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pdfOMB No. 0930-0277
Expiration Date: XX/XX/XXXX
CMHS Jail Diversion and Trauma Recovery Initiative
Priority to Veterans
Baseline Instrument- 9.1.10
Interview Date: ___ ___/ ___ ___/ ____ ____ ____ ____
MM
DD
YYYY
Study ID#:
____ ____- ____ - ____- ____ ____ ____
(Site Code) (Prog #) (Grp #) (Subject ID #)
Interviewer Name:
Interview Type
_____
Interviewer ID: ___ ___
1. Admission
Site Code
01. Connecticut
09. North Carolina
02. Colorado
10. Ohio
03. Georgia
11. Pennsylvania
04. Illinois
12. Rhode Island
05. Massachusetts 13. Texas
06. Vermont
07. Florida
08. New Mexico
2. Six month
3. Twelve Month
Program Pilot
Group Code Number
1. Pilot Site 1
1. Pre-booking Diversion
2. Pilot Site 2
2. Post-booking Diversion
3. Pilot Site 3
3. Probation/Parole
4. Pilot Site 4
Violation
5. Pilot Site 5
(TBD with
sites)
Location of Interview
1. Community setting (e.g. any residence,
Was anyone else present during
restaurant, research offices, university, outdoors)
the interview?
2. Services Site (e.g. Hospital, Treatment
1. Yes
facility/program, Shelter, Transitional housing)
3. Jail
2. No
4. Court
5. Other
(specify:____________)
If Yes- who?
_________________________
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number. The OMB control number for this
project is 0930-0277. Public reporting burden for this collection of information is estimated to average 50 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 2-1057, Rockville, Maryland, 20857.
Baseline
1
TABLE OF CONTENTS
Interviewer Instructions ................................................................................................... 3
Glossary .......................................................................................................................... 4
Introduction ..................................................................................................................... 7
1. Demographics ............................................................................................................. 8
2. Education, Employment and Income ........................................................................... 9
3. Military Service Questions ......................................................................................... 12
4. Lifetime Mental Health/Substance Use Service Questions ....................................... 14
5. Drug and Alcohol Use ............................................................................................... 15
6. Services .................................................................................................................... 17
7. Criminal Justice Questions ........................................................................................ 18
8. Functioning ................................................................................................................ 19
9. Social Connectedness .............................................................................................. 20
10. Traumatic Events .................................................................................................... 21
11. Posttraumatic Stress Disorder Checklist (PCL-C) .................................................. 23
12. BASIS 24 ................................................................................................................ 25
13. REE: Recovery Markers –Revised ........................................................................ 27
END OF THE INTERVIEW ............................................................................................ 29
Interviewer Observations............................................................................................... 30
Baseline
2
Interviewer Instructions
This interview form comprises the questions that are being collected across all study
sites. This part should be administered to the respondent in its entirety prior to your
project specific interview.
1. There is a short introductory paragraph that should be adapted to your project‟s
study, program, and consent process. Please take time to review it prior to beginning
the interview.
2. Read all questions exactly as they are worded so that each respondent is asked the
same questions in the same manner.
3. Responses in capital letters should not be read to respondents. Instructions to the
interviewer are in italics. Also, NEVER read „NA‟ „RF‟ or „DK” response categories.
4. If paper interview is being administered, please be sure to review the entire
instrument for completeness and accuracy of recording. Specifically, review the
interview for: missing data, recording errors and inconsistencies, complete cover page
information, and legibility.
Baseline
3
Glossary
Term
Definition
Active Duty
Military members who are currently serving full time in their military
capacity, with military pay and allowances in the armed forces.
Adequate
Enough or good enough.
Advocate
To support or speak in favor of something.
Alimony
An allowance that a court orders paid by one's spouse or former spouse
as a part of a legal separation or divorce.
Combat Zone
Competitive Employment
A zone designated by the President by Executive order, it is a specific
geographical area defined as an area of armed conflict.
Work in the competitive labor market that is performed on a full-time
basis and paid no less than wages for same or similar work performed
by individuals who are not disabled.
Concentrate
Focusing attention on something.
Conviction
Being found guilty of a crime.
Crisis or Respite
Program--
A system that provides regular or special relief to persons or families
providing care for persons unable to care for themselves.
Criticize
To judge, negatively or unfavorably, to find fault.
Deployment
Deployment is in preparation for battle or work including peace keeping
or training.
Family, Partner,
Significant Other
Contribution
Voluntary contribution separate from court-ordered child support.
Foster Care
A situation in which a child or children are raised by people other than
their biological parents or adoptive parents.
An institution for the care and housing of persons with mental illness &/or
substance abuse problems.
A non-secure program in which a group of young people (under the age
of 18) live and receive services at the program facility under the
supervision of adult staff.
Group Home1
Group Home2
Guilty
Feelings or awareness of having done something wrong.
Hotel or Motel
An establishment that provides lodging, paid for either by the Individual
or system/shelter/program.
Inpatient Treatment
Treatment that requires at least on overnight stay at a facility.
