Form TRAC

OMB No. 0930-XX
Expiration Date XX/XX/XX

Transformation Accountability (TRAC)
Center for Mental Health Services
NOMs Client-Level Measures for Discretionary
Programs Providing Direct Services
SERVICES TOOL
TCE NOMS

CMHS
Center for Mental Health Services
SAMHSA

Public reporting burden for this collection of information is estimated to average 30 minutes per
response if all items are asked of a consumer/participant; to the extent that providers already obtain
much of this information as part of their ongoing consumer/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 7-1045, 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 0930-0285.

RECORD MANAGEMENT
[RECORD MANAGEMENT IS REPORTED BY GRANTEE STAFF AT BASELINE, REASSESSMENT AND
DISCHARGE REGARDLESS OF WHETHER AN INTERVIEW IS CONDUCTED.]
Consumer ID

|____|____|____|____|____|____|____|____|____|____|____|

Grant ID (Grant/Contract/Cooperative Agreement) |____|____|____|____|____|____|____|____|____|____|
Site ID

|____|____|____|____|____|____|____|____|____|____|

1. Indicate Assessment Type:

Baseline


Reassessment

[ENTER THE MONTH AND YEAR WHEN
THE CONSUMER FIRST RECEIVED
SERVICES UNDER THE GRANT FOR
THIS EPISODE OF CARE.]

Which 6-month reassessment?

|____|____| / |____|____|____|____|
MONTH
YEAR


Clinical Discharge

|____|____|
[ENTER 06 FOR A 6-MONTH, 12
FOR A 12-MONTH, 18 FOR AN
18-MONTH ASSESSMENT, ETC.]

2. Was the interview conducted?

Yes


No

When?

Why not? Choose only one.

|____|____| / |____|____| / |____|____|____|____|
MONTH
DAY
YEAR

Not able to obtain consent from proxy
 Consumer was impaired or unable to provide consent
 Consumer refused this interview only
 Consumer was not reached for interview
 Consumer refused all interviews

[IF THIS IS A BASELINE, GO TO SECTION A.]
[FOR ALL REASSESSMENTS:
IF AN INTERVIEW WAS CONDUCTED, GO TO SECTION B.
IF AN INTERVIEW WAS NOT CONDUCTED, GO TO SECTION I.]
[FOR A CLINICAL DISCHARGE:
IF AN INTERVIEW WAS CONDUCTED, GO TO SECTION B.
IF AN INTERVIEW WAS NOT CONDUCTED, GO TO SECTION J.]

1

A.

DEMOGRAPHIC DATA

[SECTION A IS ONLY COLLECTED AT BASELINE. IF THIS IS NOT A BASELINE, GO TO SECTION B.]

1.

What is your gender?
 MALE
 FEMALE
 TRANSGENDER
 OTHER (SPECIFY) _____________________________________
 REFUSED

2.

Are you Hispanic or Latino?




YES
NO
REFUSED

[GO TO 3.]
[GO TO 3.]

[IF YES] What ethnic group do you consider yourself? Please answer yes or no for each of the
following. You may say yes to more than one.
YES NO REFUSED



Central American



Cuban



Dominican



Mexican



Puerto Rican



South American


OTHER
 [IF YES, SPECIFY BELOW.]
(SPECIFY) __________________________________
3.

What race do you consider yourself? Please answer yes or no for each of the following. You may say yes
to more than one.

Black or African American
Asian
Native Hawaiian or other Pacific Islander
Alaska Native
White
American Indian
4.

YES







NO







REFUSED







What is your month and year of birth?
|____|____| / |____|____|____|____|
MONTH
YEAR

 REFUSED

[IF THE BASELINE INTERVIEW WAS NOT CONDUCTED, GO TO SECTION H. ALL OTHERS CONTINUE
TO SECTION B.]

2

B.

FUNCTIONING

1.

How would you rate your overall health right now?
 Excellent
 Very Good
 Good
 Fair
 Poor
 REFUSED
 DON’T KNOW

2.

In order to provide the best possible mental health and related services, we need to know what you think
about how well you were able to deal with your everyday life during the past 30 days. Please indicate
your disagreement/agreement with each of the following statements.

