Form FTDC Form FTDC Form FTDC Form

OMB No. 0930-0330

Expiration Date: xx/xx/xx

Attachment A

FDTC Data Collection Form

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 0930-0330.  Public reporting burden for this collection of information is estimated to average 30 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.

SECTION A. RECORD MANAGEMENT

A.1 FDTCID |____|____|____|____|____|____|____|____|

A.2 CASEID |____|____|____|____|____|____|

A.3 ADULTID |____|____|____|____|____|____|____|____|

A.4 Date file opened with FDTC program. [FILE_O]

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

Month Day Year

A.5 Date file closed with FDTC program. [FILE_C]

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

Month Day Year

A.6 Data Collection Period [COLLPER]

Baseline

6 Month Follow-up

12 Month Follow-up

Discharge

SECTION B. ADULT DEMOGRAPHICS [ONLY AT BASELINE]

B.1 What is the adult’s relationship to the index child? [ARLTNSHP]

 Biological mother

 Biological father

 Step mother

 Step father

 Adoptive mother

 Adoptive father

 Foster mother

 Foster father

 Presumptive father

 Grandmother (maternal or paternal)

 Grandfather (maternal or paternal)

 Aunt (maternal or paternal)

 Uncle (maternal or paternal)

 Significant Other (unmarried partner of parent/caregiver)

 Other Relationship – includes other relatives not specified and non-relatives (e.g., godparents, other non-biological caregivers)

 Relationship not known

B.2 What is the adult’s date of birth? [ADOB] [*The system will only save month and year. To maintain confidentiality, day is not saved.]

|____|____| / |____|____| / |____|____|____|____|
Month Day Year

B.3 What is the adult’s gender? [ASEX]

Male

Female

B.4 Is the adult Hispanic/Latino? [AETHN]

No

Yes

B.5 What is the adult’s race? Please answer yes or no for each of the following. (Mark all that apply)

		N	Y
A.	American Indian/ Alaska Native			[ARACAI]
B.	Asian			[ARACAS]
C.	Black or African American			[ARACBL]
D.	Native Hawaiian or other Pacific Islander			[ARACNH]
E.	White			[ARACWH]

B.6 Is the adult a prior perpetrator of substantiated child maltreatment? [A_PRIOR]

No

Yes

Don’t Know

B.7 Is the adult pregnant? [PREG]

Pregnant

Not Pregnant

Don’t Know

B.8 What is the adult’s marital status? [MARITAL]

Never married

Now married

Separated

Divorced

Widowed

Unknown

B.9 Date enrolled FDC [FDCOPEN]

|____|____| / |____|____| / |____|____|____|____|
Month Day Year

B.10 What is the adult’s primary substance problem reported at treatment admission? (Choose only one). [SUB1]

Alcohol

Cocaine/crack

Marijuana/hashish

Heroin/other opiates (total)

Heroin

Oxycontin/ oxycodone

Hydrocodone (Lortab)

Other opiates/ synthetics

Non-prescription methadone

Hallucinogens/ psychedelics

Methamphetamine

Other amphetamines/ stimulants

Benzodiazepines

Barbiturates

Other tranquilizers or sedatives

Inhalants

Other drugs

Unknown/ missing

B.11 During the 30 days prior to treatment admission, on how many days has the adult used any of the following:

		NUMBER OF DAYS	UNKNOWN/ MISSING
A,	Alcohol	|____|____|		[ALCOHOL1]
B.	Cocaine/crack	|____|____|		[COCAINE1]
C.	Marijuana/hashish	|____|____|		[MARIJ1]
D.	Opiates	|____|____|		[OPIATES1]
E.	Heroin	|____|____|		[HEROIN1]
F.	Oxycontin/oxycodone	|____|____|		[OXYCO1]
G.	Hydrocodone	|____|____|		[HYDROCO1]
H.	Other opiates/synthetics	|____|____|		[OTHOPIA1]
I.	Non-prescription methadone	|____|____|		[METHADO1]
J.	Hallucinogens/psychedelics	|____|____|		[HALLUC1]
K.	Methamphetamine	|____|____|		[METH1]
L.	Other amphetamines/stimulants	|____|____|		[OTHSTIM1]
M.	Benzodiazepines	|____|____|		[BENZO1]
N.	Barbiturates	|____|____|		[BARBIT1]
O.	Other tranquilizers or sedatives	|____|____|		[TRANQ1]
P.	Inhalants	|____|____|		[INHAL1]
Q.	Other drugs	|____|____|		[OTHDRUG1]

B.12 In the 30 days prior to admission, how many times has the adult been arrested? [ARREST1]

|____|____| Times

Don’t Know

SECTION C. INFORMATION ABOUT THE PARENT

C.1 What is the adult’s current living situation? [LIVARAG]

Homeless (client has no fixed address; includes shelters)

Dependent living (client is living in a supervised setting such as a residential institution, including jail/prison, halfway house or group home).

