Attachment 4. Stakeholder Survey, Wave 2
OMB No. 0930-0320
Expiration Date x/x/x
Welcome to the
National Evaluation of SAMHSA’s CABHI Projects – Wave 2
Stakeholder Survey
[WELCOME] Thank you for taking time to complete the National Evaluation of SAMHSA’s CABHI Projects Stakeholder Survey. The questions in this survey are about your knowledge of and experience with [NAME OF GRANTEE ORGANIZATION]’s grant [PROJECT NAME].
Please click the “Continue” button below to proceed. If you are not affiliated with [NAME OF GRANTEE ORGANIZATION]’s grant [PROJECT NAME], please click here. [PROGRAMMER NOTE: IF R CLICKS HERE SKIP TO TERMINATE.]
[PROGRAMMER NOTE: INSERT “Continue” BUTTON]
_______________________________________________________________________________________________________
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 0930-0320. Public reporting burden for this collection of information is estimated to average 25 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, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.
[PROGRAMMER NOTE: RESPONDENTS DO NOT SEE THE CONTENTS]
MODULE B: STAKEHOLDER’S PERSONAL INVOLVEMENT 3
MODULE D: TREATMENT AND CASE MANAGEMENT SERVICES 5
MODULE E: CLIENT/ CONSUMER CHOICE IN TREATMENT 21
MODULE F: WRAPAROUND AND SUPPORT SERVICES 23
MODULE G: HEALTHCARE SERVICES 34
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[INTINTRO] For questions about the SAMSHA CABHI project, please answer only about [NAME OF GRANTEE ORGANIZATION]’s grant [PROJECT NAME], referred to throughout this survey as “SAMHSA CABHI project”. Other questions are about your organization and are explicitly identified as such.
The survey is estimated to take 25 minutes of your time, including the time it took to review the consent form. If you start and are unable to complete the survey, you can return to complete it at a later date using the same link. The survey will continue where you left off.
All the information you provide is private and will not be shared with anyone at the SAMHSA CABHI project. You will never be identified in any report that uses information from this Evaluation. Thank you again for your support.
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[STAKEINTRO] We will start with questions about your personal involvement with the SAMHSA CABHI project.
[STAKE1]
Which of the following best describes your role(s) or position(s) in this SAMHSA CABHI project? (check all that apply)
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Government official
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[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[STAKETRANS1] Please indicate whether the following describes your involvement in this SAMHSA CABHI project.
[STAKE2]
I helped plan for or prepare the initial project grant application.
Yes [1]
No [2]
[STAKE3]
I have been involved since the project was originally funded.
Yes [1]
No [2]
[STAKE3B]
Approximately what month and year did you become involved?
_ _ / _ _ [NUMERIC ACCEPT 2 CHARACTERS FOR MONTH AND 2 CHARACTERS FOR YEAR]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[STAKE4]
I regularly attend project stakeholder or advisory/consortium meetings.
Yes [1]
No [2]
[STAKE5]
I am directly involved with the project.
Yes [1]
No [2]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: Project Name: [INSERT PROJECT NAME]
[ORGINTRO] The following questions are to describe your organization and the core services it provides to clients in general, not limited to CABHI project clients.
As previously noted, if you have previously completed a prior administration of the SAMHSA CABHI Stakeholder Survey, items in this section have been “pre-filled” to show your most recent responses. Please check that the information is still correct and current. If it is, you do not need to do anything on this item. If you wish to make changes, please click on any new response(s) you wish to check, click on any currently checked response(s) you wish to uncheck, or both.
[ORG1_1]
As part of its core services, does your organization provide behavioral healthcare?
Yes [1]
No [2]
[PROGRAMMER NOTE: IF ORG1_1=1, GET ORG1_1B; ELSE SKIP TO ORG1_2]
[ORG1_1B]
Which behavioral service(s) does your organization provide? (Check all that apply)
Substance abuse treatment
Mental health treatment
Integrated substance abuse and mental health treatment
HIV/AIDS prevention or treatment
[ORG1_2]
As part of its core services, does your organization provide primary healthcare?
Yes [1]
No [2]
[PROGRAMMER NOTE: IF ORG1_2=1, GET ORG1_2B; ELSE SKIP TO ORG1_3]
[ORG1_2B]
In which setting(s) does your organization provide primary healthcare? (Check all that apply)
Hospital
Outpatient clinic
Other, please specify: ______________________________________
[ORG1_3]
As part of its core services, does your organization provide HIV/AIDS prevention or treatment?
Yes [1]
No [2]
[ORG1_4]
As part of its core services, does your organization provide housing services and supports, including identifying and securing housing?
Yes [1]
No [2]
[PROGRAMMER NOTE: IF ORG1_4=1, GET ORG1_4B; ELSE SKIP TO ORG1_5]
[ORG1_4B]
What type(s) of housing services and supports does your organization provide? (Check all that apply)
Coordinated entry (including through the HUD Continuum of Care)
Management or administration of housing vouchers
Other, for example help with applications or interviews or help maintaining housing
[ORG1_5]
As part of its core services, does your organization provide or manage housing?
Yes [1]
No [2]
[PROGRAMMER NOTE: IF ORG1_5=1, GET ORG1_5B; ELSE SKIP TO ORG1_6]
[ORG1_5B]
What type(s) of housing does your organization provide? (Check all that apply)
Permanent public housing
Permanent, privately owned housing
Transitional housing
Emergency shelter
Other, please specify: ______________________________________
[ORG1_6]
As part of its core services, does your organization provide social services (other than any addressed in preceding questions)?
