Form Client Instruments Client Instruments Client Instruments

Targeted Capacity Expansion Program for Substance Abuse Treatment and HIV/AIDS Services (TCE-HIV)

Attachment 1A-Client Instruments

Client

OMB: 0930-0317

Document [pdf]

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Attachment 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 for this project is XXXX-XXXX.

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 behaviors (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.

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.

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.

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?

PROBE 2: When you needed services, were you able to see someone as soon as
you wanted?
PROBE 3: Do/did the people who you went to for services spend enough time
with you?
PROBE 4: Do/did you help to develop your service/treatment goals?
PROBE 5: Are/were the people you received services from sensitive to your
cultural background (race, religion, language, sexual orientation,
etc.)
PROBE 6: Were you given information about different services that were
available to you?
PROBE 7: Were you given enough information to effectively handle your
problems?
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?

Attachment 1a: Document 1 - Client Focus Group Discussion Guide
Thanks for sharing how you feel about the program and for providing suggestions for
improvement in certain program areas.
IV.

Client Behaviors (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?

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?

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?

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.

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
Behaviors

* 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.)

Attachment 1a: Document 1 - Client Focus Group Discussion Guide
Additional Notes and Comments

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

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

Refused

Alaska Native
American Indian
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Refused

Client’s Age

___ ___

BL 2

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

Married

Living as Married

Separated

Divorced

Widowed

Refused

A2. In the past 30 days, with whom or where have you lived? You may say yes to more than one.
Please read response options.

Alone

With parents

With children alone

With other family members

With significant other alone

With friends

With significant other and children

In jail (short-term)

In prison (long-term)

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) __________

Refused

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

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

Medical hospitalization

On probation/parole

Inpatient mental health treatment

Lack of money

Residential substance use treatment

Other (specify) ___________________________

Not applicable – used alcohol and/or drugs in the past 30 days.

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? Do not
read response options.
1

Yes

Don’t Know

Refused

B4. In the past 30 days, did you engage in unprotected sexual activity with a female partner? Do not
read response options.
1

Yes

Don’t Know

Refused

B5. In the past 30 days, did you engage in unprotected sexual activity with both a male partner and a
female partner? Do not read response options.
1

Yes

Don’t Know

Refused

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?

of times ___

0 No
66 Don’t

Vaginal Sex

of times ___

0 No

Know

66 Don’t

Anal Sex

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

4 Cocaine/ Crack

88 Refused

5 Other

______

66 Don’t

Know
BL 4

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?

of times ___

0 No
66 Don’t

of times ___

0 No

Know

66 Don’t

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

4 Cocaine/ Crack

88 Refused

5 Other

______

66 Don’t

Know

77 N/A
88 Refused

Unprotected
sex with a
male
partner in
exchange for
money,
drugs, or
shelter?

of times ___

0 No
66 Don’t

of times ___

0 No

Know

66 Don’t

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

4 Cocaine/ Crack

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?

of times ___

0 No
66 Don’t

of times ___

0 No

Know

66 Don’t

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

4 Cocaine/ Crack

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)?

of times ___

0 No
66 Don’t

of times ___

0 No

Know

66 Don’t

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

4 Cocaine/ Crack

88 Refused

5 Other

______

66 Don’t

Know

77 N/A
88 Refused

Unprotected
sex with a
female
partner you

of times ___

0 No
66 Don’t

of times ___

0 No

Know

66 Don’t

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

BL 5

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

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

of times ___

0 No

Know

66 Don’t

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

4 Cocaine/ Crack

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?

of times ___

0 No
66 Don’t

of times ___

0 No

Know

66 Don’t

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

4 Cocaine/ Crack

88 Refused

5 Other

______

66 Don’t

Know

77 N/A
88 Refused

Unprotected
sex with a
male
partner you
know is, or
might be an
injection
drug user?

of times ___

0 No
66 Don’t

of times ___

0 No

Know

66 Don’t

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

4 Cocaine/ Crack

88 Refused

5 Other

______

66 Don’t

Know

77 N/A
88 Refused

Unprotected
sex with a
female
partner you
know is, or
might be an
injection
drug user?

of times ___

0 No
66 Don’t

of times ___

0 No

Know

66 Don’t

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

4 Cocaine/ Crack

88 Refused

5 Other

______

66 Don’t

Know

77 N/A
88 Refused

BL 6

C. HIV Testing/HIV Status

Program Staff: These questions ask 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

Don’t Know

Refused

C2. Have you ever tested positive for HIV? Do not read response options.
1

Yes

Don’t Know

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

Greater than 30 days

Don’t Know

Not applicable – Not HIV positive.