Independent living (client is living alone or with others without supervision)

Don’t know

C.2 What is the number of years of school completed? [EDUC]

|____|____| Highest Grade Completed

Don’t know

C.3 Is the adult currently employed? [EMPLOY]

Full time

Part time

Unemployed

Not in labor force

Don’t know

C.4 For how many children has the parent lost parental rights? [TPR]

|____|____| Number of Children

Don’t Know

C.5 For parents/caregivers who enter substance abuse treatment, what type of treatment do they enter? [PUBPRVTX]

Public

Private

Not applicable

Don’t know

C.6 What type of treatment setting is the adult currently in? [TXSET]

Detox, 24-hour, hospital inpatient

Detox, 24-hour, free-standing residential

Rehabilitation/ Residential – Hospital (other than detox)

Rehabilitation/ Residential – Short term (<=30 days)

Rehabilitation/ Residential – Long term (>30 days); may include transitional living such as halfway house

Ambulatory – Intensive Outpatient (at minimum, client receives treatment lasting 2 or more hours per day for 3 or more days per week)

Ambulatory – Non-intensive outpatient

Ambulatory – Detoxification (outpatient)

Unknown

C.7 What is the adult’s discharge status? [TXSTATUS]

Treatment completion

Left against professional advice (dropped out)

Terminated by facility

Transferred to another treatment program or facility (and known to report)

Transferred to another treatment program or facility, but did not report

Incarcerated

Death

Other

Unknown

Not applicable – still in treatment

SECTION D: SUPPORTIVE SERVICES

For the Supportive Services listed below, please indicate if the Adult has been assessed for each type of service and whether the service has been initiated.

D.1 Parent Training/Child Development Training Services

		N	Y	Not Identified as a Need	Our Program Does Not Provide This	Unknown
A.	Screened and/or assessed for parent training/child development training needs						[APARENT1]
B.	Services initiated						[APARENT2]

D.2 Mental Health or Counseling Services

		N	Y	Not Identified as a Need	Our Program Does Not Provide This	Unknown
A.	Screened and/or assessed for mental health needs						[AMH1]
B.	Services initiated						[AMH2]

D.3 Trauma Services

		N	Y	Not Identified as a Need	Our Program Does Not Provide This	Unknown
A.	Screened and/or assessed for trauma needs						[TRAUMA1]
B.	Services initiated						[TRAUMA2]

D.4 Child Care Services

		N	Y	Not Identified as a Need	Our Program Does Not Provide This	Unknown
A.	Screened and/or assessed for child care needs						[ACHCARE1]
B.	Services initiated						[ACHCARE2]

D.5 Transportation Services

		N	Y	Not Identified as a Need	Our Program Does Not Provide This	Unknown
A.	Screened and/or assessed for transportation needs						[ATRANSP1]
B.	Services initiated						[ATRANSP2]

D.6 Housing Assistance Services

		N	Y	Not Identified as a Need	Our Program Does Not Provide This	Unknown
A.	Screened and/or assessed for housing needs						[AHOUSE1]
B.	Services initiated						[AHOUSE2]

D.7 Family Planning Services

		N	Y	Not Identified as a Need	Our Program Does Not Provide This	Unknown
A.	Screened and/or assessed for family planning needs						[FAMPL1]
B.	Services initiated						[FAMPL2]

D.8 Domestic Violence Services

		N	Y	Not Identified as a Need	Our Program Does Not Provide This	Unknown
A.	Screened and/or assessed for domestic violence needs						[ADOMVIO1]
B.	Services initiated						[ADOMVIO2]

D.9 Employment or Vocation Training/Education Services

		N	Y	Not Identified as a Need	Our Program Does Not Provide This	Unknown
A.	Screened and/or assessed for employment or vocation training/ education needs						[AEMPLY1]
B.	Services initiated						[AEMPLY2]

D.10 Continuing Care/Recovery Support Services

		N	Y	Not Identified as a Need	Our Program Does Not Provide This	Unknown
A.	Screened and/or assessed for continuing care/recovery support needs						[ACONTCR1]
B.	Services initiated						[ACONTCR2]