Baseline
4
Intoxication
(Alcohol intoxication) the quantity of alcohol the person consumes
exceeds the individual's tolerance for alcohol and produces behavioral or
physical abnormalities. In other words, the person's mental and physical
abilities are impaired.
(Drug intoxication) excessive dosage (varies from individual to individual)
of drug can cause undesirable side effects.
Jail/Prison/Detention
Center
A state or federal confinement facility having custodial authority over
adults sentenced to confinement; a confinement facility administrated by
an agency of local government, typically a law enforcement agency,
entered for adults but sometimes also containing juveniles, which holds
persons detained pending sentencing and/or persons committed after
sentencing, usually those committed on sentences of a year or less.
Job Training
Training whose main objective is to prepare people for a work.
Medicaid & Medicare
Health care programs funded by the federal and state governments that
pay the medical expenses of people who are unable to pay some or all
of their own expenses.
Moderate
Not great or severe - in the middle of mild and severe.
National Guard/Reserve
Civilian military recruited by stated and equipped by the government that
can become part of the national army if there is war or national
emergency.
Items to meet basic needs, such as personal care items (e.g. deodorant,
shampoo).
Necessities
Outpatient
Probation
Treatment that takes place without the client being checked into a
hospital or treatment center. This treatment may take place in an office,
clinic or other type of care facility.
A punishment given out as part of a sentence where instead of jailing a
person, she/he is released to the community subject to certain conditions
and is under the supervision of the court
Program Staff
Employees of the housing/treatment program
Recreational Services
Services involving some form of play, amusement or relaxation.
Restraining Order/ Order
of Protection
Self-help/ Peer Support
No contact and order of protection are court orders that prohibits a
person from having any kind of contact with another individual usually
the victim of a crime.
Self-help and peer support refers to activities organized by people with
psychiatric diagnoses (or other characteristics in common) to share their
strengths and help each other cope and grow. It does not include
support groups led by service providers who are not peers.
Service-Connected
Disability
A disability that the US VA has determined was incurred or aggravated in
the line of duty during active military, naval or air service.
Sheltered Workshop
Subsidized work where an individual is paid a stipend by a program or
agency, because she is unable to work in a competitive work setting.
Staff
People who are paid to provide various services to individuals.
Baseline
5
Supported Housing or
Certified Apartment
Program
Services that assist individuals in finding and maintaining appropriate
housing arrangements.
Tour of Duty
A period of time in which those enrolled in the armed forces spend in
combat or performing operational duties for their Armed Forces branch.
Tours of duty can be anywhere from 5 months or to several years.
Transitional Housing
It is a type of housing that is used to assist the movement of homeless
individuals and families to permanent housing. In general, transitional
housing is time-limited, provides services beyond survival services, it
generally offers more privacy than a shelter, and is viewed as a step
between shelter and permanent housing.
Traumatic
Painfully emotional or shocking, often producing lasting psychological
effects.
V.A.
The United States Department of Veterans Affairs (VA) is a governmentrun military veteran benefit system. It is responsible for administering
programs of veterans‟ benefits for veterans, their families, and survivors.
Vocational Trade/Tech
Diploma
Education, training, a school, etc. intended to prepare one for an
occupation or trade, such as nurses' assistant, electrician, mechanic, etc.
Baseline
6
Introduction
Interviewer read to respondent*
Hi, I‟m (your name) and I work for the Jail Diversion Evaluation Study. This study is funded by
the Center for Mental Health Services within the federal government. The findings from this
study will be used to improve jail diversion programs. Thank you for agreeing to talk with me
today. I appreciate your time and cooperation in participating in this interview and the study.
After the completion of your baseline interview there will be two follow-up interviews, the first of
which will be in about 6 months.
Your answers will be kept private and will in no way affect your legal status or any other
services or money you receive. The information you give will only be seen by research staff.
Before we start, I want to review a few things. First, you should know that your participation is
completely voluntary – you do not need to do this interview and if you decide not to, it will not
affect any services you receive or your standing in the diversion program. Also, you can choose
not to answer any question I ask, or stop the interview at any time. Second, this interview asks a
lot of personal questions, some of which may be difficult to think about. Please let me know if
you are feeling upset, or need a break. Before we start, please read and sign this consent form.
[HAND RESPONDENT INFORMED CONSENT FORM, REVIEW IT WITH THEM, AND ASK
THEM TO SIGN IT]
Thank you. Do you have any questions? (If so, note questions and responses).
Okay, let‟s start. I‟m going to read you a set of questions exactly as they are worded so that
each person is asked the same questions. In some cases, you‟ll be asked to answer questions
in your own words and I‟ll write down your answers. In other cases, you‟ll be given a list of
answers and asked to choose the one that is best for you. We are interested in your personal
opinions about these questions. There are no right or wrong answers. Please take your time.
Feel free to ask me questions if you are not sure what is wanted. Some of the questions I will
ask you may sound repetitive or may not apply to you, but I have to ask them anyway.
