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pdfOMB No. 0930-0277
Expiration Date: XX/XX/XXXX
CMHS Jail Diversion and Trauma Recovery Initiative
Priority to Veterans
Six Month Interview- 9.1.10
6-Month Interview Date: ___ ___/ ___ ___/ ____ ____ ____ ____
MM
DD
YYYY
Study ID#:
____ ____- ____ - ____- ____ ____ ____
(Site Code) (Prog #) (Grp #) (Subject ID #)
Interviewer Name:
Interviewer ID: ___ ___
Date of Baseline Interview: ___ ___/ ___ ___/ ____ ____ ____ ____
MM
DD
YYYY
Interview Type _____
1.Admission
2. Six month
3. Twelve Month
Site Code
Program Pilot Group Code Number
01. Connecticut
09. North Carolina 1. Pilot Site 1
1. Pre-booking Diversion
02. Colorado
10. Ohio
2. Pilot Site 2
2. Post-booking Diversion
03. Georgia
11. Pennsylvania 3. Pilot Site 3
3. Probation/Parole
04. Illinois
12. Rhode Island 4. Pilot Site 4
Violation
05. Massachusetts 13. Texas
5. Pilot Site 5
06. Vermont
(TBD with
07. Florida
sites)
08. New Mexico
Location of Interview
1. Community setting (e.g. any residence, restaurant, Was anyone else present during
research offices, university, outdoors)
the interview?
2. Services Site (e.g. Hospital, Treatment
1. Yes
facility/program, Shelter, Transitional housing)
3. Jail
4. Court
5. Other
(specify:____________)
2. No
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 55 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.
Six Month
9.1.10
1
Table of Contents
Interviewer Instructions ................................................................................................ 3
Glossary ......................................................................................................................... 4
Introduction ................................................................................................................... 7
1. Education, Employment and Income ....................................................................... 8
2. Military Service Questions ..................................................................................... 11
3. Drug and Alcohol Use ............................................................................................. 14
4. Criminal Justice Questions .................................................................................... 15
5. Functioning .............................................................................................................. 16
6. Social Connectedness ........................................................................................... 17
7. Traumatic Events .................................................................................................... 18
8. Posttraumatic Stress Disorder Checklist (PCL-C)............................................... 19
9. BASIS 24 ................................................................................................................. 21
10. REE: Recovery Markers –Revised ..................................................................... 23
11. Services Used ........................................................................................................ 25
12. Perception of Care ................................................................................................ 31
END OF THE INTERVIEW ............................................................................................ 32
Interviewer Observations ........................................................................................... 33
Six Month
9.1.10
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.
Six Month
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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.
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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.
Six Month
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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.
Six Month
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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 six month interview, the final follow-up interview 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 wanted 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?
Six Month
9.1.10
7
1. Education, Employment and Income
In the first few questions, I will be asking you about your current activities, including school, job
training and work.
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. DK
98. REFUSED
E4. IF EMPLOYED,
YES
NO
DK
RF
a. Are you paid at or above minimum wage?
1
2
7
8
b. Are your wages paid directly to you by your
employer?
c. Could anyone have applied for this job?
1
2
7
8
1
2
7
8
Six Month
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8
E5.
I am going to read you a list of possible sources of money that you may have received in the
past 30 days. 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 as 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
__________
Six Month
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9
E6A. In the past 30 days, how many:
Number of nights/times?
DK
RF
_______ nights/times
7
8
ii. nights have you spent in a
_______ nights/times
7
hospital for mental health care?
iii. nights have you spent in a facility
________ nights/times
7
for detox/inpatient or residential
treatment?
iv. nights have you spent in a
________ nights/times
7
correctional facility, including jail or
prison
ITEMS i-iv cannot add up to more 30 nights.
8
v. times have you gone to an
emergency room for a psychiatric or
emotional problems
8
i. nights have you been homeless
E6.
In the past 30 days,
where have you been living
most of the time?
E7.
