MHBG URS Tables

Attachment A4 MHBG URS Tables.xlsx

Treatment Episode Data Set (TEDS)

MHBG URS Tables

OMB: 0930-0335

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0930-0335 can be found here:

Document [xlsx]

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Overview

Table 2A
Table 2B
Table 3
Table 4
Table 5A
Table 5B
Table 14
Table 15
Table 15A
Table 19A
Tabld 19B
Table 20A
Tabld 20B

Sheet 1: Table 2A

URS Table 2A. Profile of Persons Served, All Programs by Age, Gender and Race/Ethnicity

This table provides an aggregate profile of persons in the reporting year. The reporting year should be the latest state fiscal year for which data are available. This profile is based on a client receiving services in programs provided or funded by the state mental health agency. The client profile takes into account all institutional and community services for all such programs. Please provide unduplicated counts if possible.

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

Please report the data under the categories listed - "Total" are calculated automatically.
Table 2.
Report Year:
State Identifier:
	Total				American Indian or Alaska Native			Asian			Black or African American			Native Hawaiian or Other Pacific Islander			White			*Hispanic use only if data for Table 2b are not available.**			More Than One Race Reported			Race Not Available
	Female	Male	Not Available	Total	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available
0-12 Years	0	0	0	0
13-17 years	0	0	0	0
18-20 years	0	0	0	0
21-24	0	0	0	0
25-44	0	0	0	0
45-64	0	0	0	0
65-74 years	0	0	0	0
75+ years	0	0	0	0
Not Available	0	0	0	0
Total	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Pregnant Women	0			0
Are these numbers unduplicated?


Comments on Data (for Age):
Comments on Data (for Gender):
Comments on Data (for Race/Ethnicity):
Comments on Data (Overall):

Sheet 2: Table 2B

Table 2B. Profile of Persons Served, All Programs by Age, Gender and Race/Ethnicity

Of the total persons served, please indicate the age, gender and the number of persons who are Hispanic/Latino or not Hispanic/Latino. Total persons served would be the total as indicated in Table 2A.

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

Please report the data under the categories listed - "Total" are calculated automatically.
Table 2.
Report Year:
State Identifier:
	Not Hispanic or Latino			Hispanic or Latino			Hispanic or Latino Origin Not Available			Total
	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Total
0 - 12 Years										0	0	0	0
13 - 17 years										0	0	0	0
18 - 20 years										0	0	0	0
21-24										0	0	0	0
25-44										0	0	0	0
45-64										0	0	0	0
65-74 years										0	0	0	0
75+ years										0	0	0	0
Not Available										0	0	0	0
Total	0	0	0	0	0	0	0	0	0	0	0	0	0
Pregnant Women										0			0
Comments on Data (for Age):
Comments on Data (for Gender):
Comments on Data (for Race/Ethnicity):
Comments on Data (Overall):

Sheet 3: Table 3

Table 3. Profile of Persons served in the community mental health setting, State Psychiatric Hospitals and Other Settings

This table provides a profile for the clients that received public funded mental health services in community mental health
settings, in state psychiatric hospitals, in other psychiatric inpatient programs, and in residential treatment centers for children.

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

Table 3.

Report Year:

State Identifier:

Table 3.
Service Setting

Age 0-17

Age 18-20

Age 21-64

Age 65+

Age Not Available

Total

Female

Male

Not Available

Female

Male

Not Available

Female

Male

Not Available

Female

Male

Not Available

Female

Male

Not Available

Female

Male

Not Available

Total

Community Mental Health Programs

State Psychiatric Hospitals

Other Psychiatric Inpatient

Residential Treatment Centers

Comments on Data (for Age):

Comments on Data (for Gender):

Comments on Data (Overall):

Note: Clients can be duplicated between Rows: e.g., The same client may be served in both state psychiatric hospitals and community mental health centers during the same year and thus would be reported in counts for both rows.