Remember that your answers are private.
This interview will last about 45 minutes. I will need to keep things moving along so I hope that I
do not sound rude if I tell you we need to move on to the next question.
If at any time you feel you need to take a break or stop the interview. Please let me know.
Now, I think we are ready to begin. I am going to ask you some questions about yourself.
Sometimes I will ask you about a specific time frame, like the past week or the last 30 days, and
sometimes I will ask you about things that have happened during your lifetime. I‟ll try to be
clear, but please ask me if you are not sure about the time period involved. Do you have any
questions before we begin?
Baseline
7
1. Demographics
For the first few questions, I am going to ask you some basic questions about yourself.
D1. What is your gender?
1. Male
2. Female
3. Transgender
4. Other (Specify:_______________)
7. DK
8. Refused
D2.
1. YES
2. NO- SKIP TO QD4.
7.DK
8. Refused
Are you Hispanic or Latino?
D3. If yes, what ethnic group do you consider yourself?
Central American
Cuban
Dominican
Mexican
Puerto Rican
South American
Other: specify_________
Yes
1
1
1
1
1
1
1
No
2
2
2
2
2
2
2
DK
7
7
7
7
7
7
7
RF
8
8
8
8
8
8
8
Yes
1
1
1
1
1
No
2
2
2
2
2
DK
7
7
7
7
7
RF
8
8
8
8
8
1
2
7
8
D4. What is your race? (Select one or more)
American Indian
Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific
Islander
White
D5. What is your date of birth?
___ ___ /___ ___ / ___ ___ ___ ___
M M
DD
Y Y Y Y
2098=Refused
Please provide the Month, day and year.
Baseline
8
2. Education, Employment and Income
In this next section, I will be asking you about your current activities, including school, job
training and work. By “current,” I mean your activities in the community right before you were
arrested or picked up for the offense which led you to the diversion program. That is before
__/__/__[Enter target arrest/incident date from front cover and use calendar to orient
respondent to this time frame].
E1. Are you currently enrolled in school or a
job training program?
1. Not Enrolled
2. Enrolled Full Time
3. Enrolled Part-time
4. Other (Specify:_____________)
7. DK
8. Refused
E2. What is the highest level of education you
1. less than 12th grade
have finished, whether or not you received a
2. 12th grade/High School diploma/
degree?
Equivalent (GED)
3. VOC/Tech Diploma
4. Some College or University
5. Bachelor‟s Degree (BA, BS)
6. Graduate Work/Graduate Degree
7. DK
8. Refused
E3. Are you currently employed?
1. EMPLOYED FULL TIME (35 HOURS PER
WEEK)
[Clarify by focusing on status during most of the 2. EMPLOYED PART TIME
previous week, BEFORE the arrest or incident 3. UNEMPLOYED, LOOKING FOR WORK
for which the client was diverted, determining
4. UNEMPLOYED, DISABLED
whether client worked at all or had a regular job 5. UNEMPLOYED, VOLUNTEER WORK
but was off of work]
6. UMEMPLOYED, RETIRED
7. OTHER, SPECIFY___________________
97. Don‟t Know
98. Refused
E4. IF EMPLOYED,
a. Are you paid at or above minimum wage?
b. Are your wages paid directly to you by your
employer?
c. Could anyone have applied for this job?
Baseline
YES
1
NO DK
2
7
8
1
2
7
8
1
2
7
8
RF
9
E5.
I am going to read you a list of possible sources of money that you may have received in the
past 30 days.
By the past 30 days, I mean the 30 days before you were arrested or picked up for the offense
which led you to the diversion program. Please remember that any information that you give me
on your income is strictly private and your responses will not affect any services or money you
receive. Approximately, how much did YOU receive in the past 30 days from …
[Interviewer: Unless otherwise specified, all questions refer to pre-tax individual income]
[Repeat if needed] In the past 30 days, did you
receive…
a. Wages or money from paid employment.
This includes any wages or money received
from legal AND “under the table” employment.
YES NO
DK
RF
1
2
7
8
(If YES, ask)
How much?
__________
b. SSI, SSDI, or Disability (Non-Veteran)
1
2
7
8
__________
c. Social Security Income (SSA)
1
2
7
8
__________
d. Food Stamps
1
2
7
8
__________
e. Public assistance or other benefits, such as
welfare, general assistance, or TANF
(Temporary Assistance to Needy Families)
1
2
7
8
__________
f. Veteran‟s benefits (including disability or
other compensation)
g. Unemployment or Worker‟s Compensation
1
2
7
8
__________
1
2
7
8
__________
h. Child support or alimony
1
2
7
8
__________
i. Income from a spouse or partner‟s wages or
other money
1
2
7
8
__________
j. Money from family members or friends to buy
food, pay rent, get medical care or anything
else
1
2
7
8
__________
k. Retirement
1
2
7
8
__________
l. Income from other sources that I did not
mention [If YES, specify
source(s)______________________
________________________________]
1
2
7
8
__________
Baseline
10
E6A. In the past 30 days, how many:
Number of nights/times?
