SAMHSA FASD Center for Excellence
Form A
Knowledge-Base Expansion Assessment
The purpose of these questions is to determine your eligibility to participate in the SAMHSA FASD Center for Excellence Screening and Brief Intervention or Project CHOICES program and to assess outcomes from your participation over time. 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.
All Women
Every Session |
Client ID ____________________________ Agency Name ______________________________________ |
Record assessment status at each Client session - A. Baseline Go to 1. Demographics Date _____/_____/______ Month Day Year
B. Project CHOICES Contraception Appointment: Date _____/_____/______ Birth Control Month Day Year Method Selected: ________________________________________
C. SBI Monthly/Trimester Go to 2. Alcohol Use Date _____/_____/______ Month Day Year
D. End of Program: SBI Go to 2. Alcohol Use Date _____/_____/______ Month Day Year Project CHOICES Go to 2. Alcohol Use
E. Follow-Up: 3-month (Project CHOICES) Go to 2. Alcohol Use Date _____/_____/______ Month Day Year 6-month (Project CHOICES) Go to 2. Alcohol Use
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All Women
Baseline only
All Women Baseline/ End of Program/ Follow-Up |
1. Demographics
Under 18 19-20 years old 21-24 years old 25-29 years old 30-34 years old 35-44 years old Over 45 years old
Black or African-American Native Hawaiian or other Pacific Islander White
Married Unmarried, living with partner Widowed
Interviewer: I’m now going to ask you questions that will determine your eligibility to participate in either SBI or Project CHOICES. These programs differ for women who are pregnant or non pregnant.
Yes Go to 2. Alcohol Use No (Go to 1g)
Yes If yes – STOP. Not Eligible for CHOICES or SBI programsGo to Non-Pregnant Women Eligibility Check and Screening Results No Go to 2. Alcohol Use |
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All Women Every Session
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2. Alcohol Use Interviewer: The next set of questions is about your alcohol use in the past 30 days. [Use the Standard Drink Chart to answer alcohol use questions.] One standard drink is equal to 12 ounces of beer, 5 ounces of wine, or 1.5 ounces [one shot] of 80-proof spirits or liquor. a. During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage? Write one number between 0 and 30 days. ___________ days b. How many drinks did you have on a typical day when you were drinking alcohol in the past 30 days? Write number of drinks consumed on a typical day when drinking alcohol in past 30 days: ___________ c. Alcohol Score = 2a. X 2b. = ____________
d. How often did you have 4 or more drinks in one day in the past 30 days? ____________ days
e. Are you currently receiving outpatient alcohol treatment? This can include individual or group counseling. Yes No |
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All Women Every session except Baseline |
f. Since the first visit when we talked about drinking have you had an alcoholic beverage? Yes No |
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Pregnant Women
Baseline only
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3. Risk of Alcohol Use for Pregnant Women
a. How many weeks pregnant are you today? ________ weeks b. During the time you were pregnant but did not know you were pregnant, how many alcoholic drinks did you usually have at one time? 10 or more 9 8 7 6 5 4 3 2 1 0 c. During the time you were pregnant but did not know you were pregnant, how often did you drink beer, wine, or other alcoholic beverages? Every day 2-3 days a month Almost every day Once a month 3-4 days a week Less than once a month 1-2 days a week Never
TWEAK (Tolerance – Worry – Eye-Opener – Amnesia [Blackouts] – K[C]ut Down) d. How many drinks does it take for you to first feel the effects of alcohol? ______drinks? ______ e. Do close friends or relatives worry or complain about your drinking? No Yes ______ f. Do you sometimes take a drink in the morning when you first get up? No Yes ______ g. Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember? No Yes ______ h. Do you sometimes feel the need to cut down on your drinking? No Yes ______
Scoring
the TWEAK
Question
TWEAK d 2 or more drinks = 2 points
0
– 1 drinks = 0 points
Question
TWEAK e “Yes” = 2
points
“No”
= 0 points
Question
TWEAK f-h “Yes” = 1
point
“No”
= 0 points i. TWEAK Score [add TWEAK d-h]
Go to Pregnant Women Eligibility Check and Screening Results
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Non-Pregnant Women
Baseline only |
4. Contraception Use Questions for Non-Pregnant Women a. Have you had any of the following? Yes No 1. Tubes tied Yes No 2. Hysterectomy Yes No 3. Menopause Yes No 4. Both ovaries removed Yes No 5. Has a doctor ever told you that you cannot become pregnant? If yes, Interviewer write reason: _______________________________ If yes to any in 4a–STOP. Not Eligible for CHOICES. Go to Non-Pregnant Women Eligibility Check and Screening Results