Yes [1]
No [2]
[PROGRAMMER NOTE: IF ORG1_6=1, GET ORG1_6B; ELSE SKIP TO ORG1_7]
[ORG1_6B]
What type(s) of social services does your organization provide? (Check all that apply)
Case management
Drop-in center
Soup kitchen or other meals
Food pantry
Other, please specify: ______________________________________
[ORG1_7]
As part of its core services, does your organization provide educational services (other than any addressed in preceding questions)?
Yes [1]
No [2]
[PROGRAMMER NOTE: IF ORG1_7=1, GET ORG1_7B; ELSE SKIP TO ORG1_8]
[ORG1_7B]
What type(s) of educational services does your organization provide? (Check all that apply)
K – 12 (other than GED)
GED
Post-secondary
Other, please specify: ______________________________________
[ORG1_8]
As part of its core services, does your organization provide employment services (other than any addressed in preceding questions)?
Yes [1]
No [2]
[PROGRAMMER NOTE: IF ORG1_8=1, GET ORG1_8B; ELSE SKIP TO ORG1_9]
[ORG1_8B]
What type(s) of employment services does your organization provide? (Check all that apply)
Job training/vocational rehab
Job placement
Other employment support services (e.g. help with resume, interviewing skills, presentation)
[ORG1_9]
As part of its core services, does your organization focus on any particular groups (i.e. target groups or specific populations)?
Yes [1]
No [2]
[PROGRAMMER NOTE: IF ORG1_9=1, GET ORG1_9B; ELSE SKIP TO ORG1_10]
[ORG1_9B]
What type(s) of employment services does your organization provide? (Check all that apply)
Families
Unaccompanied youth, including runaway youth
Women
LGBTQ individuals
Veterans
Individuals with HIV/AIDS
Other, please specify: ______________________________________
[ORG1_10]
As part of its core services, does your organization provide peer support services?
Yes [1]
No [2]
[PROGRAMMER NOTE: IF ORG1_10=1, GET ORG1_10B; ELSE SKIP TO ORG1_11]
[ORG1_10B]
Is your organization peer-led or peer-run?
Yes [1]
No [2]
[ORG1_11]
Is your organization a government agency, authority or other entity?
Yes [1]
No [2]
[PROGRAMMER NOTE: IF ORG1_11=1, GET ORG1_11B; ELSE SKIP TO ORG1_12]
[ORG1_11B]
What type(s) of government entity is your organization? (Check all that apply)
Substance abuse agency/authority
Mental health agency/authority
Housing agency/authority
Medical/health agency
Social services agency
Veterans administration
Benefits, other than VA (for example, Social Security, Medicaid)
Employment services agency/authority
Criminal justice agency
Other, please specify: ______________________________________
[ORG1_11C]
What level of government is your organization? (Check all that apply)
Local, for example city or county
State or territory
Federal
[ORG1_12]
[PROGRAMMER NOTE: IF ORG1_1=2 AND ORG1_2=2 AND ORG1_3=2 AND ORG4_1=2 AND ORG1_5=2 AND ORG1_6=2 AND ORG1_7=2 AND ORG1_8=2 AND ORG1_9=2 AND ORG1_10=2, GET ORG1_12; ELSE SKIP TO ORG_INTRO2]
[ORG1_12]
It appears that your organization is not any of the organization types address above. Please indicate what type of organization it is: [SPECIFY] ________________________________
[ORG1_13]
Does your organization serve as the lead agency for Coordinated Entry?
Yes [1]
No [2]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[ORG_INTRO2]
The next questions ask about your organization’s involvement in the SAMHSA CABHI project.
[ORG2]
Has your organization received funding from this SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[ORG3]
Does your organization provide substance abuse or mental health treatment or case management to SAMHSA CABHI project clients?
Yes [1]
No [2]
Don’t know [8]
[ORG4]
Does your organization provide primary healthcare or HIV/AIDS services to SAMHSA CABHI project clients?
Yes [1]
No [2]
Don’t know [8]
[ORG5]
Does your organization provide wraparound or support services (e.g., support securing or maintaining housing, daily living skills, vocational or education services, or family services) to SAMHSA CABHI project clients?
Yes [1]
No [2]
Don’t know [8]
[ORG6]
Does your organization provide permanent housing to SAMHSA CABHI project clients?
Yes [1]
No [2]
Don’t know [8]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF ORG3=1, OR ORG4=1, OR ORG5=1, OR ORG6=1, GET ORG7; ELSE SKIP TO COLLABINTRO]
[ORG7]
How many SAMHSA Homeless project clients has your organization served to date? Please count a single client only once. If you are not certain of the exact amount, please provide your best estimate.
______________ [ALLOW 4; NUMERIC ONLY]
[PROGRAMMER NOTE: IF ORG5=1 GET MODULE D TREATMENT AND CASE MANAGEMENT SERVICES, SERVINTRO1; ELSE SKIP TO MODULE F WRAPAROUND AND SUPPORT SERVICES, WRAPINTRO1]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[SERVINTRO1] The next questions are about the substance abuse or mental health treatment or case management services your organization provides to SAMHSA CABHI project clients.
[SERV1]
Are the following services provided by your organization directly to SAMHSA CABHI project clients?
