CSAP Adult CSAP Adult

Common Data Platform

Attachment 5 CSAP Adult 12 19 2014

CSAP Client-Level Data

OMB: 0930-0346

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ATTACHMENT 5

OMB No. 0930-XXXX

Expiration Date XX/XX/XXXX


















Questions for Prevention Programs

Adult Version- Participants Age 18 and Older

(Revised 09/17/2014)




























Public reporting burden for this collection of information is estimated to average 27 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information, if all items are asked of a participant; to the extent that providers already obtain much of this information as part of their ongoing participant intake or follow up, less time will be required. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 2-1057, 1 Choke Cherry Road, Rockville, MD 20857. 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 control number for this project is 0930-xxxx.

SECTION A

RECORD MANAGEMENT


THIS SECTION TO BE COMPLETED BY STAFF ONLY



Participant ID |____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|


Grant ID |____|____|____|____|____|____|____|____|____|____|


  1. Data Collection Type [SELECT ONLY ONE TYPE]


Baseline

Exit

First follow-up after exit

Second follow-up after exit


2a. Was the data collected?


Yes

No



2b. When did the data collection take place?


Date |____|____| / |____|____| / |____|____|____|____|

Month Day Year



END SECTION A

RECORD MANAGEMENT





























SECTION B

FACTS ABOUT YOU




First, we’d like to ask some basic questions about you. Your answers will not be used to identify you in any way. Instead, your answers will help us understand how different groups (like men or women, or people of similar ages) feel about substance abuse and HIV prevention.


  1. What is your date of birth? (MONTH AND YEAR MUST BE ENTERED. DAY IS OPTIONAL AND WILL NOT BE SAVED IN THE CDP SYSTEM)


|____|____| / |____|____| / |____|____|____|____|

Month Day Year


DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


 

4.   What is your gender?

 

         Male

         Female

         Transgender

         Different identity (SPECIFY): __________________________________

         DECLINED

         DON’T KNOW/INFORMATION NOT AVAILABLE

 


5.   Which one of the following do you consider yourself to be?

 

         Straight

         Lesbian (if female) or Gay (if male)

         Bisexual

         DECLINED

         DON’T KNOW/INFORMATION NOT AVAILABLE


6. People are different in their sexual attraction to other people. Which statement best describes your feelings?


[IF MALE]

[IF FEMALE]

I am only attracted to females

I am only attracted to males

I am mostly attracted to females

I am mostly attracted to males

I am equally attracted to females and males

I am equally attracted to males and females

I am mostly attracted to males

I am mostly attracted to females

I am only attracted to males

I am only attracted to females

DECLINED

DECLINED

DON’T KNOW/INFORMATION

NOT AVAILABLE

DON’T KNOW/INFORMATION

NOT AVAILABLE








SECTION B

FACTS ABOUT YOU (CONTINUED)


7. In the past 12 months who have you had sex with?


Men only

Women only

Both men and women

I have not had sex in the past 12 months

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



8. Are you Hispanic, Latino/a, or Spanish origin? (One or more categories may be selected)


Yes, Central American

Yes, Cuban

Yes, Dominican

Yes, Mexican, Mexican American, Chicano/a

Yes, Puerto Rican

Yes, South American

Yes, another Hispanic, Latino, or Spanish origin

No, not of Hispanic, Latino/a, or Spanish origin

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


9. What is your race? (One or more categories may be selected)

White

Black or African American

American Indian

Alaska Native

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian

Native Hawaiian

Guamanian or Chamorro

Samoan

Other Pacific Islander

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


10. How well do you speak English?



Very well

Well

Not well

Not at all

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


SECTION B

FACTS ABOUT YOU (CONTINUED)


11. Do you speak a language other than English at home?

Yes

No [SKIP TO QUESTION 13]

DECLINED [SKIP TO QUESTION 13]

DON’T KNOW/INFORMATION NOT AVAILABLE [SKIP TO QUESTION 13]



12. If you speak a language other than English at home, what language do you speak?

Spanish

Other language Identify other language: ___________________

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



13. Are you deaf or do you have serious difficulty hearing?


Yes

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



14. Are you blind or have serious difficulty seeing, even when wearing glasses?


Yes

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



15. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering or making decisions?


