Form CAM Data Collectio CAM Data Collectio CAM Data Collection Form

Approved
OMB No. 0930-xxxx
Expiration Date: xx/xx/xx

Center for Substance Abuse Treatment (CSAT)
Children Affected by Methamphetamine in Families
Participating in Family Drug Treatment Court

Revised 5/2/2011

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number.
The OMB control number for this project is 0930-xxxx. Public reporting burden for this
collection of information is estimated to average 30 minutes per respondent, per year, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry
Road, Room 8-1099, Rockville, Maryland, 20857.

1

SECTION A. RECORD MANAGEMENT
A.1

CAMID

|____|____|____|____|____|____|____|____|

A.2

CASEID

|____|____|____|____|____|____|

A.3

ADULTID

|____|____|____|____|____|____|____|____|

A.4

Date file opened with CAM program. [FILE_O]
|____|____| / |____|____| / |____|____|____|____|
Month
Day
Year

A.5

Date file closed with CAM program. [FILE_C]
|____|____| / |____|____| / |____|____|____|____|
Month
Day
Year

A.6

Data Collection Period

[COLLPER]

Baseline
6 Month Follow-up
12 Month Follow-up
Discharge

2

SECTION B. ADULT DEMOGRAPHICS [ONLY AT BASELINE]
B.1 What is the adult’s relationship to the index child? [ARLTNSHP]
c
c
c
c
c
c
c
c
c
c
c
c
c
c
c

Biological mother
Biological father
Step mother
Step father
Adoptive mother
Adoptive father
Foster mother
Foster father
Presumptive father
Grandmother (maternal or paternal)
Grandfather (maternal or paternal)
Aunt (maternal or paternal)
Uncle (maternal or paternal)
Significant Other (unmarried partner of parent/caregiver)
Other Relationship – includes other relatives not specified and non-relatives (e.g.,
godparents, other non-biological caregivers)
c Relationship not known
B.2 What is the adult’s date of birth? [ADOB] [*The system will only save month and
year. To maintain confidentiality, day is not saved.]
|____|____| / |____|____| / |____|____|____|____|
Month
Day
Year
B.3 What is the adult’s gender? [ASEX]
Male
Female
B.4 Is the adult Hispanic/Latino? [AETHN]
No
Yes

3

B.5 What is the adult’s race? Please answer yes or no for each of the following. (Mark all
that apply)
N
A.
B.
C.
D.
E.

American Indian/ Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White

Y
[ARACAI]
[ARACAS]
[ARACBL]
[ARACNH]
[ARACWH]

B.6 Is the adult a prior perpetrator of substantiated child maltreatment? [A_PRIOR]
No
Yes
Don’t Know
B.7 Is the adult pregnant? [PREG]
Pregnant
Not Pregnant
Don’t Know
B.8 What is the adult’s marital status? [MARITAL]
Never married
Now married
Separated
Divorced
Widowed
Unknown
B.9 Is the adult enrolled in a family drug court related to CAM? [FDC]
No
Yes
Don’t Know
B.9A.

Date enrolled FDC [FDCOPEN]

|____|____| / |____|____| / |____|____|____|____|
Month
Day
Year

4

B.10 What is the adult’s primary substance problem reported at treatment admission?
(Choose only one). [SUB1]
Alcohol
Cocaine/crack
Marijuana/hashish
Heroin/other opiates (total)
Heroin
Oxycontin/ oxycodone
Hydrocodone (Lortab)
Other opiates/ synthetics
Non-prescription methadone
Hallucinogens/ psychedelics
Methamphetamine
Other amphetamines/ stimulants
Benzodiazepines
Barbiturates
Other tranquilizers or sedatives
Inhalants
Other drugs
Unknown/ missing

5

B.11

During the 30 days prior to treatment admission, on how many days has the adult
used any of the following:
NUMBER
OF DAYS

UNKNOWN/
MISSING

A, Alcohol

|____|____|

[ALCOHOL1]

B. Cocaine/crack

|____|____|

[COCAINE1]

C. Marijuana/hashish

|____|____|

[MARIJ1]

D. Opiates

|____|____|

[OPIATES1]

E.

Heroin

|____|____|

[HEROIN1]

F.

Oxycontin/oxycodone

|____|____|

[OXYCO1]

G. Hydrocodone

|____|____|

[HYDROCO1]

H. Other opiates/synthetics

|____|____|

[OTHOPIA1]

I.

Non-prescription methadone

|____|____|

[METHADO1]

J.