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Yes [1] |
No [2] |
Outreach or engagement [SERV1_1] |
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Discharge planning [SERV1_2] |
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Aftercare (services provided after formal discharge from the project) [SERV1_3] |
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[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF SERV1_1=1 GET SERV2; ELSE SKIP TO SERV4]
[SERV2]
Did your organization begin providing outreach or engagement services as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[SERV3]
How are outreach or engagement services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [SERV3_1]
With other funds by the grantee organization [SERV3_2]
In-kind or with other funds by your organization [SERV3_3]
Medicaid/Medicare [SERV3_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [SERV3_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [SERV3_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF SERV1_2=1 GET SERV4; ELSE SKIP TO SERV6]
[SERV4]
Did your organization begin providing discharge planning services as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[SERV5]
How are discharge planning services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [SERV5_1]
With other funds by the grantee organization [SERV5_2]
In-kind or with other funds by your organization [SERV5_3]
Medicaid/Medicare [SERV5_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [SERV5_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [SERV5_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF SERV1_3=1 GET SERV6; ELSE SKIP TO SERV8]
[SERV6]
Did your organization begin providing aftercare (services provided after formal discharge from the project) as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[SERV7]
How are aftercare services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [SERV7_1]
With other funds by the grantee organization [SERV7_2]
In-kind or with other funds by your organization [SERV7_3]
Medicaid/Medicare [SERV7_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [SERV7_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [SERV7_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[SERVE8]
Are the following services provided by your organization directly to SAMHSA CABHI project clients?
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Yes [1] |
No [2] |
Case management [SERV8_1] |
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Crisis care services (e.g., 24 hour crisis response) [SERV8_2] |
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Self-help or peer services [SERV8_3] |
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[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF SERV8_1=1 GET SERV9; ELSE SKIP TO SERV11]
[SERV9]
Did your organization begin providing case management services as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[SERV10]
How are case management services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [SERV10_1]
With other funds by the grantee organization [SERV10_2]
In-kind or with other funds by your organization [SERV10_3]
Medicaid/Medicare [SERV10_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [SERV10_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [SERV10_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF SERV8_2=1 GET SERV11; ELSE SKIP TO SERV13]
[SERV11]
Did your organization begin providing crisis care services (e.g., 24 hour crisis response) as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[SERV12]
How are crisis care services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [SERV12_1]
With other funds by the grantee organization [SERV12_2]
In-kind or with other funds by your organization [SERV12_3]
Medicaid/Medicare [SERV12_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [SERV12_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [SERV12_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF SERV8_3=1 GET SERV13; ELSE SKIP TO SERV15]
[SERV13]
Did your organization begin providing self-help or peer services as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[SERV14]
How are self-help or peer services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [SERV14_1]
With other funds by the grantee organization [SERV14_2]
In-kind or with other funds by your organization [SERV14_3]
Medicaid/Medicare [SERV14_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [SERV14_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [SERV14_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[SERV15]
Are the following services provided by your organization directly to SAMHSA CABHI project clients?
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Yes [1] |
No [2] |
Substance abuse screening/assessment [SERV15_1] |
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Substance abuse treatment [SERV15_2] |
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Detoxification services [SERV15_3] |
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[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF SERV15_1=1 GET SERV16; ELSE SKIP TO SERV18]
[SERV16]
Did your organization begin providing substance abuse screening/assessment services as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[SERV17]
How are substance abuse screening/assessment services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [SERV17_1]
With other funds by the grantee organization [SERV17_2]
In-kind or with other funds by your organization [SERV17_3]
Medicaid/Medicare [SERV17_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [SERV17_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [SERV17_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF SERV15_2=1 GET SERV18; ELSE SKIP TO SERV22]
[SERV18]
Did your organization begin providing substance abuse treatment services as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[SERV19]
How are substance abuse treatment services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [SERV19_1]
With other funds by the grantee organization [SERV19_2]
In-kind or with other funds by your organization [SERV19_3]
Medicaid/Medicare [SERV19_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [SERV19_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [SERV19_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[SERV20]
Of the SAMHSA CABHI project clients that your organization serves, what percent receive any type of substance abuse treatment directly from your organization? If you are not certain of the exact amount for any question in this survey, please select your best estimate.
1–25% [1]
26–50% [2]
51–75% [3]
76–100% [4]
Don’t know [8]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[SERV21]
Of the SAMHSA CABHI project clients that your organization serves, what percent receive the following substance abuse treatment services directly from your organization?
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None [1] |
1-25% [2] |
26-50% [3] |
51-75% [4] |
76-100% [5] |
Don’t know [8] |
Group outpatient counseling [SERV21_1] |
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Individual outpatient counseling [SERVE21_2] |
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Residential treatment (group and individual counseling) [SERV21_3] |
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Pharmacotherapy (e.g., Methadone, Buprenorphine, etc.) [SERV21_4] |
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AA/NA or other 12-step peer support [SERV21_5] |
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Detoxification (residential or outpatient) [SERV21_6] |
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Other substance abuse treatment services, specify: [ALLOW 50] [SERV21_7] |
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[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF SERV15_3=1 GET SERV22; ELSE SKIP TO SERV24]
[SERV22]
Did your organization begin providing detoxification services as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[SERV23]
How are detoxification services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [SERV23_1]
With other funds by the grantee organization [SERV23_2]
In-kind or with other funds by your organization [SERV23_3]
Medicaid/Medicare [SERV23_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [SERV23_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [SERV23_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[SERV24]
Are the following services provided by your organization directly to SAMHSA CABHI project clients?