DK
RF
MISSING
i. nights have you been homeless
_______ nights/times
97
98
99
ii. nights have you spent in a hospital for
mental health care?
iii. nights have you spent in a facility for
detox/inpatient or residential treatment?
_______ nights/times
97
98
99
________ nights/times
97
98
99
97
98
99
iv. nights have you spent in a correctional
________ nights/times
facility, including jail or prison
ITEMS i-iv cannot add up to more 30 nights.
v. times have you gone to an emergency
________ nights/times
97
98
99
room for a psychiatric or emotional
problems
E6.
In the past 30 days, where 1. Owned or Rented house,
9. Correctional Facility
have you been living most of the apartment, trailer, room
(Jail/Prison)
time?
2. Someone else‟s house,
10. VA Hospital
apartment, trailer, room
11. Nursing Home
Circle one only
3. Homeless (Shelter,
12. Veteran‟s Home
Street/Outdoors, Park)
13. Military Base
14. Detox/Inpatient or
4. Group Home1
residential substance abuse
5. Adult Foster Care
treatment facility
6. Transitional Living Facility
15. Other Housed,
7. Hospital (Medical)
Specify:_______________
8. Hospital (Psychiatric)
97. DK
98. RF
E7.
If Homeless, is that…
E8.
Did you ever live in foster
care or a group home2 before
you became 18?
Baseline
1. In a homeless shelter
2. On the street or some place like an abandoned
building, park or car
7. DK
8. RF
1. YES
2. NO
7. DK
8. RF
11
3. Military Service Questions
Now I am going to ask you some questions about your military service.
M1. Did you serve in the US Armed Forces?
1. YES
2. NO (SKIP TO SECTION 4, page 14)
7. DK
8. RF
M2.
1. Army (include Army National Guard/
Reserve)
2. Navy (include Reserve)
3. Marine Corps (include Reserve)
4. Air Force (include Air Natnl Guard/Reserve)
5. Coast Guard (include Reserve)
6. Other (Specify: ____________________)
7. DK
8. RF
In what branch(es) of the US Armed
Forces did you serve?
Select all that apply
M3.
When did you first enter the Armed
Forces?
___ ___ (Month)
___ ___ ___ ___ (Year)
Please provide the month and year.
Now I am going to ask you about your current status in the military.
M4. Are you… (read choices)
1. Still in the Military
2. Separated from service -SKIP TO M7
7. DK
8. RF
M5. If you are still in the military, which of
the following best describes your
current status?
1. Active Duty -SKIP TO M10
2. Guard/Reserve
7. DK
8. RF
M6. If Guard/Reserve, is that….
1. Traditional/part-time guard reserve
2. Currently Activated/Full-time/Reserve
7. DK
8. RF
SKIP TO QUESTION M10
M7.
If separated from service, which best
describes your current military status?
Baseline
1. Retired
2. Discharged with Severance or Military Disability
Payments
3. Discharged without severance or Payment
4. Other specify: _________________________
7. DK
8. RF
12
M8.
When were you last discharged from
the military?
Please provide the month and year.
M9.
What type of discharge did you
receive?
M10.
Please indicate which of the following
eras you have served?
Please indicate all that apply.
___ ___ (Month)
___ ___ ___ ___ (Year)
1. Honorable (includes discharges that have been
converted to honorable since leaving the military)
2. General (honorable conditions)
3. General (other than honorable)
4. Undesirable
5. Bad conduct
6. Dishonorable
7. Medical (including Section 8)
97. DK
98. Refused
1. Pre WWII (11/18-11/41)
2. WWII (12/41-12/46)
3. Pre-Korean War (1/47-6/50)
4. Korean War (7/50-1/55)
5. Between Korean -Vietnam Eras (2/55-7/64)
6. Vietnam Era (8/64-4/75)
7. Post-Vietnam (5/75-7/90)
8. Persian Gulf-Middle East Era (8/90-9/01)
9. Afghanistan/Iraq (1/02-present)
97. DK
98. Refused
1. YES
2. NO
7. DK
8. REFUSED
M11.
Has your military service caused or
contributed to any medical problems
you may have?
M12.
Has your military service caused or
contributed to any mental health or
emotional problems you may have?
1. YES
2. NO
7. DK
8. REFUSED
M13.
Do you have a VA determined
Service-Connected Disability?
M14.
Have you ever served in a combat
theater/zone?
M15.
How many tours of duty have you
served?
1. YES
2. NO
7. DK
8. REFUSED
1. YES
2. NO- (SKIP TO SECTION 4, page 14)
7. DK
8. REFUSED
_________ # tours
97. DK
98. REFUSED
M16.
Have you been deployed in the past
12 months?
Baseline
1. YES
2. NO
7. DK
8. REFUSED
13
4. Lifetime Mental Health/Substance Use Service Questions
I am now going to ask you some questions about mental health and substance abuse services.
MH1. Have you ever received outpatient
mental health services, including
counseling or therapy?
