Form Recovery Measureme Recovery Measureme Recovery Measurement Tool

Attachment 2

Recovery Measurement Tool

OMB No. 0930-03XX Expiration Date: xx/xx/xx

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 0930-03XX.  Public reporting burden for this collection of information is estimated to average 20 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.

GPRA ID_____________________________________________________ Date__________________________________________

Data Collection Site_______________________________________

Circle One: Baseline Data Six-Month Follow-Up Data

The following questions ask you about your life, health and feelings. I will read each question to you, along with the response options. Please choose the answer that seems most appropriate. For each question, please provide the ONE response that best reflects your experiences in the past 30 days. I can repeat any question that you need to hear again.

		Very poor	Poor	Neither good nor poor	Good	Very Good
1.	How would you rate your quality of life?

		Very dissatisfied	Dissatisfied	Neither satisfied or dissatisfied	Satisfied	Very dissatisfied
2.	How satisfied are you with your health?

		Not at all	A little	Moderately	Mostly	Completely
3.	Do you have enough energy for everyday life?

		Very dissatisfied	Dissatisfied	Neither satisfied or dissatisfied	Satisfied	Very dissatisfied
4.	How satisfied are you with your ability to perform your daily activities?
5.	How satisfied are you with yourself?
6.	How satisfied are you with your personal relationships?

		Not at all	A little	Moderately	Mostly	Completely
7.	Have you enough money to meet your needs?

		Very dissatisfied	Dissatisfied	Neither satisfied or dissatisfied	Satisfied	Very dissatisfied
8.	How satisfied are you with the conditions of your living space?

9. During the past 30 days, how many days have you used any alcohol?

Number of Days	Don’t Know	Refused
___________	☐	☐

10. Note: Ask this only if the number of reported drinks in Question #9 is greater than zero, and respondent is male:

During the past 30 days, how many days have you had four or more drinks in a day? [CLARIFY IF NEEDED: A standard drink =12 oz. beer, 5 oz. wine, 1.5 oz. liquor.

Number of Days	Don’t Know	Refused
____________	☐	☐

Note: Ask this only if the number of reported drinks in Question #9 is greater than zero, and respondent is female:

During the past 30 days, how many days have you had three or more drinks in a day? [CLARIFY IF NEEDED: A standard drink = 12 oz. beer, 5 oz. wine, 1.5 oz. liquor.

Number of Days	Don’t Know	Refused
____________	☐	☐

11. During the past 30 days, how many days did you use any illegal drugs, including prescription drugs that were taken for reasons or in doses other than prescribed?

Number of Days	Don’t Know	Refused
____________	☐	☐

12. 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.

	All of the time	Most of the time	Some of the time	A little of the time	None of the time	Refused	Don’t know
Nervous?
Hopeless?
Restless or fidgety?
So depressed that nothing could cheer you up?
That everything was an effort?
Worthless?

13. During the past 30 days, how much have you been bothered by these psychological or emotional problems?

Not at all	Slightly	Moderately	Considerably	Extremely	Refused	Don’t know

14. I have family or friends that are supportive of my recovery.

Strongly disagree	Disagree	Undecided	Agree	Strongly Agree	Refused	Don’t know

15. In a crisis, I would have the support I need from family or friends.

Strongly disagree	Disagree	Undecided	Agree	Strongly Agree	Refused	Don’t know

16. I feel I belong in my community.

Strongly disagree	Disagree	Undecided	Agree	Strongly Agree	Refused	Don’t know

17. I generally accomplish what I set out to do.

Strongly Disagree	Disagree	Agree	Strongly Agree	Don’t know

18. Please select the one answer that most closely matches your situation.  I feel capable of managing my health care needs:

1. On my own most of the time

2. With support from others most of the time

3. On my own some of the time and with support from others some of the time

4. Rarely or never

19. Are you currently employed? [Note: CLARIFY BY FOCUSING ON STATUS DURING MOST OF THE PREVIOUS MONTH, DETERMINING WHETHER CONSUMER WORKED AT ALL OR HAD A REGULAR JOB BUT WAS OFF WORK.]

☐ EMPLOYED FULL TIME (35+ HOURS PER WEEK, OR WOULD HAVE BEEN)

☐ EMPLOYED PART TIME

☐ UNEMPLOYED, LOOKING FOR WORK

☐ UNEMPLOYED, DISABLED

☐ UNEMPLOYED, VOLUNTEER WORK

☐ UNEMPLOYED, RETIRED

☐ UNEMPLOYED, NOT LOOKING FOR WORK

☐ OTHER (SPECIFY) _______________________

☐ REFUSED

☐ DON’T KNOW

20. Are you enrolled in school or a job training program? [If enrolled, is that full-time or part-time?]

☐ NOT ENROLLED

☐ ENROLLED, FULL TIME

☐ ENROLLED, PART TIME

☐ OTHER (SPECIFY)

☐ REFUSED

☐ DON’T KNOW

21. In the past 30 days, how many nights have you been homeless?

Number of Nights/Times	Don’t Know	Refused
______________	☐	☐