D.11 Legal Services

		N	Y	Not Identified as a Need	Our Program Does Not Provide This	Unknown
A.	Screened and/or assessed for legal needs						[LEGAL1]
B.	Services initiated						[LEGAL2]

D.12 Primary Medical Care Services

		N	Y	Not Identified as a Need	Our Program Does Not Provide This	Unknown
A.	Screened and/or assessed for primary medical care needs						[AMED1]
B.	Services initiated						[AMED2]

D.13 Dental Care Services

		N	Y	Not Identified as a Need	Our Program Does Not Provide this	Unknown
A.	Screened and/or assessed for dental care services						[ADENTAL1]
B.	Services initiated						[ADENTAL2]

SECTION E. ADULT DISCHARGE ITEMS [COMPLETE ONLY AT DISCHARGE]

E.1 During the 30 days prior to discharge from treatment, on how many days has the adult used any of the following:

		NUMBER OF DAYS	UNKNOWN/ MISSING
A.	Alcohol	|____|____|		[ALCOHOL2]
B.	Cocaine/crack	|____|____|		[COCAINE2]
C.	Marijuana/hashish	|____|____|		[MARIJ2]
D.	Opiates	|____|____|		[OPIATES2]
E.	Heroin	|____|____|		[HEROIN2]
F.	Oxycontin/oxycodone	|____|____|		[OXYCO2]
G.	Hydrocodone	|____|____|		[HYDROCO2]
H.	Other opiates/synthetics	|____|____|		[OTHOPIA2]
I.	Non-prescription methadone	|____|____|		[METHADO2
J.	Hallucinogens/psychedelics	|____|____|		[HALLUC2]
K.	Methamphetamine	|____|____|		[METH2]
L.	Other amphetamines/stimulants	|____|____|		[OTHSTIM2]
M.	Benzodiazepines	|____|____|		[BENZO2]
N.	Barbiturates	|____|____|		[BARBIT2]
O.	Other tranquilizers or sedatives	|____|____|		[TRANQ2]
P.	Inhalants	|____|____|		[INHAL2]
Q.	Other drugs	|____|____|		[OTHDRUG2]

E.2 In the 30 days prior to discharge from treatment, how many times has the adult been arrested? [ARREST2]

|____|____| Times

Don’t Know

E.3 Did the adult complete family drug court? [FDCCOMP]

No

Yes

Not Applicable/did not enroll

E.3.A. Date exited FDC [FDCCLOSE]

|____|____| / |____|____| / |____|____|____|____|
Month Day Year

SECTION F. CHILD DEMOGRAPHICS [ONLY AT BASELINE]

F.1 What is the child’s date of birth? [CHBDATE] [*The system will only save month and year. To maintain confidentiality, day is not saved.]

|____|____| / |____|____| / |____|____|____|____|
Month Day Year

F.2 What is the child’s gender? [CHSEX]

Male

Female

F.3 Is the child Hispanic/Latino? [CHETHN]

No

Yes

F.3 What is the child’s race? Please answer yes or no for each of the following. (Mark all that apply)

		N	Y
A.	American Indian/ Alaska Native				[CHRACAI]
B.	Asian				[CHRACAS]
C.	Black or African American				[CHRACBL]
D.	Native Hawaiian or other Pacific Islander				[CHRACNH]
E.	White				[CHRACWH]

F.5 Is the child currently enrolled in school? [SCHOOL]

No

Yes

Don’t Know

F.5.A [If yes] What grade? [GRADE]

Pre-School

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

Voc/tech program after high school but no voc/tech diploma

Voc/tech diploma after high school

Don’t Know

F.6 Is parental/caregiver methamphetamine use a contributing factor to the child welfare case? [METHFACT]

No

Yes

Don’t Know

F.6.A [If yes] Was manufacturing/production of methamphetamine an allegation or factor in the child welfare case? [MANUF]

No

Yes

Don’t Know

F.6.B [If yes] Was the sales of methamphetamine an allegation or factor in the child welfare case? [SALES]

No

Yes

Don’t Know

SECTION G: CHILD MALTREATMENT AND PLACEMENT

G.1 Has there been a substantiated allegation of maltreatment during the past 6 months? [MALTXVIC]

No

Yes

G.2 Has the child been removed from the home? [REMOVED]

No

Yes

G.3 What was the date the child removed from the home? [REMOVDT]

|____|____| / |____|____| / |____|____|____|____|
Month Day Year

G.4 What was the date of discharge from foster care or out-of-home care? [FCDISDT]

|____|____| / |____|____| / |____|____|____|____|
Month Day Year

G.5 What is the reason for discharge from foster care or out-of-home care? [FCDISP]

Not applicable

Reunification with parent(s) or primary caregiver(s)

Living with other relative

Adoption

Emancipation

Relative guardianship

Transfer to another agency

Runaway

Death of child

SECTION H: SUPPORTIVE SERVICES PROVIDED TO THE CHILD

For the Supportive Services listed below, please indicate if the child has been assessed for each type of service and whether the service has been initiated.