MH2. Have you ever received mental health
inpatient care or been hospitalized for
psychiatric or emotional problems?
MH3. Have you ever participated in mental
health self-help or peer support services?
MH4. At what age did you have your first
contact with mental health services?
MH5. Have you ever received outpatient
substance abuse services, including
substance abuse counseling or therapy?
MH6. Have you ever received inpatient
treatment for substance abuse, including
detox?
MH7. Have you ever participated in any
voluntary self help groups for recovery
such as Alcoholics Anonymous, Narcotics
Anonymous?
MH8. At what age did you have your first
contact with substance abuse services?
Baseline
1. YES
2. NO
7. DK
8. REFUSED
1. YES
2. NO
7. DK
8. REFUSED
1. YES
2. NO
7. DK
8. REFUSED
___ ___ years old
97. DK
98. REFUSED
99. NOT APPLICABLE
1. YES
2. NO
7. DK
8. REFUSED
1. YES
2. NO
7. DK
8. REFUSED
1. YES
2. NO
7. DK
8. REFUSED
___ ___ years old
97. DK
98. REFUSED
99. NOT APPLICABLE
14
5. Drug and Alcohol Use
The following questions refer to your feelings and behavior over your whole life.
Please listen to each statement and indicate with a „yes‟ or „no‟. Please give the
answer that is right most of the time.
SA1. Have you ever felt you should cut down on
drinking?
1. YES
2. NO
7. DK
8. REFUSED
SA2. Have people annoyed you by criticizing your
drinking?
1. YES
2. NO
7. DK
8. REFUSED
SA3. Have you ever felt guilty about your drinking?
1. YES
2. NO
7. DK
8. REFUSED
SA4. Have you ever taken a drink in the morning to
steady your nerves or get rid of a hangover, or
as an eye opener?
1. YES
2. NO
7. DK
8. REFUSED
Baseline
15
Daily or
almost
daily
Weekly
Once or
Twice
In the past 30 days, how often have you
used…..
Never
The following questions relate to your experience with alcohol, cigarettes, and other
drugs in the past 30 days. Some of the substances we‟ll talk about are prescribed by
a doctor (like pain medications). But I will only record those if you have taken them for
reasons or doses other than prescribed.
DK
RF
SA5. tobacco products (cigarettes, chewing
tobacco, cigars, etc)
0
1
2
3
7
8
SA6.
0
1
2
3
7
8
IF SA6>= ONCE OR TWICE AND RESPONDENT IS NOT MALE, ask SA8
SA7. .How many times in the past 30 days
0
1
2
3
have you had five or more drinks in a day?
7
8
Alcoholic beverages (beer, wine, liquor)
IF SA6>= ONCE OR TWICE AND RESPONDENT IS MALE, ask SA7.
SA8. How many times in the past 30 days
have you had four or more drinks in a day?
0
1
2
3
7
8
SA9. Cannabis (marijiuana, pot, grass, hash,
etc)
0
1
2
3
7
8
SA10. Cocaine (coke, crack, etc)?
0
1
2
3
7
8
SA11. Prescription stimulants (Ritalin,
Concerta, Dexedrine, Adderall, diet pills, etc.)
0
1
2
3
7
8
SA12. Methamphetamine (speed, crystal
meth, ice, etc).
0
1
2
3
7
8
SA13. Inhalants (nitrous oxide, glue, gas,
paint thinner, etc)
0
1
2
3
7
8
SA14. Sedatives or sleeping pills (Valium,
Serepax, Ativan, Librium, Xanax, Rohypnol,
GHB, etc)
0
1
2
3
7
8
SA15. Hallucinogens (LSD, acid, mushroom,
PCP, Special K, ecstasy, etc)
0
1
2
3
7
8
SA16. Street opioids (heroin, opium, etc)
0
1
2
3
7
8
SA17. Prescription opioids (fentanyl,
oxycodone [OxyContin, Percocet], hydrocone
[Vicodin], methadone, buprenorphine, etc)?
0
1
2
3
7
8
SA18. Other drugs
0
1
2
3
7
8
SA19. Other- specify:_________________
Baseline
16
6. Services
In this next section, I am going to ask you about services that you may have received in the past
30 days. Again, when I say past 30 days, I am referring to the 30 days before you were
arrested or picked up for the offense which led you to the diversion program.
YES
[IF YES]
Altogether for how
many nights/times?
NO
DK
RF
SV1. Inpatient Treatment for:
i. Physical complaint
1
_______ nights/times
2
7
8
SV2. Outpatient Treatment for:
i. Physical complaint
1
_______ nights/times
2
7
8
ii. Mental or emotional difficulties
1
_______ nights/times
2
7
8
iii. Alcohol or substance abuse
1
________ nights/times
2
7
8
_______ nights/times
2
7
8
________ nights/times
2
7
8
In the past 30 days, did you
receive…
SV3. Emergency Room Treatment for:
i. Physical complaint
1
iii. Alcohol or substance abuse
Baseline
1
17
7. Criminal Justice Questions
Next, I am going to ask you about arrests and nights you have spent in jail in the past 30 days.