Instructions:

States that have county psychiatric hospitals that serve as surrogate state hospitals should report persons served in such settings as receiving services in state hospitals.

If forensic hospitals are part of the state mental health agency system include them.

Persons who receive non-inpatient care in state psychiatric hospitals should be included in the Community MH Program Row

Persons who receive inpatient psychiatric care through a private provider or medical provider licensed and/or contracted through the SMHA should be counted in the "Other Psychiatric Inpatient" row. Persons who receive Medicaid funded inpatient services through a provider that is not licensed or contracted by the SMHA should not be counted here.

A person who is served in both community settings and inpatient settings should be included in both rows

RTC: CMHS has a standardized definition of RTC for Children: “An organization, not licensed as a psychiatric hospital, whose primary purpose is the provision of individually planned programs of mental health treatment services in conjunction with residential care for children and youth primarily 17 years old and younger. It has a clinical program that is directed by a psychiatrist, psychologist, social worker, or psychiatric nurse who has a master’s degree or doctorate. The primary reason for the admission of the clients is mental illness that can be classified by DSM-IV codes-other than the codes for mental retardation, developmental disorders, and substance-related disorders such as drug abuse and alcoholism (unless these are co-occurring with a mental illness).” If your state serves adults in residential treatment centers, these adults should be reported in the residential treatment center row using the appropriate age group columns.

Sheet 4: Table 4

Table 4. Profile of Adult Clients by Employment Status

This table describes the status of adults clients served in the report year by the public mental health system in terms of employment status. The focus is on employment for the working age population, recognizing, however, that there are clients who are disabled, retired or who are homemakers, care-givers, etc and not a part of the workforce. These persons should be reported in the “Not in Labor Force” category. This category has two subcategories: retired and other. (The totals of these two categories should equal the number in the row for “Not in Labor Force”). Unemployed refers to persons who are looking for work but have not found employment. Data should be reported for clients in non-institutional settings at time of discharge or last evaluation.

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

Table 4.
Report Year:
State Identifier:
	18-20			21-64			65+			Age Not Available			Total
Adults Served	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Total
Employed: Competitively Employed Full or Part Time (includes Supported Employment)													0	0	0	0
Unemployed													0	0	0	0
Not In Labor Force: Retired, Sheltered Employment, Sheltered Workshops, Other (homemaker, student, volunteer, disabled, etc.)													0	0	0	0
Not Available													0	0	0	0
Total	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
How Often Does your State Measure Employment Status?
What populations are included:
Comments on Data (for Age):
Comments on Data (for Gender):
Comments on Data (Overall):

Sheet 5: Table 5A

Table 5A. Profile of Clients by Type of Funding Support

This table provides a summary of clients by Medicaid coverage. Since the focus of the reporting is on clients of the public mental health service delivery system, this table focuses on the clientele serviced by public programs that are funded or operated by the State Mental Health Authority. Persons are to be counted in the Medicaid row if they received a service reimbursable through Medicaid.

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

Please note that the same person may be served in both Medicaid and Non-Medicaid programs during the same reporting period.

Table 5A
Report Year:
State Identifier:
	Total				American Indian or Alaska Native			Asian			Black or African American			Native Hawaiian or Other Pacific Islander			White			*Hispanic use only if data for Table 5b are not available.**			More Than One Race Reported			Race Not Available
	Female	Male	Not Available	Total	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available
Medicaid (only Medicaid)	0	0	0	0
Non-Medicaid Sources (only)	0	0	0	0
People Served by Both Medicaid and Non-Medicaid Sources	0	0	0	0
Medicaid Status Not Available	0	0	0	0
Total Served	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0



Comments on Data (for Race):
Comments on Data (for Gender):
Comments on Data (Overall):

Each row should have a unique (unduplicated) count of clients: (1) Medicaid Only, (2) Non-Medicaid Only, (3) Both Medicaid and Other Sources funded their treatment, and (4) Medicaid Status Not Available. If a state is unable to unduplicate between people whose care is paid for by Medicaid only or Medicaid and other funds, then all data should be reported into the 'People Served by Both Medicaid and Non-Medicaid Sources' and the 'People Served by Both includes people with any Medicaid' check box should be checked.

