Form Comparison Study T Comparison Study T Comparison Study Tool (Baseline).

Substance Abuse Mental Health Services Administration

BHTCC Comparison Study Data Collection and Abstraction Tool- Baseline

OMB No: XXXXX

Expiration Date: XXXX

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 XXXX-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.

Community Support Evaluation: BHTCC

Comparison Study Data Abstraction Tool (Baseline)

Instructions:

The following instrument will be used by the two selected comparison sites; data will be collected for up to 200 individuals per site. Questions 1-11 should be completed by the comparison site staff at baseline only. Information will be gathered through interviews with offenders at entry into the comparison site court as well as information abstracted from comparison site justice management information systems.

1. Offender ID [Provided by grantee comparison site]

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

2. Grant ID [Provided by ICF]

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

3. Interview Type (Select only one type)

• Baseline

• Reassessment: 6 months

4. Interview date

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

Month Day Year

5. 5a. Was the client screened by your program for co-occurring mental health and substance use disorders?

• Yes

• No (SKIP TO QUESTION 6)

5b. If the client was screened for co-occurring disorders, did the client screen positive for co-

occurring mental health and substance use disorders?

• Yes

• No

DEMOGRAPHICS

6. What is your gender?

• Male

• Female

• Different identity (Specify): ______________

• Declined

• Don’t know/information not available

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

• White

• Black or African American

• Alaska Native

• Native Hawaiian

• Guamanian or Chamorro

• Samoan

• Other Pacific Islander

• Asian Indian

• Chinese

• Filipino

• Japanese

• Korean

• Vietnamese

• Other Asian

• 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 (Specify):

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

• Declined

• Don’t know/information not available

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

• Straight

• Lesbian (if female) or Gay (if male)

• Bisexual

• Other (Specify): ____

• Declined

• Don’t know/information not available

10. Are you currently employed?

Instructions: Clarify by focusing on status during most of the previous week, determining whether client worked at all or had a regular job but was off work. If the client is incarcerated, select “unemployed, not looking for work”.

• 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): __________________________________

• Declined

• Don’t know/ information not available

11. Are you currently on probation or parole?

• Yes

• No

• Declined

• Don’t know/information not available

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