Yes

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



16. Do you have serious difficulty walking or climbing stairs?


Yes

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE






SECTION B

FACTS ABOUT YOU (CONTINUED)


17. Do you have difficulty dressing or bathing?


Yes

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


18. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?


Yes

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



19. What is the highest level of education you have finished, whether or not you received a degree?


Preschool

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

7th Grade

8th Grade

9th Grade

10th Grade

11th Grade

12th Grade/High School Diploma Equivalent

Some College or University

Bachelor’s Degree (BA, BS) or Higher

Vocational/Tech Diploma After High School

I never attended school or a job training program

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE
















SECTION B

FACTS ABOUT YOU (CONTINUED)


20. Are you currently employed?


[CLARIFY BY FOCUSING ON STATUS DURING MOST OF THE PREVIOUS WEEK, DETERMINING WHETHER PARTICIPANT 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 [SKIP TO QUESTION 22]

Unemployed, disabled [SKIP TO QUESTION 22]

Unemployed, volunteer work [SKIP TO QUESTION 22]

Unemployed, retired [SKIP TO QUESTION 22]

Unemployed, not looking for work [SKIP TO QUESTION 22]

Other (Specify) ___________________

DECLINED [SKIP TO QUESTION 22]

DON’T KNOW/INFORMATION NOT AVAILABLE [SKIP TO QUESTION 22]



21a. If employed, are you paid at or above the minimum wage?


Yes

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


21b. If employed, are your wages paid directly to you by your employer?


Yes

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



21c. If employed, could anyone have applied for this job?


Yes

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



22. In the past 30 days, how many nights have you spent in jail/prison?


|____|____| nights  


DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE









SECTION B

FACTS ABOUT YOU (CONTINUED)



23. Describe your current relationship status.

Oval 31 Single (never married)

Oval 673 Informally married or living with a permanent partner

Oval 674 Legally married

Oval 773 Separated

Oval 802 Divorced or broken up from an informal marriage

Oval 801 Widowed

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE




24. Think about the household members that live with you right now. About how much income have you and/or your family members made in the last year before taxes? (Include child support and/or cash payments from the government, for example, welfare [TANF], SSI, or unemployment compensation)


Oval 812 $0 - $10,000

Oval 813 $10,001 - $20,000

Oval 814 $20,001 - $30,000

Oval 815 $30,001 - $40,000

Oval 816 $40,001 - $50,000

Oval 820 $50,001 - $60,000

Oval 821 More than $60,000

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



25. Have you ever served on active, reserve, or National Guard duty?


   Yes

         No (SKIP TO QUESTION 27)

        DECLINED (SKIP TO QUESTION 27)

         DON’T KNOW/INFORMATION NOT AVAIABLE (SKIP TO QUESTION 27)


26a. If you ever served on active, reserve, or National Guard duty, in what branch of the military/uniformed services did you serve?


         Army

         Marine Corps

         Navy

         Air Force

         Coast Guard

         PHS

         NOAA

         DECLINED

         DON’T KNOW/INFORMATION NOT AVAILABLE






26b. If you ever served on active, reserve, or National Guard duty, in which component did you serve?


   Active

         Reserve

         National Guard

         DECLINED

         DON’T KNOW/INFORMATION NOT AVAILABLE


26c. If you ever served on active, reserve, or National Guard duty, are you currently on active duty or are you separated or retired?