Sheet 6: Table 5B

Table 5B. Profile of Clients by Type of Funding Support

Of the total persons covered by Medicaid, please indicate the gender and number of persons who are Hispanic/Latino or not Hispanic/Latino. Total persons covered by Medicaid would be the total indicated in Table 5A.

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

Please note that the same person may be served in both Medicaid and Non-Medicaid programs during the same reporting period.

Table 5B.
Report Year:
State Identifier:
	Not Hispanic or Latino			Hispanic or Latino			Hispanic or Latino Origin Unknown			Total
	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Total
Medicaid Only										0	0	0	0
Non-Medicaid Only										0	0	0	0
People Served by Both Medicaid and Non-Medicaid Sources										0	0	0	0
Medicaid Status Unknown										0	0	0	0
Total Served	0	0	0	0	0	0	0	0	0	0	0	0	0
Comments on Data (for Ethnicity):
Comments on Data (for Gender):
Comments on Data (Overall):

Each row should have a unique (unduplicated) count of clients: (1) Medicaid Only, (2) Non-Medicaid Only, (3) Both Medicaid and Other Sources funded their treatment, and (4) Medicaid Status Unknown.

Sheet 7: Table 14

Table 14A. Profile of Persons with SMI/SED served by Age, Gender and Race/Ethnicity

This is a developmental table similar to Table 2A. and 2B. This table requests counts for persons with SMI or SED using the definitions provided by the CMHS. Table 2A. and 2B. included all clients served by publicly operated or funded programs. This table counts only clients who meet the CMHS definition of SMI or SED. For many states, this table may be the same as Tables 2A. and 2B. For 2007, states should report using the Federal Definitions of SMI and SED if they can report them, if not, please report using your state’s definitions of SMI and SED and provide information below describing your state’s definition.

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!


Please report the data under the categories listed - "Total" are calculated automatically.
Table 14A.
Report Year:
State Identifier:
	Total				American Indian or Alaska Native			Asian			Black or African American			Native Hawaiian or Other Pacific Islander			White			*Hispanic use only if data for Table 14b are not available**			More Than One Race Reported			Race Not Available
	Female	Male	Not Available	Total	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available	Female	Male	Not Available
0-12 Years	0	0	0	0
13-17 years	0	0	0	0
18-20 years	0	0	0	0
21-64 years	0	0	0	0
65-74 years	0	0	0	0
75+ years	0	0	0	0
Not Available	0	0	0	0
Total	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Comments on Data (for Age):
Comments on Data (for Gender):
Comments on Data (for Race/Ethnicity):
Comments on Data (Overall):

1. State Definitions Match the Federal Definitions:
					Adults with SMI, if No describe or attach state definition:

					Diagnoses included in state SMI definition:

					Children with SED, if No describe or attach state definition:

					Diagnoses included in state SED definition:

Sheet 8: Table 15

Table 15. Living Situation Profile:

*Number of Clients in Each Living Situation as Collected by the Most Recent Assessment in the Reporting Period*
*All Mental Health Programs by Age, Gender, and Race/Ethnicity*
Please provide unduplicated counts, if possible. This table provides an aggregate profile of persons served in the reporting year. The reporting year should be the latest state fiscal year for which data are available. This profile is based on a client's last known Living Situation.

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!