[READ EACH STATEMENT FOLLOWED BY THE RESPONSE OPTIONS TO THE CONSUMER.]

Undecided

Agree

Strongly
Agree

a. I deal effectively with daily problems.













b. I am able to control my life.













c. I am able to deal with crisis.













d. I am getting along with my family.













e. I do well in social situations.













f.

I do well in school and/or work.













g. My housing situation is satisfactory.













h. My symptoms are not bothering me.













REFUSED

Disagree

NOT
APPLICABLE

RESPONSE OPTIONS

Strongly
Disagree

STATEMENT

3







B.

FUNCTIONING (Continued)

3.

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.

[READ EACH QUESTION FOLLOWED BY THE RESPONSE OPTIONS TO THE CONSUMER.]

Some of the
Time

A Little of
the Time

None of the
Time

a. nervous?















b. hopeless?















c. restless or fidgety?















d. so depressed that nothing could cheer you up?















e. that everything was an effort?















f. worthless?















DON’T
KNOW

During the past 30 days, about how often did you
feel …

REFUSED

Most
of the Time

RESPONSE OPTIONS

All of the
Time

QUESTION

4

B.

FUNCTIONING (Continued)

4.

The following questions relate to your experience with alcohol, cigarettes, and other drugs. Some of the
substances we’ll talk about are prescribed by a doctor (like pain medications). But I will only record
those if you have taken them for reasons or in doses other than prescribed.

[READ EACH QUESTION TO THE CONSUMER. IF THE # OF DAYS IS GREATER THAN 0 ASK THE ROUTE
OF ADMINISTRATION. NOTE THE USUAL ROUTE. IF MORE THAN ONE ROUTE, CHOOSE THE MOST
SEVERE. THE ROUTES ARE LISTED FROM LEAST SEVERE (1) TO MOST SEVERE (5).]
Route of Administration Types:
1. Oral 2. Nasal 3. Smoking 4. Non-IV injection

5. IV

[IF THE VALUE IN ANY ITEM B4g THROUGH B4t > 0, THEN THE VALUE IN B4e MUST BE > 0.]

DON’T
KNOW

REFUSED

Route

DON’T
KNOW

REFUSED

During the past 30 days, how many days have you used…

RESPONSE OPTIONS
# of Days

QUESTION

a) Tobacco products (cigarettes, chewing tobacco, cigars, etc.)?

|__|__|







b) Alcoholic beverages (beer, wine, liquor, etc.)?
[IF b=0, RF, DK, THEN SKIP TO ITEM e.]

|__|__|







c) Alcohol to intoxication (5+ drinks in one sitting)?

|__|__|







d) Alcohol to intoxication (4 or fewer drinks in one sitting and
felt high)?

|__|__|







e) Illegal drugs?

|__|__|







[IF b or e =0, RF, DK, THEN SKIP TO ITEM g.]
f) Both alcohol and drugs (on the same day)?

|__|__|







g) Cannabis (marijuana, pot, grass, hash, joints, blunts,
chronic, weed, Mary Jane, etc.)?

|__|__|



 |__|





h) Cocaine (coke, crack, etc.)?

|__|__|



 |__|





i)

Prescription stimulants (Ritalin, Concerta, Dexedrine,
Adderall, diet pills, etc.)?

|__|__|



 |__|





j) Methamphetamine or other amphetamines (crystal meth,
uppers, speed, ice, chalk, glass, fire, crank, etc.)?

|__|__|



 |__|





k) Inhalants (nitrous oxide, glue, gas, paint thinner, poppers,
snappers, rush, whippets, etc.)?

|__|__|



 |__|





5

l)

Benzodiazepines, sedatives or sleeping pills (Serepax, Ativan,
Librium, Rohypnol, GHB, etc.) Diazepam (Valium);
Alprazolam (Xanax); Triazolam (Halcion); and Estasolam
(Prosom and Rohypnol–also known as roofies, roche, and
cope)?

DON’T
KNOW

REFUSED

Route

During the past 30 days, how many days have you used…

DON’T
KNOW

FUNCTIONING (Continued)

REFUSED

B.