For this question, please INCLUDE the offense for which you were arrested or picked up,
leading you to the diversion program, even if this arrest/incident occurred MORE THAN 30 days
ago.
CJ1. In the past 30 days, how many times have
you been arrested?
___ ___ # times arrested
97. DK
98. REFUSED
Now I am going to ask you about your involvement with the criminal justice system during your
lifetime.
CJ3.
At what age were you first arrested,
booked, or taken into custody by the police?
CJ4.
Have you ever been on probation?
CJ5. Have you ever spent time in jail or prison
because of a conviction?
CJ6. How many times have you been in jail or
prison in your life?
___ ___ years old
97. DK
98. REFUSED
1. YES
2. NO
97. DK
98. REFUSED
1. YES
2. NO (SKIP TO Question CJ7)
7. DK
8. REFUSED
___ ___ # times incarcerated
97. DK
98. REFUSED
CJ7.
Has someone ever had a restraining
order, no contact order or an order of
protection against you?
1. YES
2. NO (SKIP TO NEXT SECTION)
7. DK
8. REFUSED
CJ8.
Does someone currently have a
restraining order, no contact order or an order
of protection against you?
1. YES
2. NO
7. DK
8. REFUSED
Baseline
18
8. Functioning
F1A. How would you rate your overall health
right now?
1. Excellent
2. Very Good
3. Good
4. Fair
5. Poor
7. DK
8. REFUSED
In order to provide the best possible mental health services, we need to know what you think
about how well you were able to deal with your everyday life during the last 30 days.
Statement
F1. I deal with
problems
effectively.
Strongly Disagree Undecided Agree Strongly
Disagree
Agree
1
2
3
4
5
Refuse N/A
8
F2. I am able to
control my life.
1
2
3
4
5
8
F3. I am able to deal
with crisis
1
2
3
4
5
8
F4. I am getting along
with my family
1
2
3
4
5
8
F5. I do well in social
situations.
1
2
3
4
5
8
F6. I do well in school
and/or work.
1
2
3
4
5
8
F7. My housing
situation is
satisfactory
1
2
3
4
5
8
F8. My symptoms are
not bothering me
1
2
3
4
5
8
Baseline
9
9
19
The following questions ask about how you have been feeling during the past 30 days.
For each question, please indicate how often you had this feeling.
Most of the
time
Some of
the Time
A Little of
the Time
None of the
Time
DK
All of the
time
In the past 30 days, how often did you
feel…..
RF
F9. nervous?
0
1
2
3
4
7
8
F10. hopeless?
0
1
2
3
4
7
8
F11. restless or fidgety
0
1
2
3
4
7
8
F12. so depressed that nothing could cheer
you up?
0
1
2
3
4
7
8
F13. that everything was an effort
0
1
2
3
4
7
8
F14. worthless
0
1
2
3
4
7
8
9. Social Connectedness
Please indicate your disagreement/agreement with each of the following statements. Please
answer for relationships with persons other than your mental health provider in the past 30
days.
Statement
SC1. I am happy with the
friendships I have.
SC2. I have people with
whom I can do enjoyable
things.
SC3. I feel I belong in my
community.
SC4. In a crisis, I would have
the support I need from
family or friends.
Baseline
Strongly Disagree Undecided Agree
Disagree
1
2
3
4
Strongly Refuse
Agree
5
8
1
2
3
4
5
8
1
2
3
4
5
8
1
2
3
4
5
8
20
10. Traumatic Events
Now I am going to ask you some questions about events in your life that are upsetting or
stressful to most people. Some of these questions may not apply to you, but I have to ask them
as is. Please think back over your whole life when you answer these questions- but do not
include your experiences in military combat situations. Some of these questions may be
about upsetting events people don‟t usually talk about. Your answers are important to us, BUT
you DO NOT have to answer any questions that you do not want to. Also, remember that your
answers are completely private and will be used only for research purposes.
YES NO DK RF NA
TE1. Have you ever witnessed someone seriously injured or killed
due to an unnatural event such as a shooting, stabbing, or hit-andrun accident?
a. [IF YES] Did this occur before the age 18?
1
2
7
8
9
1
2
7
8
9
b. Did this occur in the past 12 months?
TE2. Have you ever witnessed a physical or sexual assault against
a family member, friend, or other significant person?
a. [IF YES] Did this occur before the age 18?
1
1
2
2
7
7
8
8
9
9
1
2
7
8
9
b. Did this occur in the past 12 months?
1
TE3. Has an immediate family member, partner, or very close friend 1
died as a result of an accident, homicide, suicide, or in a war?
2
2
7
7
8
8
9
9
1
2
7
8
9
1
1
2
2
7
7
8
8
9
9
a. [IF YES] Did this occur before the age 18?
1
2
7
8
9
b. Did this occur in the past 12 months?