Hallucinogens/psychedelics

|____|____|

[HALLUC1]

K. Methamphetamine

|____|____|

[METH1]

L.

|____|____|

[OTHSTIM1]

M. Benzodiazepines

|____|____|

[BENZO1]

N. Barbiturates

|____|____|

[BARBIT1]

O. Other tranquilizers or sedatives

|____|____|

[TRANQ1]

P.

|____|____|

[INHAL1]

|____|____|

[OTHDRUG1]

Other amphetamines/stimulants

Inhalants

Q. Other drugs

B.12 In the 30 days prior to admission, how many times has the adult been arrested?
[ARREST1]
|____|____| Times
Don’t Know

6

SECTION C. INFORMATION ABOUT THE PARENT PARTICIPATING IN CAM
PROGRAM
C.1 What is the adult’s current living situation? [LIVARAG]
Homeless (client has no fixed address; includes shelters)
Dependent living (client is living in a supervised setting such as a residential institution,
including jail/prison, halfway house or group home).
Independent living (client is living alone or with others without supervision)
Don’t know
C.2 What is the number of years of school completed? [EDUC]
|____|____| Highest Grade Completed

Don’t know
C.3 Is the adult currently employed? [EMPLOY]
Full time
Part time
Unemployed
Not in labor force
Don’t know
C.4 For how many children has the parent lost parental rights? [TPR]
|____|____| Number of Children

Don’t Know
C.5 For parents/caregivers who enter substance abuse treatment, what type of treatment
do they enter? [PUBPRVTX]
Public
Private
Not applicable
Don’t know

7

C.6 What type of treatment setting is the adult currently in? [TXSET]
Detox, 24-hour, hospital inpatient
Detox, 24-hour, free-standing residential
Rehabilitation/ Residential – Hospital (other than detox)
Rehabilitation/ Residential – Short term (<=30 days)
Rehabilitation/ Residential – Long term (>30 days); may include transitional living
such as halfway house
Ambulatory – Intensive Outpatient (at minimum, client receives treatment lasting 2 or
more hours per day for 3 or more days per week)
Ambulatory – Non-intensive outpatient
Ambulatory – Detoxification (outpatient)
Unknown
C.7 What is the adult’s discharge status? [TXSTATUS]
Treatment completion
Left against professional advice (dropped out)
Terminated by facility
Transferred to another treatment program or facility (and known to report)
Transferred to another treatment program or facility, but did not report
Incarcerated
Death
Other
Unknown
Not applicable – still in treatment

8

SECTION D: SUPPORTIVE SERVICES
For the Supportive Services listed below, please indicate if the Adult has been assessed for each
type of service and whether the service has been initiated.
D.1 Parent Training/Child Development Training Services

N

Our Program
Not Identified
Does Not
Y
as a Need
Provide This

Unknown

A. Screened and/or
assessed for
parent
training/child
development
training needs
B. Services initiated

[APARENT1]

[APARENT2]

D.2 Mental Health or Counseling Services

N

Our Program
Not Identified Does Not
Y
as a Need
Provide This Unknown

A. Screened and/or
assessed for
mental health
needs
B. Services initiated

[AMH1]

[AMH2]

D.3 Trauma Services

N

Our Program
Not Identified Does Not
Y
as a Need
Provide This Unknown

A. Screened and/or
assessed for
trauma needs
B. Services initiated

[TRAUMA1]

[TRAUMA2]

D.4 Child Care Services

N

Our Program
Not Identified Does Not
Y
as a Need
Provide This Unknown

A. Screened and/or
assessed for child
care needs
B. Services initiated

[ACHCARE1]

[ACHCARE2]

D.5 Transportation Services
N

Y

Not Identified Our Program
as a Need
Does Not
Unknown
9

Provide This
A. Screened and/or
assessed for
transportation
needs
B. Services initiated

[ATRANSP1]

[ATRANSP2]

D.6 Housing Assistance Services

N

Our Program
Not Identified Does Not
Y
as a Need
Provide This Unknown

A. Screened and/or
assessed for
housing needs
B. Services initiated

[AHOUSE1]

[AHOUSE2]

D.7 Family Planning Services

N

Our Program
Not Identified Does Not
Y
as a Need
Provide This Unknown

A. Screened and/or
assessed for
family planning
needs
B. Services initiated

[FAMPL1]

[FAMPL2]

D.8 Domestic Violence Services

N

Our Program
Not Identified Does Not
Y
as a Need
Provide This Unknown

A. Screened and/or
assessed for
domestic violence
needs
B. Services initiated

[ADOMVIO1]

[ADOMVIO2]

10

D.9 Employment or Vocation Training/Education Services

N

Our Program
Not Identified
Does Not
Y
as a Need
Provide This Unknown

A. Screened and/or
assessed for
employment or
vocation training/
education needs
B. Services initiated

[AEMPLY1]

[AEMPLY2]