# of Days

B.

|__|__|

  |__|

 

m) Barbiturates: Mephobarbital (Mebacut) and pentobarbital
sodium (Nembutal)?

|__|__|

  |__|

 

n) Non-prescription GHB (known as Grievous Bodily Harm;
Liquid Ecstasy; and Georgia Home Boy)?

|__|__|



 |__|





o) Ketamine (known as Special K or Vitamin K)?

|__|__|



 |__|





p) Other tranquilizers, downers, sedatives or hypnotics?

|__|__|



 |__|





q) Hallucinogens/psychedelics, PCP (Angel Dust, Ozone, Wack,
Rocket Fuel) MDMA (Ecstasy, XTC, X, Adam), LSD (Acid,
Boomers, Yellow Sunshine), Mushrooms or Mescaline?

|__|__|



 |__|





r) Street opiates – heroin (Smack, H, Junk, Skag, opium etc.)?

|__|__|



 |__|





s) Prescription opioids (fentanyl, oxycodone [OxyContin,
Percocet], hydrocodone [Vicodin], methadone,
|__|__|
buprenorphine, morphine, Diluadid, Demerol, Darvon,
codeine, Tylenol 2, 3, 4, etc.) or non-prescription methadone?



 |__|





t) Other illegal drugs – specify: ______________________



 |__|





|__|__|

[IF ANY ROUTE OF ADMINISTRATION IN B4g – B4t = 4 or 5, THEN CONTINUE TO B4A;
OTHERWISE SKIP TO GAF SCORE.]
4A.

In the past 30 days, how often did you use a syringe/needle, cooker, cotton or water that
someone else used?

Always
More than half the time
Half the time
Less than half the time
Never
REFUSED
 DON’T KNOW

6

B.

FUNCTIONING (Continued)

[OPTIONAL: GAF SCORE REPORTED BY GRANTEE STAFF AT PROJECT’S DISCRETION.]

DATE GAF WAS ADMINISTERED:

|____|____| / |____|____| /|___|___|____|____|
MONTH
DAY
YEAR

WHAT WAS THE CONSUMER’S SCORE?

GAF =

|____|____|____|

7

B.

MILITARY FAMILY AND DEPLOYMENT

[QUESTIONS 5 THROUGH 8 ARE ONLY ASKED AT BASELINE. IF THIS IS NOT A BASELINE, GO TO 9.]
5.

Have you ever served in the Armed Forces, the Reserves, or the National Guard?





YES
NO
REFUSED
DON’T KNOW

[GO TO 6.]
[GO TO 6.]
[GO TO 6.]

[IF YES] In which of the following have you ever served? Please answer for each of the following.
You may say yes to more than one.
DON’T
YES NO REFUSED KNOW
Armed Forces




Reserves




National Guard






5a. Are you currently serving on active duty in the Armed Forces, the Reserves, or the National Guard?
YES
NO
REFUSED
DON’T KNOW

[GO TO 5b.]
[GO TO 5b.]
[GO TO 5b.]

[IF YES] In which of the following are you currently serving? Please answer for each of the
following. You may say yes to more than one.
DON’T
YES NO REFUSED KNOW
Armed Forces




Reserves




National Guard




5b. Have you ever been deployed to a combat zone?
 YES
 NO
REFUSED
DON’T KNOW

[GO TO 6.]
[GO TO 6.]
[GO TO 6.]

[IF YES] To which of the following combat zones have you been deployed? Please answer for each
of the following. You may say yes to more than one.
DON’T
YES NO REFUSED KNOW
Iraq or Afghanistan (e.g., Operation Enduring Freedom/Operation




Iraqi Freedom/Operation New Dawn)
Persian Gulf (Operation Desert Shield or Desert Storm)




Vietnam/Southeast Asia




Korea




WWII




Deployed to a combat zone not listed above (e.g., Somalia, Bosnia,




Kosovo)

8

B.

6.

MILITARY FAMILY AND DEPLOYMENT (Continued)
Is anyone in your family or someone close to you currently serving on active duty in or retired/separated
from the Armed Forces, the Reserves, or the National Guard?
Yes, only one person
Yes, more than one person
 No
 REFUSED
 DON’T KNOW

[GO TO 7.]
[GO TO 7.]
[GO TO 7.]

For the first person:
6.a.1 What is the relationship of that person (Service Member) to you?










