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pdfAttachment B1- N-SSATS 2017 questionnaire (Version A)
U.S. Department of Health and Human Services
OMB No. xxxx-xxxx
APPROVAL EXPIRES: XX/XX/20XX
See OMB burden statement on last page
National Survey of
Substance Abuse Treatment Services
(N-SSATS)
March 31, 2017
Substance Abuse and Mental Health Services Administration (SAMHSA)
PLEASE REVIEW THE FACILITY INFORMATION PRINTED ABOVE.
CROSS OUT ERRORS AND ENTER CORRECT OR MISSING INFORMATION.
CHECK ONE
Information is complete and correct, no changes needed
All missing or incorrect information has been corrected
PREPARED BY MATHEMATICA POLICY RESEARCH
PLEASE READ THIS ENTIRE PAGE BEFORE
COMPLETING THE QUESTIONNAIRE
Would you prefer to complete this questionnaire online? See the pink flyer enclosed in your
packet for the Internet address and your unique user ID and password. You can log on and off the
website as often as needed to complete the questionnaire. When you log on again, the program will
take you to the next unanswered question. If you need more information, call the N-SSATS helpline
at 1-888-324-8337.
INSTRUCTIONS
Most of the questions in this survey ask about “this facility.” By “this facility” we mean the specific
treatment facility or program whose name and location are printed on the front cover. If you have any
questions about how the term “this facility” applies to your facility, please call 1-888-324-8337.
Please answer ONLY for the specific facility or program whose name and location are printed on the
front cover, unless otherwise specified in the questionnaire.
If the questionnaire has not been completed online, return the completed questionnaire in the
envelope provided. Please keep a copy for your records.
For additional information about this survey and definitions of some of the terms used, please visit
our website at https://info.nssats.com.
If you have any questions or need additional blank forms, contact:
MATHEMATICA POLICY RESEARCH
1-888-324-8337
[email protected]
IMPORTANT INFORMATION
* Asterisked questions. Information from asterisked (*) questions may be published in SAMHSA’s
online Behavioral Health Treatment Services Locator (found at https://findtreatment.samhsa.gov)
and in SAMHSA’s National Directory of Drug and Alcohol Abuse Treatment Programs, unless you
designate otherwise in question 39, page 12 of this questionnaire.
Mapping feature in online Locator. Complete and accurate name and address information is needed
for the online Locator so it can correctly map the facility location.
Eligibility for online Locator and Directory. Only facilities designated as eligible by their state
substance abuse office will be listed in the online Locator and Directory. Your state N-SSATS
representative can tell you if your facility is eligible to be listed in the online Locator and Directory. For
the name and telephone number of your state representative, call the N-SSATS helpline at 1-888-3248337.
PREPARED BY MATHEMATICA POLICY RESEARCH
*2b. Does this facility routinely use medications during
detoxification?
SECTION A: FACILITY
CHARACTERISTICS
0
1
Section A asks about characteristics of individual
facilities and should be completed for this facility
only, that is, the treatment facility or program at
the location listed on the front cover.
3.
0
Which of the following substance abuse services
are offered by this facility at this location, that is,
the location listed on the front cover?
YES
2. Detoxification .................................... 1
0
5.
Is this facility a solo practice, meaning, an office
with only one independent practitioner or
counselor?
1
Yes
0
No
0
*6.
What is the primary focus of this facility at this
location, that is, the location listed on the front
cover?
3. Substance abuse treatment
(services that focus on initiating and
maintaining an individual’s recovery
from substance abuse and on averting
relapse) ............................................... 1
4. Any other substance abuse
services ............................................. 1
1a.
0
To which of the following clients does this facility,
at this location, offer mental health treatment
services (interventions such as therapy or
psychotropic medication that treat a person’s
mental health problem or condition, reduce
symptoms, and improve behavioral functioning
and outcomes)?
MARK ONE ONLY
MARK ALL THAT APPLY
5
2
3
1
Substance abuse clients
Clients other than substance abuse clients
No clients are offered mental health
treatment services
1
2
3
4
*7.
0
Yes
No
)
MARK ONE ONLY
1
Did you answer “yes” to detoxification in option 2
of question 1 above?
1
Substance abuse treatment services
Mental health services
Mix of mental health and substance abuse
treatment services (neither is primary)
General health care
Other (Specify:
Is this facility operated by . . .
2
2.
SKIP TO Q.35 (PAGE 12)
Is this facility a jail, prison, or other organization
that provides treatment exclusively for
incarcerated persons or juvenile detainees?