D.10 Continuing Care/Recovery Support Services

N

Our Program
Not Identified Does Not
Y
as a Need
Provide This Unknown

A. Screened and/or
assessed for
continuing
care/recovery
support needs
B. Services initiated

[ACONTCR1]

[ACONTCR2]

D.11 Legal Services

N

Our Program
Not Identified Does Not
Y
as a Need
Provide This Unknown

A. Screened and/or
assessed for legal
needs
B. Services initiated

[LEGAL1]

[LEGAL2]

D.12 Primary Medical Care Services

N

Our Program
Not Identified Does Not
Y
as a Need
Provide This Unknown

A. Screened and/or
assessed for
primary medical
care needs
B. Services initiated

[AMED1]

[AMED2]

11

D.13 Dental Care Services

N

Y

Not
Our Program
Identified as
Does Not
a Need
Provide this Unknown

A. Screened and/or
assessed for
dental care
services
B. Services initiated

[ADENTAL1]

[ADENTAL2]

12

SECTION E. ADULT DISCHARGE ITEMS [COMPLETE ONLY AT DISCHARGE]
E.1 During the 30 days prior to discharge from treatment, on how many days has the
adult used any of the following:
NUMBER
OF DAYS

UNKNOWN/
MISSING

A. Alcohol

|____|____|

[ALCOHOL2]

B. Cocaine/crack

|____|____|

[COCAINE2]

C. Marijuana/hashish

|____|____|

[MARIJ2]

D. Opiates

|____|____|

[OPIATES2]

E.

Heroin

|____|____|

[HEROIN2]

F.

Oxycontin/oxycodone

|____|____|

[OXYCO2]

G. Hydrocodone

|____|____|

[HYDROCO2]

H. Other opiates/synthetics

|____|____|

[OTHOPIA2]

I.

Non-prescription methadone

|____|____|

[METHADO2

J.

Hallucinogens/psychedelics

|____|____|

[HALLUC2]

K. Methamphetamine

|____|____|

[METH2]

L.

|____|____|

[OTHSTIM2]

M. Benzodiazepines

|____|____|

[BENZO2]

N. Barbiturates

|____|____|

[BARBIT2]

O. Other tranquilizers or sedatives

|____|____|

[TRANQ2]

P.

|____|____|

[INHAL2]

|____|____|

[OTHDRUG2]

Other amphetamines/stimulants

Inhalants

Q. Other drugs

E.2 In the 30 days prior to discharge from treatment, how many times has the adult been
arrested? [ARREST2]
|____|____| Times
Don’t Know
E.3 Did the adult complete family drug court? [FDCCOMP]
No
Yes
Not Applicable/did not enroll

E.3.A. Date exited FDC [FDCCLOSE]
|____|____| / |____|____| / |____|____|____|____|
Month
Day
Year
13

SECTION F. CHILD DEMOGRAPHICS [ONLY AT BASELINE]
F.1
What is the child’s date of birth? [CHBDATE] [*The system will only save month
and year. To maintain confidentiality, day is not saved.]
|____|____| / |____|____| / |____|____|____|____|
Month
Day
Year
F.2 What is the child’s gender? [CHSEX]
Male
Female
F.3 Is the child Hispanic/Latino? [CHETHN]
No
Yes
F.3 What is the child’s race? Please answer yes or no for each of the following. (Mark all
that apply)
N
A.
B.
C.
D.
E.

American Indian/ Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White

F.5 Is the child currently enrolled in school? [SCHOOL]
No
Yes
Don’t Know

14

Y
[CHRACAI]
[CHRACAS]
[CHRACBL]
[CHRACNH]
[CHRACWH]

F.5.A

[If yes] What grade? [GRADE]
Pre-School
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade/high school diploma/equivalent
Voc/tech program after high school but no voc/tech diploma
Voc/tech diploma after high school
Don’t Know

F.6 Is parental/caregiver methamphetamine use a contributing factor to the child welfare
case? [METHFACT]
No
Yes
Don’t Know
F.6.A [If yes] Was manufacturing/production of methamphetamine an allegation or
factor in the child welfare case? [MANUF]
No
Yes
Don’t Know
F.6.B[If yes] Was the sales of methamphetamine an allegation or factor in the child
welfare case? [SALES]
No
Yes
Don’t Know

15

SECTION G: CHILD MALTREATMENT AND PLACEMENT
G.1 Has there been a substantiated allegation of maltreatment during the past 6 months?
[MALTXVIC]
No
Yes
G.2 Has the child been removed from the home? [REMOVED]
No
Yes
G.3 What was the date the child removed from the home? [REMOVDT]
|____|____| / |____|____| / |____|____|____|____|
Month
Day
Year