 

 

 

MOTHER/FATHER
BROTHER/SISTER
SPOUSE/PARTNER
CHILD
OTHER, SPECIFY_____________
REFUSED
DON’T KNOW

6.b.1 Has the Service Member experienced any of the following? Please answer for each of the following.
You may say yes to more than one.
DON’T
YES
NO REFUSED KNOW
Deployed in support of Combat Operations (e.g. Iraq or Afghanistan)




Was physically injured during Combat Operations




Developed combat stress symptoms/difficulties adjusting following




deployment, including PTSD, depression, or suicidal thoughts
Died or was killed




[IF THE RESPONSE TO 6 WAS “YES, ONLY ONE PERSON”, GO TO 7. OTHERWISE, CONTINUE.]

9

B.

MILITARY FAMILY AND DEPLOYMENT (Continued)

For the second person:
6.a.2 What is the relationship of that person (Service Member) to you?
MOTHER/FATHER
BROTHER/SISTER
SPOUSE/PARTNER
CHILD
 OTHER, SPECIFY_____________
 REFUSED
 DON’T KNOW
6.b.2 Has the Service Member experienced any of the following? Please answer for each of the following.
You may say yes to more than one.
DON’T
YES NO REFUSED KNOW
Deployed in support of Combat Operations (e.g. Iraq or Afghanistan)




Was physically injured during Combat Operations




Developed combat stress symptoms/difficulties adjusting following




deployment, including PTSD, depression, or suicidal thoughts
Died or was killed




[IF THE CONSUMER HAS INFORMATION FOR ANOTHER SERVICE MEMBER, CONTINUE.
OTHERWISE, GO TO 7.]

For the third person:
6.a.3 What is the relationship of that person (Service Member) to you?
MOTHER/FATHER
BROTHER/SISTER
SPOUSE/PARTNER
CHILD
 OTHER, SPECIFY_____________
 REFUSED
 DON’T KNOW
6.b.3 Has the Service Member experienced any of the following? Please answer for each of the following.
You may say yes to more than one.
DON’T
YES NO REFUSED KNOW
Deployed in support of Combat Operations (e.g. Iraq or Afghanistan)




Was physically injured during Combat Operations




Developed combat stress symptoms/difficulties adjusting following




deployment, including PTSD, depression, or suicidal thoughts
Died or was killed




[IF THE CONSUMER HAS INFORMATION FOR ANOTHER SERVICE MEMBER, CONTINUE.
OTHERWISE, GO TO 7.]

10

B.

MILITARY FAMILY AND DEPLOYMENT (Continued)

For the fourth person:
6.a.4 What is the relationship of that person (Service Member) to you?
MOTHER/FATHER
BROTHER/SISTER
SPOUSE/PARTNER
CHILD
 OTHER, SPECIFY_____________
 REFUSED
 DON’T KNOW
6.b.4 Has the Service Member experienced any of the following? Please answer for each of the following.
You may say yes to more than one.
DON’T
YES NO REFUSED KNOW
Deployed in support of Combat Operations (e.g. Iraq or Afghanistan)




Was physically injured during Combat Operations




Developed combat stress symptoms/difficulties adjusting following




deployment, including PTSD, depression, or suicidal thoughts
Died or was killed




[IF THE CONSUMER HAS INFORMATION FOR ANOTHER SERVICE MEMBER, CONTINUE.
OTHERWISE, GO TO 7.]

For the fifth person:
6.a.5 What is the relationship of that person (Service Member) to you?
MOTHER/FATHER
BROTHER/SISTER
SPOUSE/PARTNER
CHILD
 OTHER, SPECIFY_____________
 REFUSED
 DON’T KNOW
6.b.5 Has the Service Member experienced any of the following? Please answer for each of the following.
You may say yes to more than one.
DON’T
YES NO REFUSED KNOW
Deployed in support of Combat Operations (e.g. Iraq or Afghanistan)




Was physically injured during Combat Operations




Developed combat stress symptoms/difficulties adjusting following




deployment, including PTSD, depression, or suicidal thoughts
Died or was killed




[IF THE CONSUMER HAS INFORMATION FOR ANOTHER SERVICE MEMBER, CONTINUE.
OTHERWISE, GO TO 7.]