Please report the data under the Living Situation categories listed - "Total" are calculated automatically.
Table 15.
Report Year:
State Identifier:
	Private Residence	Foster Home	Residential Care	Crisis Residence	Children's Residential Treatment	Institutional Setting	Jail/ Correctional Facility	Homeless/ Shelter	Other	NA	Total
0-17											0
18-64											0
65 +											0
Not Available											0
TOTAL	0	0	0	0	0	0	0	0	0	0	0

Female											0
Male											0
Not Available											0
TOTAL	0	0	0	0	0	0	0	0	0	0	0

American Indian/Alaska Native											0
Asian											0
Black/African American											0
Hawaiian/Pacific Islander											0
White/Caucasian											0
Hispanic *											0
More than One Race Reported											0
Race/Ethnicity Not Available											0
TOTAL	0	0	0	0	0	0	0	0	0	0	0

Hispanic or Latino Origin											0
Non Hispanic or Latino Origin											0
Hispanic or Latino Origin Not Available											0
TOTAL	0	0	0	0	0	0	0	0	0	0	0
Comments on Data:
How Often Does your State Measure Living Situation?
* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as an Ethnic Origin are not available


*Living Situation Definitions:*

Private Residence: Individual lives in a house, apartment, trailer, hotel, dorm, barrack, and/or Single Room Occupancy (SRO). Foster Home: Individual resides in a Foster Home. A Foster Home is a home that is licensed by a County or State Department to provide foster care to children, adolescents, and/or adults. This includes Therapeutic Foster Care Facilities. Therapeutic Foster Care is a service that provides treatment for troubled children within private homes of trained families. Residential Care: Individual resides in a residential care facility. This level of care may include a Group Home, Therapeutic Group Home, Board and Care, Residential Treatment, or Rehabilitation Center, or Agency-operated residential care facilities. Crisis Residence: A residential (24 hours/day) stabilization program that delivers services for acute symptom reduction and restores clients to a pre-crisis level of functioning. These programs are time limited for persons until they achieve stabilization. Crisis residences serve persons experiencing rapid or sudden deterioration of social and personal conditions such that they are clinically at risk of hospitalization but may be treated in this alternative setting. Children’s Residential Treatment Facility: Children and Youth Residential Treatment Facilities (RTF's) provide fully-integrated mental health treatment services to seriously emotionally disturbed children and youth. An organization, not licensed as a psychiatric hospital, whose primary purpose is the provision of individually planned programs of mental health treatment services in conjunction with residential care for children and youth. The services are provided in facilities which are certified by state or federal agencies or through a national accrediting agency. Institutional Setting: Individual resides in an institutional care facility with care provided on a 24 hour, 7 day a week basis. This level of care may include a Skilled Nursing/Intermediate Care Facility, Nursing Homes, Institutes of Mental Disease (IMD), Inpatient Psychiatric Hospital, Psychiatric Health Facility (PHF), Veterans Affairs Hospital, or State Hospital. Jail/ Correctional Facility: Individual resides in a Jail and/or Correctional facility with care provided on a 24 hour, 7 day a week basis. This level of care may include a Jail, Correctional Facility, Detention Centers, Prison, Youth Authority Facility, Juvenile Hall, Boot Camp, or Boys Ranch. Homeless: A person should be counted in the ""Homeless"" category if he/she was reported homeless at their most recent (last) assessment during the reporting period (or at discharge for patients discharged during the year). The “last” Assessment could occur at Admission, Discharge, or at some point during treatment. A person is considered homeless if he/she lacks a fixed, regular, and adequate nighttime residence and/or his/her primary nighttime residency is: A) A supervised publicly or privately operated shelter designed to provide temporary living accommodations, B) An institution that provides a temporary residence for individuals intended to be institutionalized, or C) A public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings (e.g., on the street). Unavailable: Information on an individual’s residence is not available.

Sheet 9: Table 15A

Table 15A. Profile of Persons served in the community mental health setting, State Psychiatric Hospitals and Other Settings for Adults with SMI and Children with SED

This table provides a profile for Adults with Serious Mental Illnesses (SMI) and Children With Serious Emotional DIsturbances (SED) that received public funded mental health services in community mental health
settings, in state psychiatric hospitals, in other psychiatric inpatient programs, and in residential treatment centers for children.