1
Yes
SKIP TO Q.41 (PAGE 12)
0
No
NO
0
Yes
No
4.
MARK “YES” OR “NO” FOR EACH
1. Intake, assessment, or referral ....... 1
SKIP TO Q.4 (BELOW)
Did you answer “yes” to substance abuse
treatment in option 3 of question 1?
1
*1.
Yes
No
3
4
5
SKIP TO Q.3 (NEXT COLUMN)
6
A private for-profit organization
A private non-profit organization
State government
Local, county, or community
government
Tribal government
Federal Government
SKIP TO Q.8
(BELOW)
SKIP TO Q.9
(NEXT PAGE)
*2a. Does this facility detoxify clients from . . .
MARK “YES” OR “NO” FOR EACH
YES
*7a.
Which Federal Government agency?
MARK ONE ONLY
NO
1
1. Alcohol ................................................... 1
0
2
2. Benzodiazepines ................................... 1
0
3
3. Cocaine ................................................. 1
0
4
4. Methamphetamines ............................... 1
0
5. Opioids .................................................. 1
0
) 1
0
6. Other (Specify:
8.
Department of Veterans Affairs
Department of Defense
Indian Health Service
Other (Specify:
)
SKIP TO
Q.9
(NEXT PAGE)
Is this facility affiliated with a religious
organization?
1
Yes
0
No
1
*9. Is this facility a hospital or located in or operated by
a hospital?
1
Yes
0
No
SKIP TO Q.10 (BELOW)
*9a. What type of hospital?
MARK ONE ONLY
1
General hospital (including VA hospital)
2
Psychiatric hospital
3
Other specialty hospital, for example,
alcoholism, maternity, etc.
(Specify:
*10.
What telephone number(s) should a potential
client call to schedule an intake appointment?
1. (______) ________ - ____________ ext._____
2. (______) ________ - ____________ ext._____
*11. Which of the following services are provided by
this facility at this location, that is, the location
listed on the front cover?
MARK ALL THAT APPLY
Assessment and Pre-Treatment Services
1 Screening for substance abuse
2 Screening for mental health disorders
3 Comprehensive substance abuse assessment
or diagnosis
4 Comprehensive mental health assessment or
diagnosis (for example, psychological or
psychiatric evaluation and testing)
5 Screening for tobacco use
6 Outreach to persons in the community who
may need treatment
7 Interim services for clients when immediate
admission is not possible
8 We do not offer any of these assessment and
pre-treatment services
Testing (Include tests performed at this location,
even if specimen is sent to an outside source for
chemical analysis.)
9
10
11
12
13
14
15
16
Breathalyzer or other blood alcohol testing
Drug or alcohol urine screening
Screening for Hepatitis B
Screening for Hepatitis C
HIV testing
STD testing
TB screening
We do not offer any of these testing services
Transitional Services
17 Discharge planning
2
)
19
18
Aftercare/continuing care
We do not offer any of these transitional services
Ancillary Services
20
Case management services
21
Social skills development
22
Mentoring/peer support
23
Child care for clients’ children
24
Assistance with obtaining social services
(for example, Medicaid, WIC, SSI, SSDI)
25
Employment counseling or training
for clients
26
Assistance in locating housing for clients
27
Domestic violence—family or partner
violence services (physical, sexual,
and emotional abuse)
28
Early intervention for HIV
29
HIV or AIDS education, counseling,
or support
30
Hepatitis education, counseling,
or support
31
Health education other than HIV/AIDS
or hepatitis
32
Substance abuse education
33
Transportation assistance to treatment
34
Mental health services
35
Acupuncture
36
Residential beds for clients’ children
37
Self-help groups (for example, AA, NA,
SMART Recovery)
38
Smoking/tobacco cessation counseling
39
We do not offer any of these ancillary services
Other Services
40
Treatment for gambling disorder
41
Treatment for Internet use disorder
42
Treatment for other addiction disorder
(non-substance abuse)
43
We do not offer any of these other services
Pharmacotherapies
44
Disulfiram (Antabuse®)
45
Naltrexone (oral)
46
Vivitrol® (injectable Naltrexone)
47
Acamprosate (Campral®)
48
Nicotine replacement
49
Non-nicotine smoking/tobacco cessation
medications (for example, Bupropion,
Varenicline)
50
Medications for psychiatric disorders
51
Methadone
52
Buprenorphine with naloxone (Suboxone®)
53
Buprenorphine without naloxone
54
We do not offer any of these pharmacotherapy
services
*12.
How does this facility treat opioid (narcotic) addiction?