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Yes [1] |
No [2] |
Mental health screening/assessment [SERV24_1] |
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Mental health treatment [SERV24_2] |
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Pharmacotherapy (substance abuse or mental health) [SERV24_3] |
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Integrated mental health and substance abuse treatment [SERV24_4] |
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[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF SERV24_1=1 GET SERV25; ELSE SKIP TO SERV27]
[SERV25]
Did your organization begin providing mental health screening/assessment services as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[SERV26]
How are mental health screening/assessment services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [SERV26_1]
With other funds by the grantee organization [SERV26_2]
In-kind or with other funds by your organization [SERV26_3]
Medicaid/Medicare [SERV26_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [SERV26_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [SERV26_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF SERV24_2=1 GET SERV27; ELSE SKIP TO SERV31]
[SERV27]
Did your organization begin providing mental health treatment services as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[SERV28]
How are mental health treatment services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [SERV28_1]
With other funds by the grantee organization [SERV28_2]
In-kind or with other funds by your organization [SERV28_3]
Medicaid/Medicare [SERV28_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [SERV28_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [SERV28_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[SERV29]
Of the SAMHSA CABHI project clients that your organization serves, what percent receive any type of mental health treatment directly from your organization?
1–25% [1]
26–50% [2]
51–75% [3]
76–100% [4]
Don’t know [8]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[SERV30]
Of the SAMHSA CABHI project clients that your organization serves, what percent receive the following mental health treatment services directly from your organization?
|
None [1] |
1-25% [2] |
26-50% [3] |
51-75% [4] |
76-100% [5] |
Don’t know |
Group outpatient counseling [SERV30_1] |
|
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|
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Individual outpatient counseling [SERV30_2] |
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Residential treatment (group and individual counseling) [SERV30_3] |
|
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Prescribed psychotropic medication (e.g., anti-depressants, anti-psychotics, anti-anxiety medications, etc.) [SERV30_4] |
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Family treatment [SERV30_5] |
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Day treatment [SERV30_6] |
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Trauma/PTSD treatment/services [SERV30_7] |
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Peer to peer mental health counseling/support [SERV30_8] |
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Treatment with a psychiatrist or psychologist [SERV30_9] |
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Other mental health treatment services, specify: [ALLOW 50] [SERV30_10] |
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[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF SERV24_3=1 GET SERV31; ELSE SKIP TO SERV33]
[SERV31]
Did your organization begin providing pharmacotherapy services (substance abuse or mental health) as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[SERV32]
How are pharmacotherapy services (substance abuse or mental health) provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [SERV32_1]
With other funds by the grantee organization [SERV32_2]
In-kind or with other funds by your organization [SERV32_3]
Medicaid/Medicare [SERV32_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [SERV32_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [SERV32_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF SERV24_4=1 GET SERV33; ELSE SKIP TO SERV43]
[SERV33]
Did your organization begin providing integrated mental health and substance abuse treatment services as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[SERV34]
How are integrated mental health and substance abuse treatment services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [SERV34_1]
With other funds by the grantee organization [SERV34_2]
In-kind or with other funds by your organization [SERV34_3]
Medicaid/Medicare [SERV34_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [SERV34_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [SERV34_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[SERV35INTRO] The next questions are about screening, assessment, and treatment your organization provides to SAMHSA CABHI project clients related to co-occurring mental health and substance abuse problems.
[SERV35]
Of the project clients that your organization serves, what percent are screened for co-occurring mental health and substance abuse problems?
None [1]
1–25% [2]
26–50% [3]
51–75% [4]
76–100% [5]
Don’t know [8]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF SERV35=1, SKIP TO SERV38; ELSE GET SERV36]
[SERV36]
Of the project clients who screen positive for co-occurring mental health and substance abuse problems, what percent does your organization formally assess for co-occurring mental health and substance abuse problems?
None [1]
1–25% [2]
26–50% [3]
51–75% [4]
76–100% [5]
Don’t know [8]
[PROGRAMMER NOTE: IF SERV36=1, SKIP TO SERV38; ELSE GET SERV37]
[SERV37]
Of the project clients that your organization serves whose assessments identify co-occurring mental health and substance abuse problems, what percent receive services to address these problems?
None [1]
1–25% [2]
26–50% [3]
51–75% [4]
76–100% [5]
Don’t know [8]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[SERV38]
How often do the project clients with co-occurring mental health and substance abuse problems that your organization serves receive mental health and substance abuse services at the same time?
Never – clients complete either mental health services first or substance abuse services first [1]
Sometimes [2]
Often [3]
Always or almost always [4]
Don’t know [8]
[SERV39]
Of your organization’s staff members who provide substance abuse or mental health treatment, what percent are cross-trained in substance use and mental health treatment?
None [1]
1–25% [2]
26–50% [3]
51–75% [4]
76–100% [5]
Don’t know [8]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF SERV39=1 OR 8, SKIP TO SERV42; ELSE GET SERV40]
[SERV40]
Which of the following statements best describes these cross-trained staff members?
All or almost all of them are mental health professionals who were cross-trained in substance abuse treatment [1]
All or almost all of them are substance abuse professionals who were cross-trained in mental health treatment [2]
About an equal number of them were either mental health professionals cross-trained in substance abuse treatment or substance abuse professionals cross-trained in mental health treatment [3]
Don’t know [8]
[SERV41]
How has the SAMHSA CABHI project primarily supported this cross-training in your organization?