If Homeless, is that…
Six Month
9.1.10
________ nights/times
1. Owned or Rented house,
apartment, trailer, room
2. Someone else‟s house,
apartment, trailer, room
3. Homeless (Shelter,
Street/Outdoors, Park)
4. Group Home1
5. Adult Foster Care
6. Transitional Living Facility
7. Hospital (Medical)
8. Hospital (Psychiatric)
7
8
8
9. Correctional Facility
(Jail/Prison)
10. VA Hospital
11. Nursing Home
12. Veteran‟s Home
13. Military Base
14. Detox/Inpatient or
residential substance
abuse treatment facility
15. Other Housed,
Specify:____________
97. DK
98. REFUSED
1. In a homeless shelter
2. On the street or some place like an abandoned
building, park or car
7. DK
8. REFUSED
10
2. 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 3, page 14)
7. DK
8. REFUSED
M2. Are you… (read choices)
1. Still in the Military (SKIP TO SECTION 3, page 14)
2. Separated from service
7. DK
8. REFUSED
M3.
If separated from service,
which best describes your
current military status?
M4.
When were you last
discharged from the
military?
Please provide the month and
year.
M5.
What type of discharge
did you receive?
M6.
Do you have a VA
determined ServiceConnected Disability?
Six Month
9.1.10
1. Retired
2. Discharged with Severance or Military Disability
Payments
3. Discharged without severance or Payment
4. Other: _____________________________
7. DK
8. REFUSED
___ ___ (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. YES
2. NO
7. DK
8. REFUSED
11
Military sexual assault is a pervasive problem, and therefore we feel it is important to ask about
these events. Please remember that this information is private and will only be used for research
purposes.
M7.
During your military service, were you
1. YES
ever sexually assaulted?
2. NO
7. DK
8. REFUSED
M8.
Have you ever served in a
combat theater/zone?
1. YES
2. NO- (SKIP TO SECTION 3, page 14)
7. DK
8. REFUSED
Below is a list of experiences military personnel often have in combat situations1. Please
indicate if you have experienced the following, in any of your tours of duty with a „Yes‟ or „No‟.
Some of these experiences may be difficult to talk about. Please remember that all responses
are private. Just do the best you can and remember that you can choose not to answer any
questions.
During your tour of duty, did you experience any of the
following…..
Yes
No
DK
RF
M9. Being attacked or ambushed?
1
2
7
8
M10. Being shot at or receiving fire, including incoming
artillery or mortar fire?
1
2
7
8
M11. Shooting or directing fire at the enemy?
1
2
7
8
M12. Patrolling areas (or riding) where there were
landmines or IEDs (Improvised Explosive Devices), or
heard explosions from enemy IED, landmine or mortar?
1
2
7
8
M13. Clearing or searching homes, buildings, or bunkers?
1
2
7
8
M14. Being wounded or injured?
1
2
7
8
M15. Providing aid to someone seriously injured or
wounded?
1
2
7
8
M16. Seeing someone seriously injured or killed?
1
2
7
8
M17. Seeing, smelling or handling dead bodies?
1
2
7
8
M18. Believing that you were responsible for the death of
someone?
1
2
7
8
1
Adapted from Hoge et al. 2004. Combat Duty in Iraq and Afghanistan, Mental Health Problems, and
Barriers to Care. The New England Journal of Medicine, 351 (1): 13-22.
Six Month
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12
M19. Were you ever a prisoner of war?
1. YES
2. NO
7. DK
8. REFUSED
Thank you for answering these questions
Six Month
9.1.10
13
3. Drug and Alcohol Use
SA5. tobacco products (cigarettes, chewing
tobacco, cigars, etc)
0
1
2
3
7
8
SA6.
0
1
2
3
7
8
Alcoholic beverages (beer, wine, liquor)
Weekly
DK
Once or
Twice
In the past 30 days, how often have you
used…..
Never
Daily or
almost daily
The following questions relate to your experience with alcohol, cigarettes, and other drugs.
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.
RF
IF Question SA6>= ONCE OR TWICE AND RESPONDENT IS MALE, ask SA7.