MARK ALL THAT APPLY
1
2
3
4
5
6
This facility does not treat opioid addiction.
This facility uses methadone or buprenorphine for pain management, emergency cases, or
research purposes. It is NOT a federally-certified OTP.
SKIP TO
Q.13
(BELOW)
This facility is “drug free.” It does not use medications to treat opioid addiction or accept clients
using medication to treat opioid addiction.
This facility accepts clients who are on methadone, buprenorphine and/or naltrexone
(Vivitrol®) maintenance or treatment, but these medications originate from or are
prescribed by another entity. (The medications may or may not be
stored/delivered/monitored onsite.)
This facility prescribes and/or administers buprenorphine and/or naltrexone (Vivitrol®). This facility
is NOT a federally-certified OTP. Buprenorphine use is authorized through a Data 2000 waivered
physician.
This facility administers and/or dispenses methadone, buprenorphine and/or naltrexone (Vivitrol®)
as a federally-certified Opioid Treatment Program (OTP). A Data 2000 waivered physician may or
may not also be onsite. (While most OTPs use methadone, some only use buprenorphine.)
*12a. Are ALL of the substance abuse clients at this facility currently receiving methadone, buprenorphine, or
naltrexone (Vivitrol®)?
1
Yes
0
No
*12b. Which of the following medication services does this program provide?
MARK ALL THAT APPLY
*13.
1
Maintenance services with methadone or buprenorphine
2
Maintenance services with medically-supervised withdrawal after a pre-determined time
3
Detoxification services with methadone or buprenorphine
4
Relapse prevention with naltrexone (Vivitrol®)
For each type of counseling listed below, please indicate approximately what percent of the substance abuse
clients at this facility receive that type of counseling as part of their substance abuse treatment program.
MARK ONE BOX FOR EACH
TYPE OF COUNSELING
TYPE OF COUNSELING
NOT OFFERED
RECEIVED BY 25% OR
LESS OF CLIENTS
RECEIVED BY 26% TO
50% OF CLIENTS
RECEIVED BY 51% TO
75% OF CLIENTS
RECEIVED BY MORE
THAN 75% OF CLIENTS
1. Individual counseling
1
2
3
4
5
2. Group counseling
1
2
3
4
5
3. Family counseling
1
2
3
4
5
4. Marital/couples counseling
1
2
3
4
5
3
*14.
For each type of clinical/therapeutic approach listed below, please mark the box that best describes how
often that approach is used at this facility.
For definitions of these approaches, go to: https://info.nssats.com
MARK ONE FREQUENCY FOR EACH APPROACH
CLINICAL/THERAPEUTIC APPROACHES
4
NEVER
RARELY
SOMETIMES
ALWAYS
OR OFTEN
NOT
FAMILIAR
WITH THIS
APPROACH
1. Substance abuse counseling
1
2
3
4
5
2. 12-step facilitation
1
2
3
4
5
3. Brief intervention
1
2
3
4
5
4. Cognitive-behavioral therapy
1
2
3
4
5
5. Dialectical behavior therapy
1
2
3
4
5
6. Contingency management/motivational incentives
1
2
3
4
5
7. Motivational interviewing
1
2
3
4
5
8. Trauma-related counseling
1
2
3
4
5
9. Anger management
1
2
3
4
5
10. Matrix Model
1
2
3
4
5
11. Community reinforcement plus vouchers
1
2
3
4
5
12. Rational emotive behavioral therapy (REBT)
1
2
3
4
5
13. Relapse prevention
1
2
3
4
5
14. Computerized substance abuse treatment/telemedicine
(including Internet, Web, mobile, and desktop
programs)
1
2
3
4
5
15. Other treatment approach (Specify: ________________)
1
2
3
4
15.
Are any of the following practices part of this
facility’s standard operating procedures?
MARK ALL THAT APPLY
Required continuing education for staff
2 Periodic drug testing of clients
3 Regularly scheduled case review with
a supervisor
4 Case review by an appointed quality review
committee
5 Outcome follow-up after discharge
6 Periodic utilization review
7 Periodic client satisfaction surveys conducted
by the facility
8 None of these practices are part of the
standard operating procedures
1
*16.
Does this facility, at this location, offer a specially
designed program or group intended exclusively
for DUI/DWI or other drunk driver offenders?
1
Yes
0
No
SKIP TO Q.17 (BELOW)
*16a. Does this facility serve only DUI/DWI clients?
*17.
*18.