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

New URS Table:

Report Year:

State Identifier:

Table 3 (New for SMI/SED).
Service Setting

Age 0-17

Age 18-20

Age 21-64

Age 65+

Age Not Available

Total

Female

Male

Not Available

Female

Male

Not Available

Female

Male

Not Available

Female

Male

Not Available

Female

Male

Not Available

Female

Male

Not Available

Total

Community Mental Health Programs

State Psychiatric Hospitals

Other Psychiatric Inpatient

Residential Treatment Centers

Comments on Data (for Age):

Comments on Data (for Gender):

Comments on Data (Overall):

Instructions:

States that have county psychiatric hospitals that serve as surrogate state hospitals should report persons served in such settings as receiving services in state hospitals.

If forensic hospitals are part of the state mental health agency system include them.

Persons who receive non-inpatient care in state psychiatric hospitals should be included in the Community MH Program Row

A person who is served in both community settings and inpatient settings should be included in both rows

Sheet 10: Table 19A

Table 19A. Profile of Criminal Justice or Juvenile Justice Involvement:

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
1. This is a developmental measure. To assist in the development process, we are asking states to report information on the arrest histories of mental health consumers with their December 2007 MHBG submission.
2. The SAMHSA National Outcome Measure for Criminal Justice measures the change in Arrests over time. The DIG Outcomes Workgroup pilot tested 3 consumer self-report items that can be used to provide this information. If your state has used the 3 Consumer self-report items on criminal justice, you may report them here.
3. If your SMHA has data on Arrest records from alternatives sources, you may also report that here. If you only have data for arrests for consumers in this year, please report that in the T2 columns. If you can calculate the change in Arrests from T1 to T2, please use all those columns.
4. Please complete the check boxes at the bottom of the table to help explain the data sources that you used to complete this table.
5. Please tell us anything else that would help us to understand your indicator (e.g., list survey or MIS questions; describe linking methodology and data sources; specify time period for criminal justice involvement; explain whether treatment data are collected).

Table 19A. Profile of Adult Criminal Justice and Youth Juvenile Justice Contacts
State:								Time period in which services were received:

For Consumers in Service for at least 12 months
	T1			T2			T1 to T2 Change						Assessment of the Impact of Services
	"T1" Prior 12 months (more than 1 year ago)			"T2" Most Recent 12 months (this year)			If Arrested at T1 (Prior 12 Months)			If Not Arrested at T1 (Prior 12 Months)			Over the last 12 months, my encounters with the police have…
	Arrested	Not Arrested	No Response	Arrested	Not Arrested	No Response	# with an Arrest in T2	# with No Arrest at T2	No Response	# with an Arrest in T2	# with No Arrest at T2	No Response	# Reduced (fewer encounters)	# Stayed the Same	# Increased	# Not Applicable	No Response	Total Responses
Total	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Total Children/Youth (under age 18)	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Male																		0
Female																		0
Gender NA																		0
Total Adults (age 18 and over)	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Male																		0
Female																		0
Gender NA																		0

For Consumers Who Began Mental Health Services during the past 12 months
	T1			T2			T1 to T2 Change						Assessment of the Impact of Services
	"T1" 12 months prior to beginning services			"T2" Since Beginning Services (this year)			If Arrested at T1 (Prior 12 Months)			If Not Arrested at T1 (Prior 12 Months)			Since starting to receive MH Services, my encounters with the police have…
	Arrested	Not Arrested	No Response	Arrested	Not Arrested	No Response	# with an Arrest in T2	# with No Arrest at T2	No Response	# with an Arrest in T2	# with No Arrest at T2	No Response	# Reduced (fewer encounters)	# Stayed the Same	# Increased	# Not Applicable	No Response	Total Responses
Total	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Total Children/Youth (under age 18)	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Male																		0
Female																		0
Gender NA																		0
Total Adults (age 18 and over)	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Male																		0
Female																		0
Gender NA																		0
See Page 2 for additional Questions about the source of this data.

