT
F1 through F8: Motivation For Treatment Questions
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SECTION F: MOTIVATION FOR TREATMENT
F1 through F8: Motivation For Treatment
Questions
Read questions F1 through F8 as written.
Using Response Card C, clients will be able to
respond “Disagree,” “Undecided or Unsure,”
“Agree” or “Strongly Agree” to each question in
the series.
Only one choice should be selected for each
question.
If the client refuses to answer the question, mark
the “Refused” box.
Note: If the client’s primary substance of choice is
alcohol, please replace underlined words with the
wording changes suggested in brackets.
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The next section of the survey should be completed
by program staff after administration of the Client
Level Survey.
The client should not be present at the time of
completion of this portion of the survey.
Please consult the client’s medical record as
necessary to complete this section.
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DRUG SCREENING TEST INFORMATION
1: Has the client received a drug screening test in
the past 14 days?
Mark “Yes” or “No” based upon whether the client
has received a drug screening test in the past 14
days.
If the client’s drug screening test history is
unknown, mark the “Unknown” box.
If the client has had a drug screening test in the
past 14 days, proceed with the remaining
questions.
If the client has not had a drug screening test in
the past 14 days (or their status is unknown),
consider the survey complete.
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DRUG SCREENING TEST INFORMATION
2: When did the client last receive a drug screening
test?
This item should only be completed if the client
has had a drug screening test in the past 14 days.
Record the date (month, day, and year) of the
client’s most recent drug screening test according
to the client’s medical record.
If the exact date of their last drug screening test is
not known, mark the “Unknown” box.
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DRUG SCREENING TEST INFORMATION
3: The client’s most recent drug screening test checked
for the presence of which substances and/or drug
groups? Mark all that apply.
This item should only be completed if the client has had
a drug screening test in the past 14 days.
Mark all substances that were tested for in the client’s
most recent drug screening test.
If you are unsure which substances were tested for,
mark the “Unknown” box.
If other substances than those listed were tested for,
mark “Other” and specify in the space provided.
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DRUG SCREENING TEST INFORMATION
4: How frequently do you conduct drug screening tests?
Mark all that apply.
This item should only be completed if the client has had
a drug screening test in the past 14 days.
Mark the frequency with which you conduct drug
screening tests.
If you conduct drug screening tests at a frequency other
than the response provided, mark “Other” and specify
the frequency in the space provided.
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DRUG SCREENING TEST INFORMATION
5: What was the result of the client’s most recent drug
screening test?
This item should only be completed if the client has
had a drug screening test in the past 14 days.
Mark the box that best reflects the results of the
client’s most recent drug screening test according to
the client’s medical record.
If the results of the client’s last drug screening test are
not known, mark the “Unknown” box.
If the client’s most recent drug screening test was
positive, proceed to question 6.
If the client’s most recent drug screening test was
negative or inconclusive (or their test results are
unknown), consider the survey complete.
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DRUG SCREENING TEST INFORMATION
6: What substances and/or drug groups were detected in
the client’s most recent drug screening test? Mark all
that apply.
This item should only be completed if the client has
tested positive on their most recent drug screening
test.
Mark all substances that were detected in the client’s
most recent drug screening test.
If an unknown substance was detected, mark the
“Unknown” box.
If other substances than those listed were detected,
mark “Other” and specify in the space provided.
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| File Type | application/pdf |
| File Title | Tce-HIV Rapid Hiv testing |
| Author | jkasten |
| File Modified | 2010-07-30 |
| File Created | 2010-07-30 |