G.4 What was the date of discharge from foster care or out-of-home care? [FCDISDT]
|____|____| / |____|____| / |____|____|____|____|
Month
Day
Year
G.5 What is the reason for discharge from foster care or out-of-home care? [FCDISP]
Not applicable
Reunification with parent(s) or primary caregiver(s)
Living with other relative
Adoption
Emancipation
Relative guardianship
Transfer to another agency
Runaway
Death of child

16

SECTION H: SUPPORTIVE SERVICES PROVIDED TO THE CHILD
For the Supportive Services listed below, please indicate if the child has been assessed for each
type of service and whether the service has been initiated.
H.1 Developmental Services

N

Y

Not Identified
as a Need

Our Program
Does Not
Provide this

Unknown

A. Screened and/or
assessed for
developmental needs
B. Services initiated

[CHDEV1]

[CHDEV2]

H.2 Mental Health or Counseling Services

N

Y

Not Identified
as a Need

Our Program
Does Not
Provide this

Unknown

A. Screened and/or
assessed for mental
health needs
B. Services initiated

[CHMH1]

[CHMH2]

H.3 Primary Pediatric Health Care Services

N

Y

Not Identified
as a Need

Our Program
Does Not
Provide this

Unknown

A. Screened and/or
assessed for primary
pediatric health care
needs
B. Services initiated

[CHMED1]

[CHMED2]

H.4 Substance Abuse Prevention Services

N

Y

Not Identified
as a Need

Our Program
Does Not
Provide this

Unknown

A. Screened and/or
assessed for
substance abuse
prevention and
education needs
B. Services initiated

[CHSAP1]

[CHSAP2]

H.5 Substance Abuse Treatment Services

N

Y

Not Identified
as a Need

A. Screened and/or

Our Program
Does Not
Provide this

Unknown
[CHSATX1]

17

assessed for
substance use
disorder
B. Services initiated

[CHSATX2]

H.6 Educational Services

N

Y

Not Identified
as a Need

Our Program
Does Not
Provide this

Unknown

A. Screened and/or
assessed for
educational needs
B. Services initiated

[CHEDUC1]

[CHEDUC2]

H.7 Neurological Effects of Prenatal Substance Use Exposure

N

Y

Not Identified
as a Need

Our Program
Does Not
Provide this

Unknown

A. Screened and/or
assessed for
neurological effects
of prenatal
substance use
exposure
B. Services initiated

[NEURO1]

[NEURO2]

H.8 Dental Care Services

N

Y

Not Identified
as a Need

Our Program
Does Not
Provide this

Unknown

A. Screened and/or
assessed for dental
care services
B. Services initiated

[CHDENTAL1]

[CHDENTAL2]

I.
FOLLOW-UP STATUS
[REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT FOLLOW-UP]

18

1.

What is the follow-up status of the client? [THIS IS A REQUIRED FIELD: NA, REFUSED,
DON’T KNOW, AND MISSING WILL NOT BE ACCEPTED].
c
c
c
c
c
c
c
c
c

2.

01 = Deceased at time of due date
11 = Completed interview within specified window
12 = Completed interview outside specified window
21 = Located, but refused, unspecified
22 = Located, but unable to gain institutional access
23 = Located, but otherwise unable to gain access
24 = Located, but withdrawn from project
31 = Unable to locate, moved
32 = Unable to locate, other (SPECIFY) ________________________

Is the client still receiving services from your program?
c
c

Yes
No

[IF THIS IS A FOLLOW-UP INTERVIEW STOP NOW, THE INTERVIEW IS
COMPLETE.]

19

J.

DISCHARGE STATUS
[REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT DISCHARGE]

1.

On what date was the client discharged?
|____|____| / |____|____| / |____|____|____|____|
MONTH
DAY
YEAR

2.

What is the client’s discharge status?
c
c

01 = Completion/Graduate
02 = Termination
If the client was terminated, what was the reason for termination? [SELECT ONE
RESPONSE.]
c 01 = Left on own against staff advice with satisfactory progress
c 02 = Left on own against staff advice without satisfactory progress
c 03 = Involuntarily discharged due to nonparticipation
c 04 = Involuntarily discharged due to violation of rules
c 05 = Referred to another program or other services with satisfactory progress
c 06 = Referred to another program or other services with unsatisfactory progress
c 07 = Incarcerated due to offense committed while in treatment/recovery with
satisfactory progress
c 08 = Incarcerated due to offense committed while in treatment/recovery with
unsatisfactory progress
c 09 = Incarcerated due to old warrant or charged from before entering
treatment/recovery with satisfactory progress
c 10 = Incarcerated due to old warrant or charged from before entering
treatment/recovery with unsatisfactory progress
c 11 = Transferred to another facility for health reasons
c 12 = Death
c 13 = Other (Specify) _________________________________

20