11

B.

MILITARY FAMILY AND DEPLOYMENT (Continued)

For the sixth person:
6.a.6 What is the relationship of that person (Service Member) to you?
MOTHER/FATHER
BROTHER/SISTER
SPOUSE/PARTNER
CHILD
 OTHER, SPECIFY_____________
 REFUSED
 DON’T KNOW
6.b.6 Has the Service Member experienced any of the following? Please answer for each of the following.
You may say yes to more than one.
DON’T
YES NO REFUSED KNOW
Deployed in support of Combat Operations (e.g. Iraq or Afghanistan)




Was physically injured during Combat Operations




Developed combat stress symptoms/difficulties adjusting following




deployment, including PTSD, depression, or suicidal thoughts
Died or was killed





B.
7.

VIOLENCE AND TRAUMA
Have you ever experienced violence or trauma in any setting (including community or school violence;
domestic violence; physical, psychological, or sexual maltreatment/assault within or outside of the family;
natural disaster; terrorism; neglect; or traumatic grief)?





8.

YES
NO
REFUSED
DON’T KNOW

[GO TO 9.]
[GO TO 9.]
[GO TO 9.]

Did any of these experiences feel so frightening, horrible, or upsetting that in the past and/or the present
you:
DON’T
YES NO REFUSED KNOW
8a. Have had nightmares about it or thought about it when you did




not want to?
8b. Tried hard not to think about it or went out of your way to avoid




situations that remind you of it?
8c. Were constantly on guard, watchful, or easily startled?









8d. Felt numb and detached from others, activities, or your
surroundings?









12

B.
9.

VIOLENCE AND TRAUMA (Continued)
In the past 30 days, how often have you been hit, kicked, slapped, or otherwise physically hurt?

Never
Once
A few times
More than a few times
REFUSED
DON’T KNOW

13

C.

STABILITY IN HOUSING

1.

In the past 30 days how many …

Number of
Nights/
Times

a.

nights have you been homeless?

b.

nights have you spent in a hospital for mental health care?

c.

nights have you spent in a facility for detox/inpatient or
residential substance abuse treatment?

|____|____|

nights have you spent in correctional facility including jail, or
prison?

|____|____|

d.

[ADD UP THE TOTAL NUMBER OF NIGHTS SPENT HOMELESS, IN
HOSPITAL FOR MENTAL HEALTH CARE, IN DETOX/INPATIENT OR
RESIDENTIAL SUBSTANCE ABUSE TREATMENT, OR IN A
CORRECTIONAL FACILITY. (ITEMS A-D, CANNOT EXCEED 30
NIGHTS).]
e.

times have you gone to an emergency room for a psychiatric or
emotional problem?

|____|____|
|____|____|

REFUSED





















|____|____|
|____|____|

[IF 1A, 1B, 1C, OR 1D IS 16 OR MORE NIGHTS, GO TO SECTION D.]

2.

In the past 30 days, where have you been living most of the time?

[DO NOT READ RESPONSE OPTIONS TO THE CONSUMER. SELECT ONLY ONE.]


















DON’T
KNOW

OWNED OR RENTED HOUSE, APARTMENT, TRAILER, ROOM
SOMEONE ELSE’S HOUSE, APARTMENT, TRAILER, ROOM
HOMELESS (SHELTER, STREET/OUTDOORS, PARK)
GROUP HOME
ADULT FOSTER CARE
TRANSITIONAL LIVING FACILITY
HOSPITAL (MEDICAL)
HOSPITAL (PSYCHIATRIC)
DETOX/INPATIENT OR RESIDENTIAL SUBSTANCE ABUSE TREATMENT FACILITY
CORRECTIONAL FACILITY (JAIL/PRISON)
NURSING HOME
VA HOSPITAL
VETERAN’S HOME
MILITARY BASE
OTHER HOUSED (SPECIFY) _______________________________________________
REFUSED
DON’T KNOW

14

D.

EDUCATION AND EMPLOYMENT

1.

Are you currently 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

2.

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

3.

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

3a.