         On active duty

         Separated

         Retired

         DECLINED

         DON’T KNOW / INFORMATION NOT AVAILABLE



26d. If you ever served on active, reserve, or National Guard duty, have you ever been deployed to a     combat zone? (SELECT ALL THAT APPLY)


         No, never deployed to a combat zone

         Yes, Iraq or Afghanistan (e.g., OEF/OIF/OND)

         Yes, Persian Gulf (Operation Desert Shield/Desert Storm)

         Yes, Vietnam/Southeast Asia

         Yes, Korea

         Yes, Persian Gulf (Operation Desert Shield/Desert Storm)

         Yes, World War II

         Yes, other (SPECIFY COMBAT ZONE): __________________________________

         DECLINED

         DON’T KNOW / INFORMATION NOT AVAILABLE



For the following questions, immediate family includes your spouse or partner, and your parents, children, brothers and sisters, whether they are biological, step, or adoptive.  Please include these family members whether or not they live with you.


27. Is anyone in your immediate family currently serving as a member of one the branches of the

      United States uniformed services on active duty, reserve components or National Guard?


         Yes

         No (SKIP TO SECTION C)

         DECLINED (SKIP TO SECTION C)

         DON’T KNOW / INFORMATION NOT AVAILABLE (SKIP TO SECTION C)














28a. If anyone in your immediate family is currently serving in the uniformed services, which member(s) are currently serving? (SELECT ALL THAT APPLY)


         My spouse

         Unmarried partner

         My mother

         My father

         My son or sons

         My daughter or daughters

         My brother or brothers

         My sister or sisters

         Another member of my immediate family (SPECIFY RELATIONSHIP): ________________

         DECLINED

         DON’T KNOW/INFORMATION NOT AVAILABLE


END SECTION B

FACTS ABOUT YOU







































SECTION C

ATTITUDES & KNOWLEDGE


Next, we’d like to ask you how you feel about substance use and health care services. Again, your answers are private and will not be used to identify you.


The next few questions ask about HOW MUCH you think people RISK HARMING themselves physically or in other ways by using alcohol, tobacco, and drugs.


29. How much do people risk harming themselves physically or in other ways when they smoke one or more packs of cigarettes per day?


Oval 769 No risk

Oval 770 Slight risk

Oval 771 Moderate risk

Oval 774 Great risk

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


30. How much do people risk harming themselves physically or in other ways when they smoke marijuana once or twice a week?


Oval 775 No risk

Oval 776 Slight risk

Oval 777 Moderate risk

Oval 778 Great risk

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


31. How much do people risk harming themselves physically or in other ways when they have five or more drinks of an alcoholic beverage once or twice a week?


Oval 780 No risk

Oval 781 Slight risk

Oval 782 Moderate risk

Oval 783 Great risk

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


32. If you have children, during the past 12 months, how many times have you talked with your children about the dangers or problems associated with the use of tobacco, alcohol, or drugs?


I don’t have any children

0 times

1 or 2 times

Oval 807 A few times

Oval 808 Many times

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



END SECTION C

ATTITUDES & KNOWLEDGE

SECTION D

BEHAVIOR & RELATIONSHIPS


SECTION D1

CIGARETTES, ALCOHOL, DRUGS


The next question is about CIGARETTES.

Think back over the past 30 days and record on how many days, if any, you used cigarettes.



33. During the past 30 days, on how many days did you smoke part or all of a cigarette? (Includes menthol and regular cigarettes and loose tobacco rolled into cigarettes)


|___| ___| Number of days in past 30 days


DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



The next question asks about other tobacco products. Please include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe


34. During the past 30 days, on how many days did you use OTHER tobacco products?


|___| ___| Number of days in past 30 days

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



The next question is about ALCOHOL. By alcohol, we mean BEER, WINE, WINE COOLERS, MALT BEVERAGES or HARD LIQUOR.


Different groups of people in the United States may use alcohol for religious reasons. For example, some churches serve wine during a church service. If you drink wine at church or for some other religious reason, do not count these times in your answers to the questions below.


Think back over the past 30 days and record on how many days, if any, you consumed alcohol in the amount described below.