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…

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?

C5.

Sharing drug injection equipment
(needles/syringes) with someone
you know has, or might have
HIV/AIDS?

C6.

Having unprotected sexual
contact?

C7.

Having unprotected sex with
someone in exchange for money,
drugs, or shelter?

C8.

Having unprotected sex with a
partner you know has, or might
have a sexually transmitted
disease (STD)?

C9.

Having unprotected sex with a
partner you know has or might
have HIV/AIDS?

C10.

Having unprotected sex with
someone you know is or might be

BL 7

Since you found out you were HIV
positive, how much have you changed…

Not at
all

A little
bit

Moderately

Quite
a bit

Extremely

N/A

Refused

an injection drug user?
C11.

Having unprotected sex while you
were under the influence of drugs
or alcohol?

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.

D2.

You have close family members who
help you stay away from drugs.

D3.

You have good friends who do not
use drugs.

D4.

You have people close to you who
can always be trusted.

D5.

You have people close to you who
understand your situation and
problems.

D6.

You work in situations where drug
use is common.

D7.

You have people close to you who
expect you to make positive changes
in your life.

D8.

You have people close to you who
help you develop confidence in
yourself.

D9.

You have people close to you who
respect you and your efforts in this
program.

BL 8

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) __________

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

E2.

Thoughts of ending your life

E3.

Suddenly scared for no reason

E4.

Feeling lonely

E5.

Feeling blue

E6.

Feeling no interest in things

E7.

Feeling fearful

E8.

Feeling hopeless about the future

E9.

Feeling tense or keyed up

E10.

Spells of terror or panic

E11.

Feeling so restless you couldn’t sit still

E12.

Feelings of worthlessness

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

A little bit

Moderately

Quite a bit

Extremely

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) __________

Refused

BL 9

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) __________

Refused

Is this your first time in a substance abuse treatment program? Do not read response options.
1

Yes

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 – 4 times

5 – 7 times

> than 7 times

Not Applicable

Refused

What type of substance abuse treatment program were you in before coming to this program? Do
not read response options.
1

Outpatient

Residential

Not Applicable

Refused

Both

Opioid Treatment

Why are you enrolling in this treatment program? Do not read response options.
1

Self-admitted

Refused

Court Mandated

Other (specify) _____________

Which drug(s) do you want to address in this treatment program?
Specify: ______________________________________________________________________
66

E21.

Don’t Know

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

I receive most of my care from this agency/organization

I receive about half of my care from this agency/organization and half from another
agency/organization

I receive most of my care from another agency/organization

BL 10

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.

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) __________

Refused

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 __________

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].

F3.

I’m not just thinking about
changing my drug use [drinking],
I’m already doing something
about it.

F4.

I have already changed my drug
use [drinking], and I am looking
for ways to keep from slipping
back to my old pattern.

F5.

I am actively doing things now to
cut down or stop my use of drugs
[drinking].

BL 11

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].

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.

End of INTAKE/BASELINE Client-Level Survey
Thank you for your time!

BL 12

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

At each session

Randomly

Discharge

Post-discharge

Never

Other (specify) ____________

2. For what reason(s) does your program conduct drug testing? Mark all that apply.
1

Scheduled

At the request of the legal system (e.g., parole officer, court mandated)

For Cause

Other (specify) ____________

3. Has the client received a drug test in the past 90 days?
1

Yes (specify how many times) __________

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: __________________________

Unknown

5. What method was used to conduct the client’s most recent drug test?
1
66

Saliva

Blood

Urine

Hair

Sweat

Breath

Unknown

6. Was the sample collection directly observed?
1

Yes

Unknown

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) ____________________________

Unknown

8. What were the results of the client’s most recent drug test?
1

Negative for all drugs tested

Positive (specify for which substances) ______________________________

Other outcome (i.e., neither negative nor positive), specify ________________________

Unknown

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) ________________________________________________
66

Unknown

BL 13

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

3 = Moderately

3 = Uncertain

3 = Undecided or Unsure

4 = Quite a bit

4 = Agree

5 = Extremely

5 = Agree Strongly

5 = Strongly Agree

BL 14

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.