Primarily by providing mental health treatment training to substance abuse professionals [1]
Primarily by providing substance abuse treatment training to mental health professionals [2]
By providing mental health treatment training to substance abuse professionals and substance abuse treatment training to mental health professionals equally [3]
The project has not supported cross-training staff in my organization [4]
Don’t know [8]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[SERV42]
How often do your organization’s mental health and substance abuse treatment staff members collaborate in developing and implementing treatment plans?
Never – mental health treatment staff and substance abuse treatment staff develop and implement separate treatment plans [1]
Sometimes [2]
Often [3]
Always or almost always [4]
Don’t know [8]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[SERVINTRO43] The next questions are about your organization.
[SERV43]
How much emphasis does your organization place on….
|
No emphasis [1] |
Some emphasis [2] |
A lot of emphasis [3] |
Don’t know [8] |
Assessing [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] trauma history [SERV43_1] |
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Tailoring treatment to [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “clients’”; IF PROGRAM=3 OR 4 INSERT “consumers’”] trauma history [SERV43_2] |
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Offering trauma-specific treatment or services [SERV43_3] |
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Training staff on trauma-informed treatment or services [SERV43_4] |
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Offering gender-specific treatment or service options [SERV43_5] |
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Training staff on gender-specific treatment or services [SERV43_6] |
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Using [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] satisfaction surveys to improve services [SERV43_7] |
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[IF SERV15_2=1 OR SERV24_2=1 OR SERV24_4=1 GET MODULE E CLIENT CHOICE IN TREATMENT, TXINTRO; ELSE SKIP TO MODULE F WRAPAROUND AND SUPPORT SERVICES, WRAPINTRO1]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[TXINTRO] The next few questions refer to the [PROGRAMMER NOTE: IF SERV15_2=1 AND SERV24_2=2 AND SERV24_4=2 INSERT “substance abuse”; IF SERV15_2=2 AND SERV24_2=1 AND SERV24_4=2 INSERT “mental health”; IF SERV15_2=1 AND SERV24_2=1 OR SERV24_4=1 INSERT “substance abuse and mental health”] treatment your organization provides to SAMHSA CABHI project clients.
[TX1]
Does your organization accommodate [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] choice in treatment?
Yes [1]
No [2]
Don’t know [8]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[IF TX1=1, GET TX2; IF TX1=2 OR 8 SKIP TO TX3]
[TX2]
In what ways does your organization accommodate [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] choice in treatment? (check all that apply)
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client”; IF PROGRAM=3 OR 4 INSERT “Consumer”] decides on the…
Type(s) of treatment received (e.g., trauma informed treatment, integrated treatment) [TX2_1]
Type(s) of medication prescribed [TX2_2]
Modality of treatment (e.g., group vs. individual) [TX2_3]
Treatment setting (e.g., residential, outpatient, continuing day treatment, in residence) [TX2_4]
Length of treatment [TX2_5]
Other ways, specify: [ALLOW 50] [TX2_6]
Don’t know [TX2_8]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[TX3]
[PROGRAMMER NOTE: IF TX1=2, 8] Which of the following are a factor in determining [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “clients’ ”; IF PROGRAM=3 OR 4 INSERT “consumers’ ”] treatment plan or treatment options?
[PROGRAMMER NOTE: IF TX1=1] Which of the following are also a factor in determining [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “clients’ ”; IF PROGRAM=3 OR 4 INSERT “consumers’ ”] treatment plan or treatment options?
(check all that apply)
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[PROGRAMMER NOTE: IF ORG6=1 GET MODULE F WRAPAROUND AND SUPPORT SERVICES, WRAPINTRO1; ELSE SKIP TO MODULE G HOUSING SERVICES, HOUSGINTRO1]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[WRAPINTRO1] The next questions are about the wraparound or support services (e.g., housing readiness training, daily living skills, medical care, HIV/AIDS services, vocational or education services, family services) your organization provides to SAMSHA Homeless project clients.
[WRAP1]
Are the following services provided by your organization directly to SAMHSA CABHI project clients?
|
Yes [1] |
No [2] |
Housing application assistance and placement [WRAP1_1] |
|
|
Housing readiness training [WRAP1_2] |
|
|
Independent living skills or daily living skills training (e.g., food shopping, cleaning, hygiene, money management, etc.) [WRAP1_3] |
|
|
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF WRAP1_1=1 GET WRAP2; ELSE SKIP TO WRAP4]
[WRAP2]
Did your organization begin providing housing application assistance and placement services as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[WRAP3]
How are housing application assistance and placement services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [WRAP3_1]
With other funds by the grantee organization [WRAP3_2]
In-kind or with other funds by your organization [WRAP3_3]
Medicaid/Medicare [WRAP3_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [WRAP3_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [WRAP3_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF WRAP1_2=1 GET WRAP4; ELSE SKIP TO WRAP6]
[WRAP4]
Did your organization begin providing housing readiness training as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[WRAP5]
How is housing readiness training provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [WRAP5_1]
With other funds by the grantee organization [WRAP5_2]
In-kind or with other funds by your organization [WRAP5_3]
Medicaid/Medicare [WRAP5_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [WRAP5_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [WRAP5_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF WRAP1_3=1 GET WRAP6; ELSE SKIP TO WRAP8]
[WRAP6]
Did your organization begin providing independent living skills or daily living skills training (e.g., food shopping, cleaning, hygiene, money management, etc.) as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[WRAP7]
How are independent living skills or daily living skills training provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [WRAP7_1]
With other funds by the grantee organization [WRAP7_2]
In-kind or with other funds by your organization [WRAP7_3]
Medicaid/Medicare [WRAP7_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [WRAP7_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [WRAP7_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[WRAP8]
Are the following services provided by your organization directly to SAMHSA CABHI project clients?