IF Question SA6>= ONCE OR TWICE AND RESPONDENT IS NOT MALE, ask SA8.
SA7. How many times in the past 30 days
0
1
2
3
7
8
have you had five or more drinks in a day?
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- specify:
0
1
2
3
7
8
Six Month
9.1.10
14
4. Criminal Justice Questions
Next, I am going to ask you about arrests and nights you have spent in jail in the past 30 days.
CJ1.
In the past 30 days, how many times
have you been arrested?
___ ___ # times arrested
97. DK
98. REFUSED
CJ2. 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
CJ3. Since the baseline interview (that is since
Baseline Date), have you been under
probation, parole or court supervision as a
condition of your diversion?
1. YES
2. NO
7. DK
8. REFUSED
Six Month
9.1.10
15
5. 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. Please
indicate your disagreement/agreement with each of the following statements.
Statement
F1. I deal effectively
with my daily
problems.
F2. I am able to
control my life.
F3. I am able to deal
with crisis
F4. I am getting along
with my family
F5. I do well is social
situations.
F6. I do well in school
and/or work.
F7. My housing
situation is
satisfactory
F8. My symptoms are
not bothering me
Strongly Disagree Undecided Agree Strongly
Disagree
Agree
1
2
3
4
5
Refuse N/A
8
1
2
3
4
5
8
1
2
3
4
5
8
1
2
3
4
5
8
1
2
3
4
5
8
1
2
3
4
5
8
1
2
3
4
5
8
1
2
3
4
5
8
9
9
All of the
time
Most of
the time
Some of
the Time
A Little of
the Time
None of
the Time
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.
In the past 30 days, how often did you
DK RF
feel…..
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
Six Month
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16
F14. worthless
0
1
2
3
4
7
8
6. Social Connectedness
Please indicate your disagreement/agreement with each of the following statements. Please
answer for relationships with person 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.
Six Month
9.1.10
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
17
7. Traumatic Events
Now I am going to ask you some questions about events that may have happened in the past 6
months 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 the past 6 months or since your last
interview on __ __/__ __/ __ ___. Please do not include any 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. In the past 6 months, have you witnessed someone seriously
injured or killed due to an unnatural event such as a shooting,
stabbing, or hit-and-run accident?
1
2
7
8
9
TE2. In the past 6 months, have you witnessed a physical or sexual
assault against a family member, friend, or other significant
person?
TE3. In the past 6 months, has an immediate family member,
partner, or very close friend died as a result of an accident,
homicide, suicide, or in a war?
1
2
7
8
9
1
2
7
8
9
TE4. In the past 6 months, have you 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?
1
2
7
8
9
TE5. In the past 6 months, have you 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?
1
2
7
8
9
TE6. In the past 6 months, have you 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?
1
2
7
8
9
TE7. In the past 6 months, have you experienced sexual assault or
sexual molestation, such as being forced to touch yours 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
TE8. In the past 6 months, have you experienced sexual assault or
sexual molestation, such as being forced to touch yours or
someone else‟s private parts, forced to have sex or any other
sexual molestation by someone you knew?
1
2
7
8
9
Six Month
9.1.10
18
8. Posttraumatic Stress Disorder Checklist (PCL-C)2
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…
2
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.
Six Month
9.1.10
19
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…
Six Month
9.1.10
Not at
all
Moderately
Quite a
bit
Extremely DK
RF
3
4
5
7
8
20
9. BASIS 243
Extreme
difficulty
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
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.
3
Feel confident in yourself?
A little
of the
time
All of
the time
RF
Most of
the time
DK
Half of
the Time
During the PAST WEEK, how much of the
time did you….
None of
the Time
Quite a bit
of 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.
BASIS 24, McLean Hospital, 2001©
Six Month
9.1.10
21
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
Six Month
9.1.10
22
10. REE: Recovery Markers –Revised4
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
1
2
3
4
7
8
safe home to me.
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
4
Priscilla Ridgway, 2004, 2009. Recovery Enhancing Environment measure (REE), ©
Six Month
9.1.10
23
Strongly
Agree
1
Agree
2
3
1
2
3
1
2
REE19. I have a sense of belonging.