D/C 1

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

Refused

Alaska Native
American Indian
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Refused

Client’s Age

___ ___

D/C 2

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

Married

Living as Married

Separated

Divorced

Widowed

Refused

A2. In the past 30 days, with whom or where have you lived? You may say yes to more than one.
Please read response options.

Alone

With parents

With children alone

With other family members

With significant other alone

With friends

With significant other and children

In jail (short-term)

In prison (long-term)

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) __________

Refused

Don’t Know

D/C 3

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

Medical hospitalization

On probation/parole

Inpatient mental health treatment

Lack of money

Residential substance use treatment

Other (specify) ___________________________

Not applicable – used alcohol and/or drugs since entering treatment.

Refused

Yes

Don’t Know

Refused

B4. In the past 30 days, did you engage in unprotected sexual activity with a female partner? Do not
read response options.
1

Yes

Don’t Know

Refused

B5. In the past 30 days, did you engage in unprotected sexual activity with both a male partner and a
female partner? Do not read response options.
1

Yes

Don’t Know

Refused

***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?

of times ___

0 No
66 Don’t

Vaginal Sex

of times ___

0 No

Know

66 Don’t

Anal Sex

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

4 Cocaine/ Crack

88 Refused

5 Other

______

66 Don’t

Know
D/C 4

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?

of times ___

0 No
66 Don’t

of times ___

0 No

Know

66 Don’t

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

4 Cocaine/ Crack

88 Refused

5 Other

______

66 Don’t

Know

77 N/A
88 Refused

Unprotected
sex with a
male
partner in
exchange for
money,
drugs, or
shelter?

of times ___

0 No
66 Don’t

of times ___

0 No

Know

66 Don’t

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

4 Cocaine/ Crack

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?

of times ___

0 No
66 Don’t

of times ___

0 No

Know

66 Don’t

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

4 Cocaine/ Crack

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

of times ___

0 No
66 Don’t

of times ___

0 No

Know

66 Don’t

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

4 Cocaine/ Crack

88 Refused

5 Other

______

66 Don’t

Know

77 N/A
88 Refused
1#

of times ___

0 No
66 Don’t

of times ___

0 No

Know

66 Don’t

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

D/C 5

Oral Sex

know had, or
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

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

of times ___

0 No

Know

66 Don’t

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

4 Cocaine/ Crack

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?

of times ___

0 No
66 Don’t

of times ___

0 No

Know

66 Don’t

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

4 Cocaine/ Crack

88 Refused

5 Other

______

66 Don’t

Know

77 N/A
88 Refused

Unprotected
sex with a
male
partner you
knew was, or
suspected of
being an
injection
drug user?

of times ___

0 No
66 Don’t

of times ___

0 No

Know

66 Don’t

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

4 Cocaine/ Crack

88 Refused

5 Other

______

66 Don’t

Know

77 N/A
88 Refused

Unprotected
sex with a
female
partner you
knew was, or
suspected of
being an
injection
drug user?

of times ___

0 No
66 Don’t

of times ___

0 No

Know

66 Don’t

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

4 Cocaine/ Crack

88 Refused

5 Other

______

66 Don’t

Know

77 N/A
88 Refused

D/C 6

C. HIV Testing/HIV Status

Yes

Don’t Know

Refused

C2. Have you ever tested positive for HIV? Do not read response options.
1

Yes

Don’t Know

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

Greater than 30 days

Don’t Know

Not applicable – Not HIV positive.

Refused

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?

C5.

Sharing drug injection equipment
(needles/syringes) with someone
you know had, or suspected of
having HIV/AIDS?

C6.

Having unprotected sexual
contact?

C7.

Having unprotected sex with
someone in exchange for money,
drugs, or shelter?

C8.

Having unprotected sex with a
partner you know had, or
suspected of having a sexually
transmitted disease (STD)?

C9.