LESS THAN 12TH GRADE
12TH GRADE/HIGH SCHOOL DIPLOMA/EQUIVALENT (GED)
VOC/TECH DIPLOMA
SOME COLLEGE OR UNIVERSITY
BACHELOR’S DEGREE (BA, BS)
GRADUATE WORK/GRADUATE DEGREE
REFUSED
DON’T KNOW

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

[IF EMPLOYED]




1

Are you paid at or above the minimum wage1?
Are your wages paid directly to you by your employer?
Could anyone have applied for this job?

Yes




No




REFUSED





DON’T KNOW





For information on Federal minimum wage go to http://www.dol.gov/dol/topic/wages/.

15

E.

CRIME AND CRIMINAL JUSTICE STATUS

1.

In the past 30 days, how many times have you been arrested?
|____|____| TIMES

 REFUSED

 DON’T KNOW

[IF THIS IS A BASELINE, GO TO SECTION G. OTHERWISE, GO TO SECTION F.]

16

F.

PERCEPTION OF CARE

[SECTION F IS NOT COLLECTED AT BASELINE. FOR BASELINE INTERVIEWS, GO TO SECTION G.]
1.

In order to provide the best possible mental health and related services, we need to know what you think
about the services you received during the past 30 days, the people who provided it, and the results.
Please indicate your disagreement/agreement with each of the following statements.

[READ EACH STATEMENT FOLLOWED BY THE RESPONSE OPTIONS TO THE CONSUMER.]

Undecided

Agree

Strongly
Agree

REFUSED

a. Staff here believe that I can grow, change and
recover.













b. I felt free to complain.













c. I was given information about my rights.













d. Staff encouraged me to take responsibility for
how I live my life.













e. Staff told me what side effects to watch out for.









































































k. I, not staff, decided my treatment goals.













l.













m. If I had other choices, I would still get services
from this agency.













n. I would recommend this agency to a friend or
family member.













f.

Staff respected my wishes about who is and who
is not to be given information about my
treatment.
g. Staff were sensitive to my cultural background
(race, religion, language, etc.).
h. Staff helped me obtain the information I needed
so that I could take charge of managing my
illness.
i. I was encouraged to use consumer run programs
(support groups, drop-in centers, crisis phone
line, etc.).
j. I felt comfortable asking questions about my
treatment and medication.

I like the services I received here.

17

NOT
APPLICABLE

Disagree

RESPONSE OPTIONS

Strongly
Disagree

STATEMENT



F.

PERCEPTION OF CARE (Continued)

2.

[INDICATE WHO ADMINISTERED SECTION F - PERCEPTION OF CARE TO THE RESPONDENT
FOR THIS INTERVIEW.]
ADMINISTRATIVE STAFF
CARE COORDINATOR
CASE MANAGER
CLINICIAN PROVIDING DIRECT SERVICES
CLINICIAN NOT PROVIDING SERVICES
CONSUMER PEER
DATA COLLECTOR
EVALUATOR
FAMILY ADVOCATE
RESEARCH ASSISTANT STAFF
SELF-ADMINISTERED
OTHER (SPECIFY) ____________________________

18

G.

SOCIAL CONNECTEDNESS

1.

Please indicate your disagreement/agreement with each of the following statements. Please answer for
relationships with persons other than your mental health provider(s) over the past 30 days.

[READ EACH STATEMENT FOLLOWED BY THE RESPONSE OPTIONS TO THE CONSUMER.]

Disagree

Undecided

Agree

Strongly
Agree

REFUSED

RESPONSE OPTIONS
Strongly
Disagree

STATEMENT

a. I am happy with the friendships I have.













b. I have people with whom I can do enjoyable things.













c. I feel I belong in my community.













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













19

H.

PROGRAM SPECIFIC QUESTIONS

[QUESTIONS 1 AND 2 APPLY ONLY TO BASELINES. IF THIS IS NOT A BASELINE GO TO
QUESTION 3.]
1. INDICATE THE PROGRAMMATIC FOCUS FOR THE CLIENT/CONSUMER BELOW.
1a. PROGRAMMATIC
FOCUS (CHECK ALL
THAT APPLY.)

1b. PREDOMINANT
FOCUS (CHECK ONLY
ONE.)

