Client Data Sheet

OMB No. 0930-####

Expiration Date: ##/##/####

This form is to be completed prior to the semi-structured interviews.

VITEL Evaluation

Client Focus Group Participant Information

CSAT would like to learn more about you and your involvement in this organization/program. Please take a few minutes to answer these questions before the focus group begins. Your help in answering these questions is greatly appreciated and your answers will be held in confidence.

Grantee ID Number: _______________________ Date: ____________________

1. How long have you been a client of the program? _________________

2. Is this your first time in a substance use disorder treatment program?

Yes No

If no, how many times have you been in treatment? __________________

3. What is your gender? Male Female Transgender

4. What is your age? _____________

5. Are you Hispanic or Latino? Yes No

6. 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.

Central American Yes No

Cuban Yes No

Dominican Yes No

Mexican Yes No

Puerto Rican Yes No

South American Yes No Other Yes No

(If Yes, Specify) ____________________________________

7. What is your race? Please answer yes or no for each of the following. You may check all that apply.

American Indian / Yes No Alaska Native

Asian Yes No

Black / African American Yes No

Native Hawaiian / Yes No

Other Pacific Islander

White Yes No

8. Education (Highest Completed):

Some High School Some Vocational/technical training

High School Diploma/GED Vocational/technical certificate or diploma

Associate’s Degree Bachelor’s Degree (e.g., BS, BA)

Other (please specify) _____________________

Notice to Respondent

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-xxxx. Public reporting burden for this collection of information is estimated to average 10 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.

Satisfaction with VITEL Program Services

9. VITEL program satisfaction

Please indicate how much you agree or disagree with each statement below. Please select the one that best describes how you feel for each statement.

	Disagree	Somewhat Agree	Agree	Strongly Agree	Does Not Apply
When I needed intimate partner violence (IPV) services right away, I was able to see someone as soon as I wanted.
The people who delivered intimate partner violence (IPV) screenings and referrals were adequately trained.
The people were courteous and provided a safe and respectful environment for IPV screening.
I received adequate support and/or resources to make it to my IPV referral appointment(s).
The people I went to for IPV services spent enough time with me.
The people I went to for IPV services were sensitive to my cultural background (race, religion, language, sexual orientation, etc.).
I was given information about different IPV intervention services that were available to me.
I was given enough information to effectively handle my problems.

THANK YOU!