b. In the last 30 days, have you had vaginal sex with a man? Yes No If no in 4b – STOP. Not Eligible for CHOICES. Go to Non-Pregnant Women Eligibility Check and Screening Results
c. If you have had vaginal sex in the last 30 days, have you used birth control? Yes Go to # d and # e No If no in 4b – STOP. Eligible for CHOICES. Go to Non-Pregnant Women Eligibility Check and Screening Results |
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Non-Pregnant Women
Baseline/ End of Program/ Follow-Up
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Interviewer: Now I am going to ask you a few questions about different types of birth control methods that you may or may not have used. For each method that you have used, I will ask you some additional questions about your use of that method. Remember that these questions are about what you did in the last three months. A response of either “yes” or “no” is required to determine eligibility. Please describe the type of birth control used in the past 30 days and whether it was effective: e. Effective? (Show Perfect Use Cards and ask: Did you use [method] exactly d. Type as directed each time you had vaginal sex?) Condoms d1. e1. Yes No Diaphragm / contraception d2. e2. Yes No Birth control pills d3. e3. Yes No Vaginal ring (NuvaRing) d4. e4. Yes No Patch d5. e5. Yes No Emergency contraception d6. e6. Yes No Depo-Provera shot d7. e7. Yes No IUD d8. e8. Yes No Implanon d9. e9. Yes No Other _____________________ d10. e10. Yes No [Baseline only] If birth control is effective (yes to #e for all methods listed) – STOP. Go to Non-Pregnant Women Project CHOICES Eligibility Check and Screening Results |
Pregnant Women
Screening Results |
Pregnant Women Eligibility Check and Screening Results SBI Eligibility Check Interviewer: Indicate if woman meets eligibility criteria by checking box below.
Eligibility
Question
Eligibility
Response
Meet
Eligibility Criteria?
Pregnancy
Status (Question
1f)
Yes
Alcohol
Score
(Question
2a)*
1 or more
TWEAK
(Question
3i)*
2 or more
*Note: Woman is eligible if she meets 1 or both of the alcohol criteria.
5. SBI Screening Results Interviewer: Indicate if woman meets eligibility criteria by checking box below: a. Eligible for SBI program and agreed to participate
Schedule and record next appointment below. Next Appointment: Date _____/_____/______ Session ________________________ Month Day Year
b. Eligible for SBI program, but referred for alcohol treatment.
Client qualified for Alcohol Brief Intervention based on
drinking and/or TWEAK score, but was referred
c. Eligible for SBI program and did not agree to participate.
d. Not eligible for SBI program. 1) Scored less than 2 on TWEAK, and 2) did not consume at least one alcoholic drink in past 30 days. Interviewer: Thank you for your time, based on your answers, the SBI program would not meet your needs at this time.
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Non-Pregnant Women
Screening Results |
Non-Pregnant Women Eligibility Check and Screening Results
Project CHOICES Eligibility Check Interviewer: Check the relevant boxes below when you have completed the screening interview.
Eligibility
Question
Eligibility
Response
Meet
Eligibility Criteria?
Pregnancy
Status (Question
1f)
No
Pregnancy
Planning (Question
1g)
No
Age
(Q1a)
18 - 44
Alcohol Criteria:
Alcohol
Score
(Q2c)*
31 or more
Alcohol
Binge
(Q2d)*
1 or more
Outpatient
treatment (Q2e)*
Yes
Ability
to conceive (Q4a)
Yes
Sexual
Activity (Q4b
or Q4c)
Yes
Effective
Contraception (Q4c
or
Qe1, or e2, or ... e10)
No
* * Note: woman is eligible if she meets 1 or more of the alcohol criteria 6. Project CHOICES Screening Results Interviewer: Check the relevant boxes below when you have completed the screening interview. a. Eligible for Project CHOICES and agreed to participate Client qualified for Project CHOICES based on the following.
Not pregnant or planning to conceive Age Sexual Activity Ability to Conceive Alcohol Score/Binge/Outpatient Ineffective Contraception
Next Appointment: Date _____/_____/______ Session ________________________ Month Day Year
b.Eligible for Project CHOICES and did not agree to participate
c.Not eligible for Project CHOICES. Client does not qualify for Project CHOICES based on the following: Age No Sexual Activity Inability to Conceive Pregnant Alcohol Score/Binge/Outpatient Effective Contraception Planning to Conceive
Interviewer: Thank you for your time, based on your answers, the Project CHOICES program would not meet your needs at this time.
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Page
| File Type | application/msword |
| Author | SIG |
| Last Modified By | DHHS |
| File Modified | 2013-07-02 |
| File Created | 2013-07-02 |