|
Yes [1] |
No [2] |
Assistance with medical insurance applications, including Medicaid and Medicare, or other benefits applications (e.g., SSI/SSDI, food stamps) [WRAP8_1] |
|
|
Legal assistance related to families, for example support for family re-unification [WRAP8_2] |
|
|
Childcare [WRAP8_3] |
|
|
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF WRAP8_1=1 GET WRAP9; ELSE SKIP TO WRAP11]
[WRAP9]
Did your organization begin providing assistance with medical insurance applications, including Medicaid and Medicare, or other benefits applications (e.g., SSI/SSDI, food stamps) services as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[WRAP10]
How are assistance with medical insurance or other benefits applications services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [WRAP10_1]
With other funds by the grantee organization [WRAP10_2]
In-kind or with other funds by your organization [WRAP10_3]
Medicaid/Medicare [WRAP10_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [WRAP10_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [WRAP10_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF WRAP8_2=1 GET WRAP11; ELSE SKIP TO WRAP13]
[WRAP11]
Did your organization begin providing Legal assistance related to families, for example support for family re-unification as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[WRAP12]
How is Legal assistance related to families, for example support for family re-unification provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [WRAP12_1]
With other funds by the grantee organization [WRAP12_2]
In-kind or with other funds by your organization [WRAP12_3]
Medicaid/Medicare [WRAP12_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [WRAP12_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [WRAP12_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF WRAP8_3=1 GET WRAP13; ELSE SKIP TO WRAP15]
[WRAP13]
Did your organization begin providing childcare as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[WRAP14]
How is childcare provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [WRAP14_1]
With other funds by the grantee organization [WRAP14_2]
In-kind or with other funds by your organization [WRAP14_3]
Medicaid/Medicare [WRAP14_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [WRAP14_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [WRAP14_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[WRAP15]
Are the following services provided by your organization directly to SAMHSA CABHI project clients?
|
Yes [1] |
No [2] |
HIV/AIDS testing and medical treatment [WRAP15_1] |
|
|
HIV/AIDS/STD prevention education [WRAP15_2] |
|
|
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF WRAP15_1=1 GET WRAP16; ELSE SKIP TO WRAP18]
[WRAP16]
Did your organization begin providing HIV/AIDS testing and medical treatment as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[WRAP17]
How are HIV/AIDS testing and medical treatment provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [WRAP17_1]
With other funds by the grantee organization [WRAP17_2]
In-kind or with other funds by your organization [WRAP17_3]
Medicaid/Medicare [WRAP17_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [WRAP17_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [WRAP17_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF WRAP15_2=1 GET WRAP18; ELSE SKIP TO WRAP20]
[WRAP18]
Did your organization begin providing HIV/AIDS/STD prevention education as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[WRAP19]
How is HIV/AIDS/STD prevention education provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [WRAP19_1]
With other funds by the grantee organization [WRAP19_2]
In-kind or with other funds by your organization [WRAP19_3]
Medicaid/Medicare [WRAP19_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [WRAP19_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [WRAP19_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[WRAP20]
Are the following services provided by your organization directly to SAMHSA CABHI project clients?
|
Yes [1] |
No [2] |
Employment or vocational services [WRAP20_1] |
|
|
Education/GED programs [WRAP20_2] |
|
|
Legal assistance [WRAP20_3] |
|
|
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF WRAP20_1=1 GET WRAP21; ELSE SKIP TO WRAP23]
[WRAP21]
Did your organization begin providing employment or vocational services as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[WRAP22]
How are employment or vocational services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [WRAP22_1]
With other funds by the grantee organization [WRAP22_2]
In-kind or with other funds by your organization [WRAP22_3]
Medicaid/Medicare [WRAP22_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [WRAP22_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [WRAP22_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF WRAP20_2=1 GET WRAP23; ELSE SKIP TO WRAP25]
[WRAP23]
Did your organization begin providing education/GED programs as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[WRAP24]
How are education/GED programs provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [WRAP24_1]
With other funds by the grantee organization [WRAP24_2]
In-kind or with other funds by your organization [WRAP24_3]
Medicaid/Medicare [WRAP24_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [WRAP24_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [WRAP24_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF WRAP20_3=1 GET WRAP25; ELSE SKIP TO WRAP27]
[WRAP25]
Did your organization begin providing legal assistance as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[WRAP26]
How is legal assistance provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [WRAP26_1]
With other funds by the grantee organization [WRAP26_2]
In-kind or with other funds by your organization [WRAP26_3]
Medicaid/Medicare [WRAP26_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [WRAP26_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [WRAP26_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[WRAP27]
Are the following services provided by your organization directly to SAMHSA CABHI project clients?