1
2
7
8
9
TE5. Have you ever experienced physical violence, such as being
slapped, kicked, bitten, hit, choked, strangled, smothered, or being
threatened or assaulted with a weapon by someone you did not
know?
a.[IF YES] Did this occur before the age 18?
1
2
7
8
9
1
2
7
8
9
b. Did this occur in the past 12 months?
TE6.Have you ever experienced physical violence, such as being
slapped, kicked, bitten, hit, choked, strangled, smothered, or being
threatened or assaulted with a weapon by someone you knew?
a. [IF YES] Did this occur before the age 18?
1
1
2
2
7
7
8
8
9
9
1
2
7
8
9
1
2
7
8
9
a. [IF YES] Did this occur before the age 18?
b. Did this occur in the past 12 months?
TE4. Have you ever been stripped searched, forcibly restrained, or
held against your will, including in a jail or hospital, by a provider of
mental health or substance abuse services or by someone else?
b. Did this occur in the past 12 months?
Baseline
21
TE7. Have you ever experienced sexual assault or sexual
molestation, such as being forced to touch your or someone else‟s
private parts, forced to have sex or any other sexual molestation by
someone you did not know?
1
2
7
8
9
a. [IF YES] Did this occur before the age 18?
1
2
7
8
9
b. Did this occur in the past 12 months?
1
2
7
8
9
1
2
7
8
9
a. [IF YES] Did this occur before the age 18?
1
2
7
8
9
b. Did this occur in the past 12 months?
1
2
7
8
9
TE8. Have you ever experienced sexual assault or sexual
molestation, such as being forced to touch your or someone else‟s
private parts, forced to have sex or any other sexual molestation by
someone you knew?
Thank you for answering these questions.
Baseline
22
11. Posttraumatic Stress Disorder Checklist (PCL-C)1
I‟m going to read a list of problems and complaints people sometimes have in response to
stressful life experiences. For each item, please tell me how much you‟ve been bothered by that
problem in the past month.
TR1. Repeated disturbing
memories, thoughts, or images of
a stressful experience from the
past?
TR2. Repeated, disturbing dreams
of a stressful experience from the
past?
TR3. Suddenly acting or feeling as
if a stressful experience from the
past were happening again (as if
you were reliving it)?
1
A
little
bit
2
1
2
3
4
5
7
8
1
2
3
4
5
7
8
TR4. Feeling very upset when
something reminded you of a
stressful experience from the
past?
1
2
3
4
5
7
8
TR5. Having physical reactions
(e.g heart pounding, trouble
breathing, sweating) when
something reminded you of a
stressful experience from the
past?
1
2
3
4
5
7
8
TR6. Avoiding thinking about or
talking about a stressful
experience from the past?
1
2
3
4
5
7
8
TR7. Avoiding activities or
situations because they reminded
you of a stressful experience from
the past?
1
2
3
4
5
7
8
TR8. Trouble remembering
important parts of a stressful
experience from the past?
1
2
3
4
5
7
8
TR9. Loss of interest in activities
that you used to enjoy?
1
2
3
4
5
7
8
In the past month how much have
you been bothered by…
1
Not at
all
Moderately
Quite a
bit
Extremely DK
RF
3
4
5
7
8
Weathers, Litz, Huska, & Keane; National Center for PTSD - Behavioral Science Division.
Baseline
23
TR10. Feeling distant or cut off
from other people?
1
A
little
bit
2
TR11. Feeling emotionally numb or
being unable to have loving
feelings for those close to you?
1
2
3
4
5
7
8
TR12. Feeling as if your future will
somehow be cut short?
1
2
3
4
5
7
8
TR13. Trouble falling or staying
asleep?
1
2
3
4
5
7
8
TR14. Feeling irritable or having
angry outbursts?
1
2
3
4
5
7
8
TR15. Having difficulty
concentrating?
1
2
3
4
5
7
8
TR16. Being “super-alert” or
watchful or on guard?
1
2
3
4
5
7
8
TR17. Feeling jumpy or easily
startled?
1
2
3
4
5
7
8
In the past month how much have
you been bothered by…
Baseline
Not at
all
Moderately
Quite a
bit
Extremely DK
RF
3
4
5
7
8
24
12. BASIS 242
Quite a bit
of difficulty
Extreme
difficulty
RF
Moderate
Difficulty
DK
A little
difficulty
During the PAST WEEK, how much
difficulty did you have…..
No difficulty
This section of the interview asks about how you are feeling and doing in different areas
of life. Please indicate which response describes yourself in the PAST WEEK. If you
are unsure about how to answer, please give the best answer you can.
BA1.
Managing your day- to-day life?
0
1
2
3
4
7
8
BA2.
Coping with problems in your life?
0
1
2
3
4
7
8
BA3.
Concentrating?
0
1
2
3
4
7
8
DK
RF
None of
the Time
A little of
the time
Half of
the Time
Most of
the time
All of the
time
During the PAST WEEK, how much of the
time did you….
Get along with people in your family?
0
1
2
3
4
7
8
BA5. Get along with people outside of your
family?