SUBSTANCE ABUSE
TREATMENT





MENTAL HEALTH
TREATMENT





SUBSTANCE ABUSE
PREVENTION





2. How would you describe your sexual orientation?






Straight or heterosexual
Bisexual
Gay or lesbian
REFUSED
DON’T KNOW

[IF THIS IS A BASELINE AND THE INTERVIEW WAS NOT CONDUCTED STOP HERE]

3. Do you have health care coverage?
Yes, government insurance
 Yes, private insurance
 No
 REFUSED
 DON’T KNOW
The following questions pertain to your attitudes and beliefs about alcohol, tobacco, and drugs.
4. How much do people risk harming themselves physically or in other ways when they smoke one or
more packs of cigarettes per day?







No risk
Slight risk
Moderate risk
Great risk
REFUSED
DON’T KNOW
20

H.

PROGRAM SPECIFIC QUESTIONS

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

No risk
Slight risk
Moderate risk
Great risk
REFUSED
DON’T KNOW

6. 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?







No risk
Slight risk
Moderate risk
Great risk
REFUSED
DON’T KNOW

The following questions pertain to your beliefs and attitudes about sex.
How much do people risk harming themselves physically…
7. if they have sex without a condom?






No risk
Slight risk
Moderate risk
Great risk
REFUSED

8. if they have sex under the influence of alcohol?






No risk
Slight risk
Moderate risk
Great risk
REFUSED

9. if they have sex while high on drugs?






No risk
Slight risk
Moderate risk
Great risk
REFUSED

21

H.

PROGRAM SPECIFIC QUESTIONS

HIV/AIDS and Substance Abuse Prevention
The following questions are to determine what you know about HIV/AIDS and substance abuse
prevention.
10. Birth control pills protect women from getting the HIV/AIDS virus.





True
False
REFUSED
DON’T KNOW

11. There are drugs available to treat HIV that can lengthen the life of a person infected with the virus.





True
False
REFUSED
DON’T KNOW

12. There is no cure for AIDS.





True
False
REFUSED
DON’T KNOW

13. Would you know where to go in your community to see a health care professional regarding
HIV/AIDS or sexually transmitted health issues?
 YES
 NO
 REFUSED
14. Would you know where to go in your community to see a health care professional regarding a drug
or alcohol problem?
 YES
 NO
 REFUSED

22

H.

PROGRAM SPECIFIC QUESTIONS

Recent Sexual Activity
The following questions are regarding recent sexual activity.
15. During the past 30 days, did you engage in sexual activity?






YES [GO TO 15a.]
NO
NOT PERMITTED TO ASK
REFUSED
DON’T KNOW

[IF THE RESPONSE TO 15 WAS “NO”, “NOT PERMITTED TO ASK”, “REFUSED”, OR “DON’T
KNOW”, SKIP 15a, b, AND c.]
[IF YES] Altogether, how many…
a. sexual contacts (vaginal, oral, or anal) did you have?
b. unprotected sexual contacts did you have?

CONTACTS

|____|____|____|
|____|____|____|

REFUSED

DON’T KNOW









[THE VALUE IN 15b CANNOT BE GREATER THAN THE VALUE IN 15a.]
[IF THE RESPONSE TO 15b IS 0, REFUSED, OR DON’T KNOW, SKIP 15c1-3.]
c. unprotected sexual contacts were with an individual
who is or was:
1.

HIV positive or has AIDS?

2.

an injection drug user?

3.

high on some substance?

CONTACTS

|____|____|____|
|____|____|____|
|____|____|____|

REFUSED

DON’T KNOW













[THE VALUE IN 15c1, 15c2, or 15c3 CANNOT BE GREATER THAN THE VALUE IN 15b.]

[IF THIS IS A BASELINE INTERVIEW, THE INTERVIEW IS COMPLETE.]
[IF THIS IS A REASSESSMENT INTERVIEW, GO TO SECTION I.]
[IF THIS IS A CLINICAL DISCHARGE INTERVIEW, GO TO SECTION J.]

23

I.

REASSESSMENT STATUS

[SECTION I IS REPORTED BY GRANTEE STAFF AT REASSESSMENT.]

1.

Have you or other grant staff had contact with the consumer within 90 days of the last encounter?



2.

Yes
No

Is the consumer still receiving services from your project?