H.1 Developmental Services

		N	Y	Not Identified as a Need	Our Program Does Not Provide this	Unknown
A.	Screened and/or assessed for developmental needs						[CHDEV1]
B.	Services initiated						[CHDEV2]

H.2 Mental Health or Counseling Services

		N	Y	Not Identified as a Need	Our Program Does Not Provide this	Unknown
A.	Screened and/or assessed for mental health needs						[CHMH1]
B.	Services initiated						[CHMH2]

H.3 Primary Pediatric Health Care Services

		N	Y	Not Identified as a Need	Our Program Does Not Provide this	Unknown
A.	Screened and/or assessed for primary pediatric health care needs						[CHMED1]
B.	Services initiated						[CHMED2]

H.4 Substance Abuse Prevention Services

		N	Y	Not Identified as a Need	Our Program Does Not Provide this	Unknown
A.	Screened and/or assessed for substance abuse prevention and education needs						[CHSAP1]
B.	Services initiated						[CHSAP2]

H.5 Substance Abuse Treatment Services

		N	Y	Not Identified as a Need	Our Program Does Not Provide this	Unknown
A.	Screened and/or assessed for substance use disorder						[CHSATX1]
B.	Services initiated						[CHSATX2]

H.6 Educational Services

		N	Y	Not Identified as a Need	Our Program Does Not Provide this	Unknown
A.	Screened and/or assessed for educational needs						[CHEDUC1]
B.	Services initiated						[CHEDUC2]

H.7 Neurological Effects of Prenatal Substance Use Exposure

		N	Y	Not Identified as a Need	Our Program Does Not Provide this	Unknown
A.	Screened and/or assessed for neurological effects of prenatal substance use exposure						[NEURO1]
B.	Services initiated						[NEURO2]

H.8 Dental Care Services

		N	Y	Not Identified as a Need	Our Program Does Not Provide this	Unknown
A.	Screened and/or assessed for dental care services						[CHDENTAL1]
B.	Services initiated						[CHDENTAL2]

I. FOLLOW-UP STATUS

[REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT FOLLOW-UP]

1. What is the follow-up status of the client? [THIS IS A REQUIRED FIELD: NA, REFUSED, DON’T KNOW, AND MISSING WILL NOT BE ACCEPTED].

 01 = Deceased at time of due date

 11 = Completed interview within specified window

 12 = Completed interview outside specified window

 21 = Located, but refused, unspecified

 22 = Located, but unable to gain institutional access

 23 = Located, but otherwise unable to gain access

 24 = Located, but withdrawn from project

 31 = Unable to locate, moved

 32 = Unable to locate, other (SPECIFY) ________________________

2. Is the client still receiving services from your program?

 Yes

 No

[IF THIS IS A FOLLOW-UP INTERVIEW STOP NOW, THE INTERVIEW IS COMPLETE.]

J. DISCHARGE STATUS

[REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT DISCHARGE]

1. On what date was the client discharged?

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

Month Day Year

2. What is the client’s discharge status?

 01 = Completion/Graduate

 02 = Termination

If the client was terminated, what was the reason for termination? [Select one response.]

 01 = Left on own against staff advice with satisfactory progress

 02 = Left on own against staff advice without satisfactory progress

 03 = Involuntarily discharged due to nonparticipation

 04 = Involuntarily discharged due to violation of rules

 05 = Referred to another program or other services with satisfactory progress

 06 = Referred to another program or other services with unsatisfactory progress

 07 = Incarcerated due to offense committed while in treatment/recovery with satisfactory progress

 08 = Incarcerated due to offense committed while in treatment/recovery with unsatisfactory progress

 09 = Incarcerated due to old warrant or charged from before entering treatment/recovery with satisfactory progress

 10 = Incarcerated due to old warrant or charged from before entering treatment/recovery with unsatisfactory progress

 11 = Transferred to another facility for health reasons

 12 = Death

 13 = Other (Specify)

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