1
Yes
0
No
Does this facility provide substance abuse
treatment services in sign language at this
location for the deaf and hard of hearing (for
example, American Sign Language, Signed
English, or Cued Speech)?
Mark “yes” if either a staff counselor or an on-call
interpreter provides this service.
1
Yes
0
No
Does this facility provide substance abuse
treatment services in a language other than
English at this location?
1
Yes
0
No
SKIP TO Q.19 (PAGE 6)
18a. At this facility, who provides substance abuse
treatment services in a language other than
English?
MARK ONE ONLY
1
Staff counselor who speaks a language
other than English
2
On-call interpreter (in person or by phone)
brought in when needed
SKIP TO Q.19
3
BOTH staff counselor and on-call interpreter
(PAGE 6)
*18a1. Do staff counselors provide substance abuse
treatment in Spanish at this facility?
1
Yes
0
No
SKIP TO Q.18b (BELOW)
18a2. Do staff counselors at this facility provide
substance abuse treatment in any other
languages?
1
Yes
0
No
SKIP TO Q.19 (PAGE 6)
*18b. In what other languages do staff counselors
provide substance abuse treatment at this
facility?
Do not count languages provided only by on-call
interpreters.
MARK ALL THAT APPLY
American Indian or Alaska Native:
1 Hopi
2 Lakota
3 Navajo
4 Ojibwa
5 Yupik
6 Other American Indian or
Alaska Native language
(Specify:_______________________________)
Other Languages:
7 Arabic
8 Any Chinese language
9 Creole
10 Farsi
11 French
12 German
13 Greek
14 Hebrew
15 Hindi
16 Hmong
17 Italian
18 Japanese
19 Korean
20 Polish
21 Portuguese
22 Russian
23 Tagalog
24 Vietnamese
25 Any other language
(Specify:______________________________)
5
*19.
Individuals seeking substance abuse treatment can vary by age, gender or other characteristics. Which
categories of individuals listed below are served by this facility, at this location?
MARK “YES” OR “NO” FOR
EACH CATEGORY
SERVED BY THIS FACILITY
Type of Client
1
1. Female
1
2. Male
Yes
Yes
0
0
IF SERVED, WHAT IS
THE LOWEST AGE SERVED
IF SERVED, WHAT IS
THE HIGHEST AGE SERVED
0
No minimum
age
| | |
YEARS
0
No
| | |
YEARS
No maximum
age
0
No minimum
age
| | |
YEARS
0
No
| | |
YEARS
No maximum
age
*19a. Many facilities have clients in one or more of the following categories. For which client categories does this
facility at this location offer a substance abuse treatment program or group specifically tailored for clients in
that category? If this facility treats clients in any of these categories but does not have a specifically tailored
program or group for them, do not mark the box for that category.
MARK ALL THAT APPLY
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
1
2
Adolescents
Young adults
Adult women
Pregnant/postpartum women
Adult men
Seniors or older adults
Lesbian, gay, bisexual, transgender (LGBT) clients
Veterans
Active duty military
Members of military families
Criminal justice clients (other than DUI/DWI)
Clients with co-occurring mental and substance abuse disorders
Clients with HIV or AIDS
Clients who have experienced sexual abuse
Clients who have experienced intimate partner violence, domestic violence
Clients who have experienced trauma
Specifically tailored programs or groups for any other types of clients
(Specify: ______________________________________________)
18
*20.
No specifically tailored programs or groups are offered
Does this facility offer HOSPITAL INPATIENT substance abuse services at this location, that is, the location
listed on the front cover?
1
Yes
0
No
SKIP TO Q.21 (NEXT PAGE)
*20a. Which of the following HOSPITAL INPATIENT services are offered at this facility?
MARK “YES” OR “NO” FOR EACH
YES
1. Hospital inpatient detoxification ............................................................................................................. 1
(Similar to ASAM Levels IV-D and III.7-D, medically managed or monitored inpatient detoxification)
2. Hospital inpatient treatment ................................................................................................................... 1
(Similar to ASAM Levels IV and III.7, medically managed or monitored intensive inpatient treatment)
NOTE: ASAM is the American Society of Addiction Medicine.
For more information on ASAM please go to https://info.nssats.com.
6
NO
0
0
*21.
Does this facility offer RESIDENTIAL
(non-hospital) substance abuse services at this
location, that is, the location listed on the front
cover?
1
Yes
0
No
*23. Does this facility use a sliding fee scale?
YES
3.
*22.