1
REE20. I feel alert and alive.
REE21. I feel hopeful about my
future.
REE22. I am able to deal with
stress.
REE23. I believe I can make positive
changes in my life.
REE16. I control the important
decisions in my life.
REE17. I contribute to my
community.
REE18. I am growing as a person.
Six Month
9.1.10
Disagree
Strongly
Disagree
4
DK
RF
7
8
4
7
8
3
4
7
8
2
3
4
7
8
1
2
3
4
7
8
1
2
3
4
7
8
1
2
3
4
7
8
1
2
3
4
7
8
24
11. Services Used
First, I am going to ask you about services you have used in the past 30 days. During the past
30 days, did you receive:
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
1
_______ nights/times
2
7
8
1
_______ nights/times
2
7
8
SV3. Emergency Room Treatment for:
i. Physical complaint
1
_______ nights/times
2
7
8
2
7
8
ii. Mental or emotional
difficulties
iii. Alcohol or substance abuse
iii. Alcohol or substance abuse
1
_______ nights/times
Now I am going to ask you about services you may have received since the baseline
interview, that is, since ___/___/___. Please indicate with a „yes‟ or „no‟ if you have
received the following services.
Since the baseline interview (DATE)……
SV4. did you receive outpatient mental health treatment, such as
individual, family, group therapy, day treatment, or other
outpatient treatment? (do not include case management
services)
1. YES
2. NO
7. DK
8. REFUSED
IF YES- Where did you receive mental health outpatient treatment services?
Facility Name, Street, City, State
1.
2.
3.
4.
Six Month
9.1.10
25
Since the baseline interview (DATE)……
SV5. did you receive any trauma-specific treatment; that is,
groups or services specifically addressing traumatic
experiences and responses to these experiences (e.g.,
TREM (Trauma Recovery Empowerment Motivation)
groups, Seeking Safety Groups, etc.)?
1. YES
2. NO
7. DK
8. REFUSED
IF YES- Where did you receive trauma-specific treatment services?
Facility Name, Street, City, State
1.
2.
3.
4.
SV6. did you see a doctor or nurse about psychiatric medications
that you are taking or planning to take?
1. YES
2. NO
7. DK
8. REFUSED
IF YES- Where did you see the doctor(s) and/or nurse(s) about psychiatric
medication services?
Facility Name, Street, City, State
1.
2.
3.
4.
SV7. did you receive treatment in a substance abuse program
where you stayed overnight, or in a detox program?
1. YES
2. NO
7. DK
8. REFUSED
IF YES- Where did you receive inpatient or detox substance abuse treatment?
Facility Name, Street, City, State
1.
2.
3.
4.
Six Month
9.1.10
26
Since the baseline interview (DATE)……
SV8. did you receive any outpatient substance abuse treatment?
1. YES
2. NO
7. DK
8. REFUSED
IF YES- Where did you receive outpatient substance abuse treatment?
Facility Name, Street, City, State
1.
2.
3.
4.
SV9. did you live in a residential treatment facility, group home,
adult home, or halfway house or other community setting
where you received treatment?
1. YES
2. NO
7. DK
8. REFUSED
IF YES- Where was the residential treatment facility, group home, adult home,
halfway house or other community setting treatment services?
Facility Name, Street, City, State
1.
2.
3.
4.
SV10. did you receive any case management services?
Case management refers to a person or team that helps you
obtain or coordinate services, entitlements (Medicaid, SSI) and
advocates on your behalf.
1. YES
2. NO
7. DK
8. REFUSED
IF YES- Where did you receive case management services?
Facility Name, Street, City, State
1.
2.
3.
4.
Six Month
9.1.10
27
Since the baseline interview (DATE)……
SV11. did you receive any vocational or rehabilitation services,
such as supported employment, vocational counseling,
clubhouse program or supported education? (See glossary
for definitions)
1. YES
2. NO
7. DK
8. REFUSED
IF YES- Where did you receive vocational or rehabilitation services?