Yes
No

[GO TO SECTION K.]

24

J.

CLINICAL DISCHARGE STATUS

[SECTION J IS REPORTED BY GRANTEE STAFF ABOUT THE CONSUMER AT CLINICAL DISCHARGE.]

1.

On what date was the consumer discharged?
|____|____| / |____|____|____|____|
MONTH
YEAR

2.

What is the consumer’s discharge status?
 Mutually agreed cessation of treatment
Withdrew from/refused treatment
 No contact within 90 days of last encounter
 Clinically referred out
 Death
 Other (Specify) __________________________________

[GO TO SECTION K.]

25

K.

SERVICES RECEIVED

OMB No. 0930-0208
Expiration Date 4/30/2013

[SECTION K IS REPORTED BY GRANTEE STAFF AT REASSESSMENT AND DISCHARGE UNLESS THE
CONSUMER REFUSED THIS INTERVIEW OR ALL INTERVIEWS, IN WHICH CASE IT IS OPTIONAL.]
[IF THE INFORMATION BELOW IS UNKNOWN, RECORD “UNK” IN THE SPACE PROVIDED. IF THE
SERVICE IS NOT AVAILABLE PLEASE ENTER “SNA” IN THE SPACE PROVIDED.]
1.

On what date did the consumer last receive services?
Identify the number of DAYS of services
provided to the client during the client’s
course of treatment/recovery. [ENTER
ZERO IF NO SERVICES PROVIDED. YOU
SHOULD HAVE AT LEAST ONE DAY FOR
MODALITY.]
Modality
1. Case Management
2. Day Treatment
3. Inpatient/Hospital (Other
than Detox)
4. Outpatient
5. Outreach
6. Intensive Outpatient
7. Methadone
8. Residential/Rehabilitation
9. Detoxification (Select only one)
A. Hospital Inpatient
B. Free Standing
Residential
C. Ambulatory
Detoxification
10. After Care
11. Recovery Support
12. Other
(Specify)______________

Days
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|

Identify the number of SESSIONS provided
to the client during the client’s course of
treatment/recovery. [ENTER ZERO IF NO
SERVICES PROVIDED.]
Treatment Services
1. Screening
2. Referral to Treatment
3. Assessment
4. Treatment/Recovery Planning
5. Individual Counseling
6. Group Counseling
7. Family/Marriage Counseling
8. Co-Occurring Treatment/
Recovery Services

Sessions
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|

|____|____| / |____|____|____|____|
MONTH
YEAR
Sessions
9. Pharmacological Interventions |__|__|__|
10. HIV/AIDS Counseling
|__|__|__|
11. Other Clinical Services
(Specify)_________________ |__|__|__|
Case Management Services
1. Family Services (Including
Marriage Education,
Parenting, Child Development
Services)
2. Child Care
3. Employment Service
A. Pre-Employment
B. Employment Coaching
4. Individual Services
Coordination
5. Transportation
6. HIV/AIDS Service
7. Supportive Transitional DrugFree Housing Services
8. Other Case Management
Services
(Specify)_________________

Sessions

Medical Services
1. Medical Care
2. Alcohol/Drug Testing
3. HIV/AIDS Medical Support &
Testing
4. Other Medical Services
(Specify) _________________

Sessions
|__|__|__|
|__|__|__|

After Care Services
1. Continuing Care
2. Relapse Prevention
3. Recovery Coaching
4. Self-Help and Support Groups
5. Spiritual Support
6. Other After Care Services
(Specify)_________________

Sessions
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|

|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|

|__|__|__|

|__|__|__|
|__|__|__|

|__|__|__|

|__|__|__|

26

K.

SERVICES RECEIVED (Continued)
Education Services
1. Substance Abuse Education
2. HIV/AIDS Education
3. Other Education Services
(Specify)_________________

Sessions
|__|__|__|
|__|__|__|
|__|__|__|

Peer-To-Peer Recovery Support
Services
1. Peer Coaching or Mentoring
2. Housing Support
3. Alcohol- and Drug-Free Social
Activities
4. Information and Referral
5. Other Peer-To-Peer Recovery
Support Services
(Specify)_________________

Sessions
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|

|__|__|__|

27