|
Yes [1] |
No [2] |
Transportation [WRAP27_1] |
|
|
Family and parenting services [WRAP27_2] |
|
|
Other services provided by your organization, specify: [ALLOW 100] [WRAP27_3] |
|
|
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF WRAP27_1=1 GET WRAP28; ELSE SKIP TO WRAP30]
[WRAP28]
Did your organization begin providing transportation services as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[WRAP29]
How are transportation services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [WRAP29_1]
With other funds by the grantee organization [WRAP29_2]
In-kind or with other funds by your organization [WRAP29_3]
Medicaid/Medicare [WRAP29_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [WRAP29_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [WRAP29_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF WRAP27_2=1 GET WRAP30; ELSE SKIP TO WRAP32]
[WRAP30]
Did your organization begin providing family and parenting services as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[WRAP31]
How are family and parenting services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [WRAP31_1]
With other funds by the grantee organization [WRAP31_2]
In-kind or with other funds by your organization [WRAP31_3]
Medicaid/Medicare [WRAP31_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [WRAP31_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [WRAP31_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF WRAP27_3=1 GET WRAP32; ELSE SKIP TO MODULE G HOUSING SERVICES, HOUSGINTRO1]
[WRAP32]
Did your organization begin providing [PROGRAMMER NOTE: ENTER OTHER SERVICES FROM WRAP27_3] services as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[WRAP33]
How are [PROGRAMMER NOTE: ENTER OTHER SERVICES FROM WRAP27_3] services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [WRAP33_1]
With other funds by the grantee organization [WRAP33_2]
In-kind or with other funds by your organization [WRAP33_3]
Medicaid/Medicare [WRAP33_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [WRAP33_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [WRAP33_6]
[PROGRAMMER NOTE: IF ORG8=1 GET MODULE G HEALTHCARE SERVICES, HEALTHINTRO1; ELSE SKIP TO MODULE H, HOUSGINTRO1]
[HEALTHINTRO1] The next questions are about the healthcare services your organization provides to SAMHSA CABHI project clients.
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[HEALTH1]
Are the following services provided by your organization directly to SAMHSA CABHI project clients?
|
Yes [1] |
No [2] |
Outpatient medical care [HEATLH1_1] |
|
|
Inpatient medical care [HEATLH1_2] |
|
|
Emergency care (e.g., hospital emergency room, urgent care) [HEATLH1_3] |
|
|
HIV/AIDS testing and treatment [HEATLH1_4] |
|
|
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF HEALTH1=1 GET HEALTH2; ELSE SKIP TO HEALTH3]
[HEALTH2]
How are outpatient medical care services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [HEALTH2_1]
With other funds by the grantee organization [HEALTH2_2]
In-kind or with other funds by your organization [HEALTH2_3]
Medicaid/Medicare [HEALTH2_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [HEALTH2_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [HEALTH2_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF HEALTH1_2=1 GET HEALTH4; ELSE SKIP TO HEALTH5]
[HEALTH4]
How is inpatient medical care provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [HEALTH4_1]
With other funds by the grantee organization [HEALTH4_2]
In-kind or with other funds by your organization [HEALTH4_3]
Medicaid/Medicare [HEALTH4_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [HEALTH4_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [HEALTH4_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF HEALTH1_3=1 GET HEALTH5; ELSE SKIP TO HEALTH6]
[HEALTH5]
How is emergency medical care provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [HEALTH5_1]
With other funds by the grantee organization [HEALTH5_2]
In-kind or with other funds by your organization [HEALTH5_3]
Medicaid/Medicare [HEALTH5_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [HEALTH5_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [HEALTH5_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF HEALTH1_4=1 GET HEALTH6; ELSE SKIP TO HEALTH8]
[HEALTH6]
Did your organization begin providing HIV/AIDS testing and treatment services as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[HEALTH7]
How are HIV/AIDS testing and treatment services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [HEALTH7_1]
With other funds by the grantee organization [HEALTH7_2]
In-kind or with other funds by your organization [HEALTH7_3]
Medicaid/Medicare [HEALTH7_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [HEALTH7_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [HEALTH7_6]
[HEALTH8]
Are the following services provided by your organization directly to SAMHSA CABHI project clients?
|
Yes [1] |
No [2] |
Dental care [HEATLH8_1] |
|
|
Vision care [HEATLH8_2] |
|
|
Preventative healthcare visits and screening [HEATLH8_3] |
|
|
Nutrition and healthy living education [HEATLH8_4] |
|
|
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF HEALTH8_1=1 GET HEALTH9; ELSE SKIP TO HEALTH10]
[HEALTH9]
How is dental care provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [HEALTH9_1]
With other funds by the grantee organization [HEALTH9_2]
In-kind or with other funds by your organization [HEALTH9_3]
Medicaid/Medicare [HEALTH9_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [HEALTH9_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [HEALTH9_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF HEALTH8_2=1 GET HEALTH10; ELSE SKIP TO HEALTH11]
[HEALTH10]
How is vision care provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [HEALTH10_1]
With other funds by the grantee organization [HEALTH10_2]
In-kind or with other funds by your organization [HEALTH10_3]
Medicaid/Medicare [HEALTH10_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [HEALTH10_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [HEALTH10_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF HEALTH8_3=1 GET HEALTH11; ELSE SKIP TO HEALTH12]
[HEALTH11]
How are preventative healthcare visits and screening provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [HEALTH11_1]
With other funds by the grantee organization [HEALTH11_2]
In-kind or with other funds by your organization [HEALTH11_3]
Medicaid/Medicare [HEALTH11_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [HEALTH11_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [HEALTH11_6]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF HEALTH8_4=1 GET HEALTH12; ELSE SKIP TO HOUSINGINTRO1]
[HEALTH12]
Did your organization begin providing Nutrition and healthy living education services as a result of your involvement in the SAMHSA CABHI project?
