Form FormB_SBI_Process

OMB No. 0930-0302

Expiration Date: xx/xx/xxxx

SAMHSA FASD Center for Excellence

Form B

Screening and Brief Intervention Process Information

This is a form to collect information related to your participation in the SAMHSA FASD Center for Excellence Screening and Brief Intervention program. To protect your privacy, your name and any other individually identifying information will not be reported to SAMHSA. It is important to us to obtain this information to maintain and improve the quality of our services; however, your participation is voluntary.

Client ID ____________________________ Agency Name ______________________________________ Date _____/_____/______ Month Day Year

SBI Monthly/ Trimester

1. What drinking goal did the client set for the next month?  Stop drinking  Cut down on drinking  Goal was not set 2. How many minutes did it take to give the alcohol intervention? ______________ Minutes 3. What did the client say will be the maximum number of drinks she will consume per week in the next month? _______________ Maximum drinks per week in next month Next Appointment: Date _____/_____/______ Session ________________________ Month Day Year

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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 0930-0302. Public reporting burden for this collection of information is estimated to average 1 minute per client 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.