35. [ASK ONLY TO WOMEN 21 YEARS OLD OR OLDER ONLY; OTHERWISE SELECT NOT APPLICABLE]


During the past 30 days, on how many days did you have 3 more drinks on the same occasion? [By 'occasion,' we mean at the same time or within a couple of hours of each other].



|___| ___| Number of days in past 30 days


NOT APPLICABLE – PARTICIPANT IS MALE OR UNDER THE AGE OF 21

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



SECTION D1

CIGARETTES, ALCOHOL, DRUGS AND RECOVERY (CONTINUED)


36. [ASK ONLY TO MEN 21 YEARS OLD OR OLDER ONLY; OTHERWISE SELECT NOT APPLICABLE]


During the past 30 days, on how many days did you have 4 or more drinks on the same occasion? [By 'occasion,' we mean at the same time or within a couple of hours of each other].


|___| ___| Number of days in past 30 days


NOT APPLICABLE – PARTICIPANT IS FEMALE OR UNDER THE AGE OF 21

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


The next question is about MARIJUANA or HASHISH. Marijuana is sometimes called weed, blunt, hydro, grass, or pot. Hashish is sometimes called hash or hash oil.


Think back over the past 30 days and record on how many days, if any, you used marijuana or hashish.



37. During the past 30 days, on how many days did you use marijuana or hashish?


|___| ___| Number of days in past 30 days


DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



The next question is about OTHER ILLEGAL DRUGS, excluding marijuana or hashish.


These include substances like inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to feel good or get high), heroin, crack, or cocaine, methamphetamine, hallucinogens (drugs that cause people to see or experience things that are not real) such as LSD (sometimes called acid), Ecstasy (MDMA), PCP, peyote (sometimes called angel dust), and prescription drugs used without a doctor’s orders.


Think back over the past 30 days and record on how many days, if any, you used illegal drugs OTHER THAN MARIJANNA AND HASSISH.



38. During the past 30 days, on how many days did you use any illegal drug OTHER THAN MARIJUANNA AND HASSISH?


|___| ___| Number of days in past 30 days


DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE












SECTION D1

CIGARETTES, ALCOHOL, DRUGS AND RECOVERY (CONTINUED)


Now we would like to ask about your use of prescription drugs without a doctor’s orders during the past 30 days.



39. During the past 30 days, on how many days have you used prescription drugs without a doctor’s orders?


|___| ___| Number of days in past 30 days


DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



The next few questions ask about programs or classes you may have attended recently.



40. In the past 30 days, did you attend any voluntary self-help groups for recovery that were not affiliated with a religious or faith-based organization?


In other words, did you participate in a non-professional, peer-operated organization that is devoted to helping individuals who have addiction related problems such as: Alcoholics Anonymous, Narcotics Anonymous, Oxford House, Secular Organization for Sobriety, or Women for Sobriety, etc.


Yes If yes, |___| ___| Number of times in past 30 days

No

DECLINED

DON’T KNOW/INFORMATION OT AVAILABLE



41. In the past 30 days did you attend any religious/faith affiliated recovery self-help groups?


Yes If yes, |___| ___| Number of times in past 30 days

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



42. In the past 30 days, did you attend meetings of organizations that support recovery other than the organizations described above?


Yes If yes, |___| ___| Number of times in past 30 days

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE






END SECTION D1

CIGARETTES, ALCOHOL, DRUGS AND RECOVERY





SECTION D2

VIOLENCE AND TRAUMA


The next few questions ask about abuse you might have experienced.


43. In your life have you ever experienced an event, series of events, or set of circumstances that resulted in you feeling physically or emotionally harmed or threatened?