Please Describe the Sources of your Criminal Justice Data
Source of adult criminal justice information:	1) Consumer survey (recommended questions)					2) Other Consumer Survey: Please send copy of questions					3) Mental health MIS
	4) State criminal justice agency					5) Local criminal justice agency					6) Other (specify)

Sources of children/youth criminal justice information:	1) Consumer survey (recommended questions)					2) Other Consumer Survey: Please send copy of questions					3) Mental health MIS
	4) State criminal/juvenile justice agency					5) Local criminal/juvenile justice agency					6) Other (specify)

Measure of adult criminal justice involvement:	1) Arrests				2) Other: (specify)

Measure of children/youth criminal justice involvement:	1) Arrests				2) Other: (specify)

Mental health programs included:	1) Adults with SMI only				2) Other adults (specify)								3) Both (all adults)
	1) Children with SED only				2) Other Children (specify)								3) Both (all Children)

Region for which adult data are reported:	1) The whole state			2) Less than the whole state (please describe)
Region for which children/youth data are reported:	1) The whole state			2) Less than the whole state (please describe)

What is the Total Number of Persons Surveyed or for whom Criminal Justice Data Are Reported
						Child/Adolescents		Adults
1. If data is from a survey, What is the total Number of people from which the sample was drawn?
2. What was your sample size? (How many individuals were selected for the sample)?
3. How many survey Contacts were made? (surveys to valid phone numbers or addresses)
4. How many surveys were completed? (survey forms returned or calls completed) If data source was not a Survey, How many persons were CJ data available for?
5. What was your response rate? (number of Completed surveys divided by number of Contacts):
State Comments/Notes:
Instructions:
If you have responses to a survey by person not in the expected age group, you should include those responses with other responses from the survey. e.g. if a 16 or 17 year old responds to the Adult MHSIP survey, please include their responses in the Adult categories (since that was the survey they used).

Sheet 11: Tabld 19B

Table 19b. Profile of Change in School Attendance

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

1. This is a developmental measure. To assist in the development process, we are asking states to report information on the school attendance outcomes of mental health consumers with their December 2007 MHBG submission.

2. The SAMHSA National Outcome Measure for School Attendance measures the change in days attended over time. The DIG Outcomes Workgroup pilot tested 3 consumer self-report items that can be used to provide this information. If your state has used the 3 Consumer Self-Report items on School Attendance, you may report them here.

3. If your SMHA has data on School Attendance from alternatives sources, you may also report that here. If you only have data for School attendance for consumers in this year, please report that in the T2 columns. If you can calculate the change in Attendance from T1 to T2, please use all these columns.

4. Please complete the check boxes at the bottom of the table to help explain the data sources that you used to complete this table.

5. Please tell us anything else that would help us to understand your indicator (e.g., list survey or MIS questions; describe linking methodology and data sources; specify time period for criminal justice involvement; explain whether treatment data are collected).

Table 19b. Profile of Change in School Attendance

State:

Time period in which services were received:

For Consumers in Service for at least 12 months

T1 to T2 Change

Impact of Services

"T1" Prior 12 months
(more than 1 year ago)

"T2" Most Recent 12 months
(this year)

If Suspended at T1 (Prior 12 Months)

If Not Suspended at T1 (Prior 12 Months)

Over the last 12 months, the number of days my child was in school have

# Suspended or Expelled

# Not Suspended or Expelled

No Response

# Suspended or Expelled

# Not Suspended or Expelled

No Response

# with an Expelled or Suspended in T2

# with No Suspension or Expulsion at T2

No Response

# with an Expelled or Suspended in T2

# with No Suspension or Expulsion at T2

No Response

# Greater (Improved)

# Stayed the Same

# Fewer days (gotten worse)

# Not Applicable

No response

Total Responses

Total

Gender

Male

Female

Gender NA

Age

Under 18

For Consumers Who Began Mental Health Services during the past 12 months

T1 to T2 Change

Impact of Services

"T1" 12 months prior to beginning services

"T2" Since Beginning Services
(this year)