Residential detoxification .................. 1
(Similar to ASAM Level III.2-D,
clinically managed residential
detoxification or social detoxification)
Residential short-term treatment ...... 1
(Similar to ASAM Level III.5, clinically
managed high-intensity residential
treatment, typically 30 days or less)
Residential long-term treatment........ 1
(Similar to ASAM Levels III.3
and III.1, clinically managed
medium- or low-intensity residential
treatment, typically more than 30 days)
Yes
0
No
No
SKIP TO Q.24 (BELOW)
The online Locator and Directory will explain that
sliding fee scales are based on income and other
factors.
NO
0
0
0
*24.
1
Yes
0
No
Does this facility offer treatment at no charge to
clients who cannot afford to pay?
1
Yes
0
No
SKIP TO Q.25 (BELOW)
24a. Do you want the availability of free care for eligible
clients published in SAMHSA’s online Locator and
Directory?
Does this facility offer OUTPATIENT substance
abuse services at this location, that is, the
location listed on the front cover?
1
0
23a. Do you want the availability of a sliding fee scale
published in SAMHSA’s online Locator and
Directory?
MARK “YES” OR “NO” FOR EACH
2.
Yes
SKIP TO Q.22 (BELOW)
*21a. Which of the following RESIDENTIAL services are
offered at this facility?
1.
1
The online Locator and Directory will explain that
potential clients should call the facility for
information on eligibility.
1
Yes
0
No
SKIP TO Q.23 (TOP OF NEXT COLUMN)
*22a. Which of the following OUTPATIENT services are
offered at this facility?
MARK “YES” OR “NO” FOR EACH
YES
1. Outpatient detoxification ..................... 1
NO
0
(Similar to ASAM Levels I-D and II-D,
ambulatory detoxification)
Do not include Medicare, Medicaid, or federal
military insurance. These forms of client
payments are included in Q.26 on the next page.
2. Outpatient methadone/
buprenorphine maintenance
or Vivitrol® treatment ........................... 1
0
0
3. Outpatient day treatment or
partial hospitalization .......................... 1
(Similar to ASAM Level II.5,
20 or more hours per week)
4. Intensive outpatient treatment ............ 1
*25. Does this facility receive any funding or grants
from the Federal Government, or state, county
or local governments, to support its substance
abuse treatment programs?
0
0
1
Yes
0
No
d
Don’t Know
(Similar to ASAM Level II.1,
9 or more hours per week)
5. Regular outpatient treatment .............. 1
(Similar to ASAM Level I,
outpatient treatment, non-intensive)
7
*26. Which of the following types of client payments or insurance are accepted by this facility for substance abuse
treatment?
MARK “YES,” “NO,” OR “DON’T KNOW” FOR EACH
YES
27.
NO
DON’T
KNOW
1. No payment accepted (free treatment for ALL clients) ............ 1
0
d
2. Cash or self-payment ............................................................... 1
0
d
3. Medicare ................................................................................... 1
0
d
4. Medicaid ................................................................................... 1
0
d
5. State-financed health insurance plan other than Medicaid ...... 1
0
d
6. Federal military insurance (e.g., TRICARE) ............................. 1
0
d
7. Private health insurance ........................................................... 1
0
d
8. Access To Recovery (ATR) vouchers ...................................... 1
0
d
9. IHS/Tribal/Urban (ITU) funds.................................................... 1
0
d
10. Other (Specify: _____________________________) ............. 1
0
d
For each of the following activities, please indicate if staff members routinely use computer or electronic
resources, paper only, or a combination of both to accomplish their work.
MARK ONE METHOD FOR EACH ACTIVITY
WORK ACTIVITY
COMPUTER/
ELECTRONIC
ONLY
PAPER ONLY
BOTH
ELECTRONIC
AND PAPER
NA
1.
Intake
1
2
3
na
2.
Scheduling appointments
1
2
3
na
3.
Assessment
1
2
3
na
4.
Treatment plan
1
2
3
na
5.
Client progress monitoring
1
2
3
na
6.
Discharge
1
2
3
na
7.
Referrals
1
2
3
na
8.
Issue/receive lab results
1
2
3
na
9.
Billing
1
2
3
na
10. Outcomes management
1
2
3
na
11. Medication prescribing/dispensing
1
2
3
na
12. Health records
1
2
3
na
13. Interoperability with other providers (such as
primary care, mental health providers, criminal
justice, etc.)
1
2
3
na
8
SECTION B:
REPORTING CLIENT COUNTS
28.
Questions 29 through 34 ask about the number of
clients in treatment. If possible, report clients for
this facility only. However, we realize that is not
always possible. Please indicate whether the
clients you report will be for . . .