0
1
2
3
4
7
8
BA6.
Get along in social situations?
0
1
2
3
4
7
8
BA7.
Feel close to another person?
0
1
2
3
4
7
8
BA8. Feel like you had someone to turn to if
you needed help?
0
1
2
3
4
7
8
BA9.
0
1
2
3
4
7
8
BA10. Feel sad or depressed?
0
1
2
3
4
7
8
BA11. Think about ending your life
0
1
2
3
4
7
8
BA12. Feel nervous?
0
1
2
3
4
7
8
BA4.
2
Feel confident in yourself?
BASIS 24, McLean Hospital, 2001©
Baseline
25
Sometimes
Often
Always
RF
Rarely
DK
Never
During the PAST WEEK, how much of the
time did you……
BA13. Have thoughts racing through your
head?
0
1
2
3
4
7
8
BA14.
Think you have special powers?
0
1
2
3
4
7
8
BA15.
Hear voices or see things?
0
1
2
3
4
7
8
BA16.
Think people are watching you?
BA17.
Think people are against you?
0
1
2
3
4
7
8
BA18.
Have mood swings?
0
1
2
3
4
7
8
BA19.
Feel short-tempered?
0
1
2
3
4
7
8
BA20.
Think about hurting yourself?
0
1
2
3
4
7
8
BA21. Did you have the urge to drink
alcohol or take street drugs?
0
1
2
3
4
7
8
BA22. Did anyone talk to you about your
drinking or drug use?
0
1
2
3
4
7
8
BA23. Did you try to hide your drinking or
drug use?
0
1
2
3
4
7
8
BA24. Did you have problems from your
drinking or drug use?
0
1
2
3
4
7
8
Baseline
26
13. REE: Recovery Markers –Revised3
For each of the following statements, circle the one answer that is most true for you right now.
Please indicate if you Strongly Agree, Agree, Disagree or Strongly Disagree with each
statement.
Strongly Agree
Disagree Strongly
DK RF
Agree
Disagree
REE1. My living situation feels like a
safe home to me.
1
2
3
4
7
8
REE2. I have people I trust whom I can
turn to for help.
1
2
3
4
7
8
REE3. I have at least one close mutual
(give-and-take) relationship.
1
2
3
4
7
8
REE4. I am involved in activities I find
meaningful.
1
2
3
4
7
8
REE5. My psychiatric symptoms are
under control.
1
2
3
4
7
8
REE6. I have enough income to meet
my needs.
1
2
3
4
7
8
REE7. I am learning new things that
are important to me.
1
2
3
4
7
8
REE8. I am in good physical health.
1
2
3
4
7
8
REE9. I have a positive spiritual
life/connection to a higher power.
1
2
3
4
7
8
REE10. I like and respect myself.
1
2
3
4
7
8
REE11. I'm using my personal
strengths, skills or talents.
1
2
3
4
7
8
REE12. I have goals I'm working to
achieve.
1
2
3
4
7
8
REE13. I have reasons to get out of
bed in the morning.
1
2
3
4
7
8
REE14. I have more good days than
bad.
1
2
3
4
7
8
REE15. I have a decent quality of life.
1
2
3
4
7
8
REE16. I control the important
decisions in my life.
1
2
3
4
7
8
3
Priscilla Ridgway, 2004, 2009. Recovery Enhancing Environment measure (REE), ©
Baseline
27
Strongly
Agree
Agree
Disagree
Strongly
Disagree
DK
RF
REE17. I contribute to my community.
1
2
3
4
7
8
REE18. I am growing as a person.
1
2
3
4
7
8
REE19. I have a sense of belonging.
1
2
3
4
7
8
REE20. I feel alert and alive.
1
2
3
4
7
8
REE21. I feel hopeful about my future.
1
2
3
4
7
8
REE22. I am able to deal with stress.
1
2
3
4
7
8
REE23. I believe I can make positive
changes in my life.
1
2
3
4
7
8
Baseline
28
END OF THE INTERVIEW
This is the end of the interview. I want to remind you that all of your answers will be kept
private; we will not share them with anyone outside of the research team.
Thank you for your time and participation.
Pay respondent and have them sign the receipt.
We will be contacting you in about 5 months to conduct another interview, and then
again for the 12-month interview. Before we end the interview, I want to review some of
the ways we might get in contact with you.
Interviewer- Complete Locator Information and information releases.
Baseline
29
Interviewer Observations
IO1.
Please estimate the respondent‟s
understanding of the interview.
IO2. How accurate do you think the
respondent‟s answers were?
Baseline
1. No difficulty- no language or
comprehension problems
2. Just a little difficulty- few language or
comprehension problems
3. A fair amount of difficulty- some
language or comprehension problems
4. A lot of difficulty- considerable language
or comprehension problems
1. Very accurate
2. Fairly accurate
3. Not very accurate
4. Not accurate at all
30
| File Type | application/pdf |
| File Title | LE1 |
| Author | jbrown |
| File Modified | 2012-12-27 |
| File Created | 2012-12-27 |