Yes

No [SKIP TO QUESTION 45]

DECLINED [SKIP TO QUESTION 45]

DON’T KNOW/INFORMATION NOT AVAILABLE [SKIP TO QUESTION 45]



44. What kind of event was this? (Please select all that apply):


Natural or man-made disaster

Community or school violence

Interpersonal violence (including physical, sexual or psychological)

Military trauma

    • Other (SPECIFY): __________________________________

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



45. In the past 30 days, how often have you been hit, kicked, slapped, or otherwise physically hurt?


Oval 30 Never

Oval 29 A few times

Oval 28 More than a few times

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


END SECTION D2

VIOLENCE AND TRAUMA



END SECTION D


SECTION E

HEALTH AND HEALTH CARE SERVICES


46. Would you know where to go in your neighborhood to see a health care professional regarding HIV/AIDS or other sexually transmitted health issues?


Oval 785 Yes

Oval 786 No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



47. Would you know where to go in your neighborhood to see a health care professional regarding a drug or alcohol problem?


Yes

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



48. Do you currently have health care or medical insurance? (Select all that apply)


Oval 822 Yes, private insurance

Oval 825 Yes, Medicare

Oval 826 Yes, Medicaid

Oval 827 Yes, public assistance other than Medicare or Medicaid (e.g. TRICARE)

Oval 823 No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


49. Have you seen a doctor, nurse, or other health care provider in the past 12 months?


Oval 829 Yes

Oval 830 No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


50. During the past 30 days, did you engage in any sexual activity?

Yes

No [SKIP TO SECTION F IF APPLICABLE TO YOUR PROGRAM]

DECLINED [SKIP TO SECTION F IF APPLICABLE TO YOUR PROGRAM]

DON’T KNOW [SKIP TO SECTION F IF APPLICABLE TO YOUR PROGRAM]

NOT PERMITTED TO ASK [SKIP TO SECTION F IF APPLICABLE TO YOUR PROGRAM]













SECTION E

HEALTH AND HEALTH CARE SERVICES (CONTINUED)



51a. In the past 30 days, did you engage in protected or unprotected—



Yes,

Protected

Yes,

Unprotected

No

DECLINED

DON’T KNOW

(1) Vaginal sexual

Contacts

(2) Oral sexual contacts






(3) Anal sexual contacts








51b. In the past 30 days did you engage in unprotected sexual contact with an individual who is or was:


Yes

No

DECLINED

DON’T KNOW

(1) HIV positive or has AIDS

(2) An injection drug user





(3) High on some substance









END SECTION E

HEALTH AND HEALTH CARE SERVICES


















SECTION F

HIV AND TESTING SERVICES


NOTE: THIS SECTION SHOULD ONLY BE COMPLETED BY PARTICIPANTS IN HIV PROGRAMS


52. At any time during the past 12 months, were you offered an HIV test? An HIV test checks whether someone has the virus that causes AIDS.


Oval 829 Yes

Oval 830 No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


53. Would you like to be tested for HIV?


Yes [REFER TO HIV TESTING CENTER]

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


54. Have you ever been tested for HIV?

Oval 791 Yes

Oval 792 No [SKIP TO QUESTION 56]

Oval 793 DECLINED [SKIP TO QUESTION 56]

Oval 793 DON’T KNOW/INFORMATION NOT AVAILABLE [SKIP TO QUESTION 56]


55a. If you have been tested for HIV, did you receive your test results?

Oval 795 Yes, I received my results

Oval 796 No, I did not receive my results [SKIP TO QUESTION 56]

Oval 793 DECLINED [SKIP TO QUESTION 56]

Oval 793 DON’T KNOW/INFORMATION NOT AVAILABLE [SKIP TO QUESTION 56]


55b. If you have been tested for HIV, what is your current status?


Oval 8 Negative/Non-Reactive [SKIP TO QUESTION 56]

Oval 9 Positive/Reactive

Oval 10 Invalid/Indeterminate [SKIP TO QUESTION 56]

DECLINED [SKIP TO QUESTION 56]

DON’T KNOW/INFORMATION NOT AVAILABLE [SKIP TO QUESTION 56]


55c. If your HIV test was Positive/Reactive, did you receive a confirmatory test?