MARK ONE ONLY
1
Only this facility
2
This facility plus others
3
SKIP TO Q.29 (TOP OF
NEXT
COLUMN)
HOSPITAL INPATIENT CLIENT COUNTS
29.
0
No
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)
1. Hospital inpatient detoxification _____________
(Similar to ASAM Levels IV-D
and III.7-D, medically managed or
monitored inpatient detoxification)
28a. How many facilities will be included in your client
counts?
2. Hospital inpatient treatment
_____________
(Similar to ASAM Levels IV
and III.7, medically managed or
monitored intensive inpatient treatment)
1
HOSPITAL INPATIENT
TOTAL BOX
+ ADDITIONAL FACILITIES
TOTAL FACILITIESα
α
For Section B, please include all of these
facilities in the client counts that you report
in questions 29 through 34.
SKIP TO Q.30 (PAGE 10)
29a. On March 31, 2017, how many patients received
the following HOSPITAL INPATIENT substance
abuse services at this facility?
COUNT a patient in one service only, even if the
patient received both services.
DO NOT count family members, friends, or other
non-treatment patients.
Another facility will report this facility’s
client counts
SKIP TO Q.35 (PAGE 12)
THIS FACILITY
On March 31, 2017, did any patients receive
HOSPITAL INPATIENT substance abuse services
at this facility?
1 Yes
NOTE: ASAM is the American Society of Addiction Medicine.
For more information on ASAM please go to https://info.nssats.com.
29b. How many of the patients from the HOSPITAL
INPATIENT TOTAL BOX were under the age of 18?
ENTER A NUMBER
(IF NONE, ENTER “0”)
Number under age 18
28b. To avoid double-counting clients, we need to know
which facilities are included in your counts. How
will you report this information to us?
MARK ONE ONLY
1
2
By listing the names and location addresses
of these additional facilities in the “Additional
Facilities Included in Client Counts” section
on page 13 of this questionnaire or attaching
a sheet of paper to this questionnaire
29c.
_______________
How many of the patients from the HOSPITAL
INPATIENT TOTAL BOX received:
Include patients who received these drugs for
detoxification or maintenance purposes.
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)
1.
Methadone dispensed
at this facility
_______________
2.
Buprenorphine dispensed or
prescribed at this facility
_______________
3.
Vivitrol® administered
at this facility
Please call me for a list of the additional
facilities included in these counts
_______________
9
29d. On March 31, 2017, how many hospital inpatient
beds were specifically designated for substance
abuse treatment?
30d.
On March 31, 2017, how many residential beds
were specifically designated for substance abuse
treatment?
ENTER A NUMBER
(IF NONE, ENTER “0”)
Number of beds
ENTER A NUMBER
(IF NONE, ENTER “0”)
_______________
Number of beds
RESIDENTIAL (NON-HOSPITAL)
CLIENT COUNTS
30.
30a.
On March 31, 2017, did any clients receive
RESIDENTIAL (non-hospital) substance abuse
services at this facility?
1 Yes
0 No
SKIP TO Q.31 (NEXT COLUMN)
On March 31, 2017, how many clients received
the following RESIDENTIAL substance abuse
services at this facility?
COUNT a client in one service only, even if the
client received multiple services.
DO NOT count family members, friends, or other
non-treatment clients.
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)
1. Residential detoxification
___________
(Similar to ASAM Level III.2-D,
clinically managed residential
detoxification or social detoxification)
2. Residential short-term treatment
___________
(Similar to ASAM Level III.5,
clinically managed high-intensity
residential treatment, typically
30 days or less)
3. Residential long-term treatment
___________
(Similar to ASAM Levels III.3 and
III.1, clinically managed medium- or
low-intensity residential treatment,
typically more than 30 days)
RESIDENTIAL
TOTAL BOX
30b.
How many of the clients from the RESIDENTIAL
TOTAL BOX were under the age of 18?
ENTER A NUMBER
(IF NONE, ENTER “0”)
Number under age 18
30c.
_______________
How many of the clients from the RESIDENTIAL
TOTAL BOX received:
Include clients who received these drugs for
detoxification or maintenance purposes.
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)
1. Methadone dispensed
at this facility
_______________
OUTPATIENT CLIENT COUNTS
31.
31a.
During the month of March 2017, did any clients
receive OUTPATIENT substance abuse services
at this facility?
1
Yes
0
No
SKIP TO Q.32 (PAGE 11)
How many clients received each of the following
OUTPATIENT substance abuse services at this
facility during March 2017?
clients who received treatment
in March AND were
still enrolled in treatment on
ONLY INCLUDE
March 31, 2017.