Having unprotected sex with a
partner you know had, or
suspected of having HIV/AIDS?

C10.

Having unprotected sex with

D/C 7

Since you found out you were HIV
positive, how much have you changed…

Not at
all

A little
bit

Moderately

Quite
a bit

Extremely

N/A

Refused

someone you know was, or
suspected of being an injection
drug user?
C11.

Having unprotected sex while you
were under the influence of drugs
or alcohol?

D. Social Support

Disagree

Uncertain

Agree

Agree
Strongly

Refused

D1.

You have people close to you who
motivate and encourage your recovery.

D2.

You have close family members who
help you stay away from drugs.

D3.

You have good friends who do not
use drugs.

D4.

You have people close to you who
can always be trusted.

D5.

You have people close to you who
understand your situation and
problems.

D6.

You work in situations where drug
use is common.

D7.

You have people close to you who
expect you to make positive changes
in your life.

D8.

You have people close to you who
help you develop confidence in
yourself.

D9.

You have people close to you who
respect you and your efforts in this
program.

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) __________

Refused

D/C 8

E. Mental Health and Medical Health

Not at
all

A little
bit

Moderately

Quite
a bit

Extremely

Refused

E1.

Nervousness or shakiness inside

E2.

Thoughts of ending your life

E3.

Suddenly scared for no reason

E4.

Feeling lonely

E5.

Feeling blue

E6.

Feeling no interest in things

E7.

Feeling fearful

E8.

Feeling hopeless about the future

E9.

Feeling tense or keyed up

E10.

Spells of terror or panic

E11.

Feeling so restless you couldn’t sit still

E12.

Feelings of worthlessness

E13.

E14.

Not at all

A little bit

Moderately

Quite a bit

Extremely

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) __________

Refused

During the past 3 months, were you prescribed a medication for mental or emotional difficulties
(e.g., Prozac, Cymbalta)?
1

Yes (specify medications) __________

Refused

D/C 9

E16.

E17.

Why did you enroll in this treatment program? Do not read response options.
1

Self-admitted

Refused

Court Mandated

Other (specify) _____________

Which drug(s) did you want to address in this treatment program?
Specify: ______________________________________________________________________
66

E18.

Don’t Know

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

I receive most of my care from this agency/organization

I receive about half of my care from this agency/organization and half from another
agency/organization

I receive most of my care from another agency/organization

Medical Health
E19.

E20.

E21.

Yes, other Government health insurance
0

Refused

Yes (specify how many times) __________

Refused

D/C 10

F. Motivation for Treatment

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].

F3.

I’m not just thinking about
changing my drug use [drinking],
I’m already doing something
about it.

F4.

I have already changed my drug
use [drinking], and I am looking
for ways to keep from slipping
back to my old pattern.

F5.

I am actively doing things now to
cut down or stop my use of drugs
[drinking].

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].

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.

End of DISCHARGE Client Level Survey
Thank you for your time!

D/C 11

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

At each session

Randomly

Discharge

Post-discharge

Never

Other (specify) ____________

2. For what reason(s) does your program conduct drug testing? Mark all that apply.
1

Scheduled

At the request of the legal system (e.g., parole officer, court mandated)

For Cause

Other (specify) ____________

3. Has the client received a drug test in the past 90 days?
1

Yes (specify how many times) __________

Unknown

5. What method was used to conduct the client’s most recent drug test?
1
66

Saliva

Blood

Urine

Hair

Sweat

Breath

Unknown

6. Was the sample collection directly observed?
1

Yes

Unknown

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) ____________________________

Unknown

8. What were the results of the client’s most recent drug test?
1

Negative for all drugs tested

Positive (specify for which substances) ______________________________

Other outcome (i.e., neither negative nor positive), specify ________________________

Unknown

D/C 12

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

3 = Moderately

3 = Uncertain

3 = Undecided or Unsure

4 = Quite a bit

4 = Agree

5 = Extremely

5 = Agree Strongly

5 = Strongly Agree

D/C 13

File Type	application/pdf
File Title	TCE-HIV SITE VISIT CONSENT FORM AND DATA COLLECTION INSTRUMENT
Author	Administrator
File Modified	2010-10-20
File Created	2010-10-20