Facility Name, Street, City, State
1.
2.
3.
4.
SV12. did you receive any help with housing services; for
example, help finding shelter or housing, dealing with a
landlord or eviction, help getting a housing subsidy?
1. YES
2. NO
7. DK
8. REFUSED
IF YES- Where did you receive housing services?
Facility Name, Street, City, State
1.
2.
3.
4.
SV13. did you receive any help with transportation to meet
basic needs; for example, help getting to work or
appointments?
1. YES
2. NO
7. DK
8. REFUSED
IF YES- Where did you receive transportation services?
Facility Name, Street, City, State
1.
2.
3.
4.
Six Month
9.1.10
28
Since the baseline interview (DATE)……
SV14. did you participate in any self-help or peer support
services?
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.
1. YES
2. NO
7. DK
8. REFUSED
IF YES- Where did you receive self-help or peer support services?
Facility Name, Street, City, State
1.
2.
3.
4.
SV15. did you receive any childcare services; that is, help
finding childcare or obtaining a subsidy or other financial
support for childcare?
1. YES
2. NO
7. DK
8. REFUSED
IF YES- Where did you receive childcare services?
Facility Name, Street, City, State
1.
2.
3.
4.
SV16. did you receive help with social or recreational activities,
such as help finding or planning enjoyable things for play or
relaxation?
Six Month
9.1.10
1. YES
2. NO
7. DK
8. REFUSED
29
IF YES- Where did you receive help with social or recreational activities?
Facility Name, Street, City, State
1.
2.
3.
4.
Since the baseline interview (DATE)……
SV17. did you receive any other services not yet mentioned?
If yes: _________________________________________
_______________________________________________
1. YES
2. NO
7. DK
8. REFUSED
IF YES- Where did you receive these services?
Facility Name, Street, City, State
1.
2.
3.
4.
Six Month
9.1.10
30
12. Perception of Care
In order to provide the best possible mental health services, we need to know what you think
about the services you received during the past 30 days, the people who provided it, and the
results. Please indicate your disagreement/agreement with each of the following statements.
Undecided
Strongly
Agree
PC1. Staff here believe that I can grow,
change, and recover.
1
2
3
4
5
7
8
PC2. I feel free to complain.
1
2
3
4
5
7
8
PC3. I was given information about my
rights.
1
2
3
4
5
7
8
PC4. Staff encouraged me to take
responsibility for how I live my life.
1
2
3
4
5
7
8
PC5. Staff told me what side effects to
watch out for.
1
2
3
4
5
7
8
PC6. Staff respected my wishes about
who is and who is not to be given
information about my treatment.
1
2
3
4
5
7
8
PC7. Staff were sensitive to my cultural
background (race, religion,
language, etc).
1
2
3
4
5
7
8
PC8. Staff helped me obtain the
information I needed so that I could
take charge of my illness.
1
2
3
4
5
7
8
PC9. I was encouraged to use
consumer run programs (support
groups, drop-in centers, crisis phone
line, etc)
1
2
3
4
5
7
8
PC10. I felt comfortable asking questions
about my treatment and medication.
1
2
3
4
5
7
8
PC11. I, not staff, decided my treatment
goals.
1
2
3
4
5
7
8
PC12. I like the services I received here.
1
2
3
4
5
7
8
PC13. If I had other choices, I would get
services from this agency.
1
2
3
4
5
7
8
PC14. I would recommend this agency
to a friend or family member.
1
2
3
4
5
7
8
Six Month
9.1.10
RF
DK
Agree
Disagree
Strongly
Disagree
Statement
31
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 the final 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.
Six Month
9.1.10
32
Interviewer Observations
IO1.
Please estimate the respondent‟s
understanding of the interview.
IO2. How accurate do you think the
respondent‟s answers were?
Six Month
9.1.10
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
33
| File Type | application/pdf |
| File Title | LE1 |
| Author | jbrown |
| File Modified | 2012-12-27 |
| File Created | 2012-12-27 |