COUNT a client in one service only, even if the
client received multiple services.
DO NOT count family members, friends, or other
non-treatment clients.
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)
1. Outpatient detoxification
_________
(Similar to ASAM
Levels I-D and II-D,
ambulatory detoxification)
2. Outpatient methadone/
_________
buprenorphine maintenance
or Vivitrol® treatment
(Count methadone/buprenorphine/
Vivitrol® clients on this line only)
3. Outpatient day treatment
_________
or partial hospitalization
(Similar to ASAM Level II.5,
20 or more hours per week)
4. Intensive outpatient treatment
_________
(Similar to ASAM Level II.1,
9 or more hours per week)
5. Regular outpatient treatment
_________
(Similar to ASAM Level I,
outpatient treatment,
non-intensive)
_______________
2. Buprenorphine dispensed
or prescribed at this facility _______________
3. Vivitrol® administered
at this facility
_______________
OUTPATIENT
TOTAL BOX
10
31b.
How many of the clients from the OUTPATIENT
TOTAL BOX were under the age of 18?
ALL SUBSTANCE ABUSE
TREATMENT SETTINGS
Including Hospital Inpatient,
Residential (non-hospital) and/or Outpatient
ENTER A NUMBER
(IF NONE, ENTER “0”)
32.
Number under age 18
_______________
This question asks you to categorize the
substance abuse treatment clients at this
facility into three groups: clients in treatment for
(1) abuse of both alcohol and substances other
than alcohol; (2) abuse only of alcohol; or
(3) abuse only of substances other than alcohol.
Enter the percent of clients on March 31, 2017,
who were in each of these three groups:
Clients in treatment for abuse of:
31c.
How many of the clients from the OUTPATIENT
TOTAL BOX received:
1. BOTH alcohol and substances
Include clients who received these drugs for
detoxification or maintenance purposes.
2. ONLY alcohol
other than alcohol
___________%
___________%
3. ONLY substances other than
alcohol
___________%
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)
TOTAL
1. Methadone dispensed
at this facility
_______________
33.
100%
Approximately what percent of the substance
abuse treatment clients enrolled at this facility
on March 31, 2017, had a diagnosed co-occurring
mental and substance abuse disorder?
2. Buprenorphine dispensed or
prescribed at this facility
3. Vivitrol® administered
at this facility
31d.
_______________
PERCENT OF CLIENTS
(IF NONE, ENTER “0”)
34.
_______________
On average, during March 2017, were the
outpatient substance abuse treatment services
at this facility operating over, under, or at
capacity?
MARK ONE ONLY
1
Well over capacity (over 120%)
2
Somewhat over capacity (106 to 120%)
3
At or about capacity (95 to 105%)
4
Somewhat under capacity (80 to 94%)
5
Well under capacity (under 80%)
%
Using the most recent 12-month period for
which you have data, approximately how many
substance abuse treatment ADMISSIONS did
this facility have?
OUTPATIENT CLIENTS: Count admissions into
treatment, not individual treatment visits. Consider
an admission to be the initiation of a treatment
program or course of treatment. Count any
re-admission as an admission.
IF THIS IS A MENTAL HEALTH FACILITY: Count
all admissions in which clients received substance
abuse treatment, even if substance abuse was
their secondary diagnosis.
NUMBER OF SUBSTANCE
ABUSE ADMISSIONS IN A
12-MONTH PERIOD
11
SECTION C:
GENERAL INFORMATION
*38. Does this facility have a website or web page with
information about the facility’s substance abuse
treatment programs?
*35. Does this facility operate transitional housing or a
halfway house for substance abuse clients at this
location, that is, the location listed on the front
cover?
1
Yes
0
No
1
3
4
5
6
2
40.
*37. Is this facility or program licensed, certified, or
accredited to provide substance abuse services
by any of the following organizations?
Do not include personal-level credentials or general
business licenses such as a food service license.
MARK “YES,” “NO,” OR “DON’T KNOW” FOR EACH
YES
DON’T
NO KNOW
No
41.
1
Yes
0
No
The Directory may be published on CD. If so,
would you like to receive a free copy of the CD?
(The Directory will also be available at
http://store.samhsa.gov in PDF format; search for
Directory.)
1
Yes
0
No
Who was primarily responsible for completing this
form? This information will only be used if we need
to contact you about your responses. It will not be
published.