If Suspended at T1 (Prior 12 Months)

If Not Suspended at T1
(Prior 12 Months)

Since starting to receive MH Services, the number of days my child was in school have

# Suspended or Expelled

# Not Suspended or Expelled

No Response

# Suspended or Expelled

# Not Suspended or Expelled

No Response

# with an Expelled or Suspended in T2

# with No Suspension or Expulsion at T2

No Response

# with an Expelled or Suspended in T2

# with No Suspension or Expulsion at T2

No Response

# Greater (Improved)

# Stayed the Same

# Fewer days (gotten worse)

# Not Applicable

No response

Total Responses

Total

Gender

Male

Female

Gender NA

Age

Under 18

See Page 2 for additional Questions about the source of this data.

Source of School Attendance Information

1) Consumer survey (recommended items)

2) Other Survey: Please send us items

3) Mental health MIS

4) State Education Department

5) Local Schools/Education Agencies

6) Other (specify)

Measure of School Attendance

1) School Attendance

2) Other: (Specify)

Mental health programs include:

1) Children with SED only

2) Other Children (specify)

3) Both.

Region for which data are reported:

1) The whole state

2) Less than the whole state (please describe)

What is the Total Number of Persons Surveyed or for whom School Attendance Data Are Reported

Child/Adolescents

1. If data is from a survey, What is the total Number of people from which the sample was drawn?

2. What was your sample size? (How many individuals were selected for the sample)?

3. How many survey Contacts were made? (surveys to valid phone numbers or addresses)

4. How many surveys were completed? (survey forms returned or calls completed) If data source was not a Survey, How many persons were data available for?

5. What was your response rate? (number of Completed surveys divided by number of Contacts):

State Comments/Notes

Sheet 12: Table 20A

Table 20A. Profile of Non-Forensic (Voluntary and Civil-Involuntary) Patients Readmission to Any State Psychiatric Inpatient Hospital Within 30/180 Days of Discharge

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!


Table 20A.
Report Year:
State Identifier:
	Total number of Discharges in Year	Number of Readmissions to ANY STATE Hospital within		Percent Readmitted
		Number of Readmissions to ANY STATE Hospital within		Percent Readmitted
		30 days	180 days	30 days	180 days
TOTAL	0	0	0

Age
0-12
13-17
18-20
21-64
65-74
75+
Not Available

Gender
Female
Male
Gender Not Available

Race
American Indian/ Alaska Native
Asian
Black/African American
Hawaiian/Pacific Islander
White
Hispanic*
More than one race
Race Not Available

Hispanic/Latino Origin
Hispanic/Latino Origin
Non Hispanic/Latino
Hispanic/Latino Origin Not Available

Are Forensic Patients Included?

Comments on Data:

* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as a Ethnic Origin are not available

Sheet 13: Tabld 20B

Table 20B. Profile of Forensic Patients Readmission to Any State Psychiatric Inpatient Hospital Within 30/180 Days of Discharge

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!


Table 20B.
Report Year:
State Identifier:
	Total number of Discharges in Year	Number of Readmissions to ANY STATE Hospital within		Percent Readmitted
		Number of Readmissions to ANY STATE Hospital within		Percent Readmitted
		30 days	180 days	30 days	180 days
TOTAL	0	0	0

Age
0-12
13-17
18-20
21-64
65-74
75+
Not Available

Gender
Female
Male
Gender Not Available

Race
American Indian/ Alaska Native
Asian
Black/African American
Hawaiian/Pacific Islander
White
Hispanic*
More than one race
Race Not Available

Hispanic/Latino Origin
Hispanic/Latino Origin
Non Hispanic/Latino
Hispanic/Latino Origin Not Available

Comments on Data:

* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as a Ethnic Origin are not available

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File Modified	0000-00-00
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