Oval 791 Yes

Oval 792 No

Oval 793 DECLINED

Oval 793 DON’T KNOW/INFORMATION NOT AVAILABLE


56. Have you ever been tested for Hepatitis B?


Oval 4 Yes

Oval 5 No [SKIP TO QUESTION 58]

Oval 6 DECLINED [SKIP TO QUESTION 58]

Oval 7 DON’T KNOW/INFORMATION NOT AVAILABLE [SKIP TO QUESTION 58]


SECTION F

HIV AND TESTING SERVICES (CONTINUED)


NOTE: THIS SECTION SHOULD ONLY BE COMPLETED BY HIV PROGRAMS


57a. If you have been tested for Hepatitis B, did you receive your test results?

Oval 795 Yes, I received my results

Oval 796 No, I did not receive my results [SKIP TO QUESTION 58]

Oval 793 DECLINED [SKIP TO QUESTION 58]

Oval 793 DON’T KNOW/INFORMATION NOT AVAILABLE [SKIP TO QUESTION 58]

57b. If you have been tested for Hepatitis B, what was your test result?


Oval 8 Negative/Non-Reactive [SKIP TO QUESTION 58]

Oval 9 Positive/Reactive

Oval 10 Invalid/Indeterminate [SKIP TO QUESTION 58]

DECLINED [SKIP TO QUESTION 58]

DON’T KNOW/INFORMATION NOT AVAILABLE [SKIP TO QUESTION 58]


57c. If your Hepatitis B test was Positive/Reactive, did you receive a confirmatory test?


Oval 791 Yes

Oval 792 No

Oval 793 DECLINED

Oval 793 DON’T KNOW/INFORMATION NOT AVAILABLE


58. Have you ever been tested for Hepatitis C?


Oval 817 Yes

Oval 648 No [STOP HERE; THE DATA COLLECTION IS COMPLETE]

Oval 649 DECLINED [STOP HERE; DATA COLLECTION IS COMPLETE]

Oval 650 DON’T KNOW/INFORMATION NOT AVAILABLE [STOP HERE; DATA COLLECTION IS COMPLETE]


59a. If you have been tested for Hepatitis C, did you receive your test results?

Oval 795 Yes, I received my results

Oval 796 No, I did not receive my results [STOP HERE; THE DATA COLLECTION IS COMPLETE]

Oval 793 DECLINED [STOP HERE; THE DATA COLLECTION IS COMPLETE]

Oval 793 DON’T KNOW/INFORMATION NOT AVAILABLE [STOP HERE; THE DATA COLLECTION IS COMPLETE]


59b. If you have been tested for Hepatitis C, what was your test result?


Oval 8 Negative/Non-Reactive [STOP HERE; DATA COLLECTION IS COMPLETE]

Oval 9 Positive/Reactive

Oval 10 Invalid/Indeterminate [STOP HERE; DATA COLLECTION IS COMPLETE]

DECLINED [STOP HERE; DATA COLLECTION IS COMPLETE]

DON’T KNOW/INFORMATION NOT AVAILABLE [STOP HERE; DATA COLLECTION IS COMPLETE]






SECTION F

HIV AND TESTING SERVICES (CONTINUED)


NOTE: THIS SECTION SHOULD ONLY BE COMPLETED BY HIV PROGRAMS


59c. If your Hepatitis C test was Positive/Reactive, did you receive a confirmatory test?


  • Yes [STOP HERE; DATA COLLECTION IS COMPLETE]

  • No [STOP HERE; DATA COLLECTION IS COMPLETE]

DECLINED [STOP HERE; DATA COLLECTION IS COMPLETE]

DON’T KNOW/INFORMATION NOT AVAILABLE [STOP HERE; DATA COLLECTION IS COMPLETE]




END SECTION F

HIV AND TESTING SERVICES




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