0
d
2. State mental health department ..... 1
0
d
3. State department of health ............. 1
0
d
4. Hospital licensing authority ............ 1
d
5
0
5. The Joint Commission .................... 1
0
d
Name:
0
d
of Rehabilitation Facilities (CARF)..1
Quality Assurance (NCQA) ............ 1
0
d
8. Council on Accreditation (COA) ..... 1
0
d
0
d
0
d
10. Other national organization
(Specify:
1
Ms.
2
Mrs.
3
Mr.
)
4
Dr.
Other (Specify:
)
Title:
Fax Number:
(_____) ____ -
Email Address:
9. Healthcare Facilities
or federal, state, or local agency .... 1
MARK ONE ONLY
Phone Number: (_____) ____ -
7. National Committee for
Accreditation Program (HFAP) ....... 1
SKIP TO Q.39 (BELOW)
If eligible, does this facility want to be listed in the
Directory and the online Locator? (See inside front
cover for eligibility information.)
1. State substance abuse agency ...... 1
6. Commission on Accreditation
12
0
Web Address:
39.
Not permitted to smoke anywhere outside or
within any building
Permitted in designated outdoor area(s)
Permitted anywhere outside
Permitted in designated indoor area(s)
Permitted anywhere inside
Permitted anywhere without restriction
Yes
*38a. If eligible, the website address for this facility will
appear in the Directory and online Locator. Please
provide the address exactly as it should be
entered in order to reach your site.
*36. Which of the following statements BEST describes
this facility’s smoking policy for clients?
MARK ONE ONLY
1
Facility Email Address:
Ext.
ADDITIONAL FACILITIES INCLUDED IN CLIENT COUNTS
Complete this section if you reported clients for this facility plus other facilities, as indicated in Question 28.
For each additional facility, please mark if that facility offers hospital inpatient, residential and/or outpatient
substance abuse services at that location.
FACILITY NAME:
FACILITY NAME:
ADDRESS:
ADDRESS:
CITY:
CITY:
STATE:
ZIP:
STATE:
PHONE:
PHONE:
FACILITY EMAIL
ADDRESS:
FACILITY EMAIL
ADDRESS:
HOSPITAL INPATIENT
RESIDENTIAL
OUTPATIENT
HOSPITAL INPATIENT
FACILITY NAME:
FACILITY NAME:
ADDRESS:
ADDRESS:
CITY:
CITY:
STATE:
ZIP:
PHONE:
FACILITY EMAIL
ADDRESS:
FACILITY EMAIL
ADDRESS:
RESIDENTIAL
OUTPATIENT
HOSPITAL INPATIENT
FACILITY NAME:
FACILITY NAME:
ADDRESS:
ADDRESS:
CITY:
CITY:
STATE:
ZIP:
PHONE:
FACILITY EMAIL
ADDRESS:
FACILITY EMAIL
ADDRESS:
RESIDENTIAL
OUTPATIENT
HOSPITAL INPATIENT
RESIDENTIAL
OUTPATIENT
ZIP:
RESIDENTIAL
If you require additional space, please continue on the next page.
13
OUTPATIENT
ZIP:
STATE:
PHONE:
HOSPITAL INPATIENT
RESIDENTIAL
STATE:
PHONE:
HOSPITAL INPATIENT
ZIP:
OUTPATIENT
ANY ADDITIONAL COMMENTS
PLEDGE TO RESPONDENTS: The information you provide will be protected to the fullest extent allowable under Section 501(n) of the Public Health
Service Act (42 USC 290aa(n)). This law permits the public release of identifiable information about an establishment only with the consent of that
establishment and limits the use of the information to the purposes for which it was supplied. With the explicit consent of eligible treatment facilities,
information provided in response to survey questions marked with an asterisk may be published in SAMHSA’s online Behavioral Health Treatment Services
Locator, the National Directory of Drug and Alcohol Abuse Treatment Programs, and other publically available listings. Responses to non-asterisked
questions will be published with no direct link to individual treatment facilities.
Thank you for your participation. Please return this questionnaire in the envelope provided.
If you no longer have the envelope, please mail this questionnaire to:
MATHEMATICA POLICY RESEARCH
ATTN: RECEIPT CONTROL - Project 06667
P.O. Box 2393
Princeton, NJ 08543-2393
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 40 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.
14
| File Type | application/pdf |
| File Title | N-SSATS 2015 National Survey of Substance Abuse Treatment Services (N-SSATS) VARIABLE |
| Subject | Questionnaire |
| Author | MATHEMATICA STAFF |
| File Modified | 2015-07-02 |
| File Created | 2015-07-02 |