Yes [1]
No [2]
Don’t know [8]
[HEALTH13]
How are nutrition and healthy living education services provided by your organization to SAMHSA CABHI project clients paid for? (check all the apply)
CABHI/GBHI/SSH/PATH grant funds [HEALTH13_1]
With other funds by the grantee organization [HEALTH13_2]
In-kind or with other funds by your organization [HEALTH13_3]
Medicaid/Medicare [HEALTH13_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] private insurance [HEALTH13_5]
Out-of-pocket by [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] [HEALTH13_6]
[PROGRAMMER NOTE: IF ORG7=1 GET MODULE G HOUSING SERVICES, HOUSGINTRO1; ELSE SKIP TO CLOSE1]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[HOUSGINTRO1] The next questions are about the housing services your organization provides to SAMHSA CABHI project clients.
[HOUSG1]
Which type(s) of housing does your organization provide to SAMHSA CABHI project clients? (check all that apply)
|
|
Examples |
|
|
Emergency housing [HOUSG1_1] |
Emergency shelter, crisis housing |
|
|
Safe Haven [HOUSG1_2] |
|
|
|
Housing in residential treatment [HOUSG1_3] |
Therapeutic communities, community residential facilities |
|
|
Transitional housing, time limited [HOUSG1_4] |
Halfway house, Three-quarter house, Sober homes |
|
|
Permanent supportive housing (PSH) [HOUSG1_5] |
Subsidized or unsubsidized housing with no time limit, program participants hold the lease, and formal supportive services are provided |
|
|
Permanent subsidized housing without formal PSH support services [HOUSG1_6] |
Affordable housing for seniors or persons with disabilities or public housing that may include outside case management |
|
|
Permanent private/unsubsidized housing without formal PSH support services [HOUSG1_7] |
May include outside case management |
|
|
Other type of housing, specify: [ALLOW 50] [HOUSG1_8] |
|
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[HOUSG2]
What types of housing arrangements does your organization provide to SAMHSA CABHI project clients? (check all that apply)
|
|
Example |
|
|
Congregate housing, including shelter [HOUSG2_1] |
All beds or rooms located in the same site with shared common areas |
|
|
Single room occupancy (SRO) [HOUSG2_2] |
Single room unit that may have kitchen and/or bathroom facilities in the unit or in a shared space |
|
|
Single-site housing [HOUSG2_3] |
2 or more units/apartments set aside for clients in one site |
|
|
Scatter-site housing [HOUSG2_4] |
Units/apartments located in different buildings and/or neighborhoods |
|
|
Hotels/motels [HOUSG2_5] |
|
|
|
Other housing arrangements, specify: [ALLOW 50] [HOUSG2_6] |
|
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[HOUSG3]
Does your organization provide services to support clients obtaining or maintaining housing?
Yes [1]
No [2]
Don’t know [8]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF HOUSG3=1 GET HOUSG4; ELSE SKIP TO HOUSG6]
[HOUSG4]
Are housing supportive services time-limited?
Yes – All supportive services are time-limited [1]
Yes – Some supportive services are time-limited and some are not time-limited [2]
No [3]
Don’t know [8]
[HOUSG5]
Which of the following best describes where housing supportive services are provided?
Primarily on-site (in project office space) [1]
Primarily off-site (in participant homes or other locations in the community) [2]
Equally on-site and off-site [3]
Don’t know [8]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[HOUSG6]
Which of the following best describes your agency’s housing philosophy?
|
|
Example |
|
|
Housing First [1] |
Priority is placed on assisting clients in obtaining permanent housing without pre-conditions for entering or adhering to treatment or sobriety requirements. |
|
|
Housing Ready [2] |
Clients must demonstrate they are “ready” for housing by adhering to specific treatment or sobriety requirements before permanent housing is obtained |
|
|
Some other housing philosophy, specify: [ALLOW 50] [3] |
|
|
|
Don’t know [8] |
|
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[HOUSG7]
What types of housing subsidies are used by SAMHSA CABHI project clients? (check all that apply)
|
|
|
|
|
|
|
|
|
|
|
|
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[HOUSG8]
Does your agency accommodate [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] choice in housing?
Yes [1]
No [2]
Don’t know [8]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[PROGRAMMER NOTE: IF HOUSG8=1, GET HOUSG9; ELSE SKIP TO HOUSG10]
[HOUSG9]
In what ways does your organization accommodate [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “client”; IF PROGRAM=3 OR 4 INSERT “consumer”] choice in housing? (check all that apply)
|
|
Example |
|
|
Type of housing [HOUSG9_1] |
Permanent, transitional, emergency |
|
|
Housing location, neighborhood [HOUSG9_2] |
|
|
|
Type of housing unit [HOUSG9_3] |
Shared bedroom, SRO, apartment |
|
|
Choice among multiple units [HOUSG9_4] |
|
|
|
Housing composition [HOUSG9_5] |
Who the client lives with |
|
|
Treatment requirements [HOUSG9_6] |
Substance abuse or mental health |
|
|
Other housing arrangements, Specify: [ALLOW 50] [HOUSG9_7] |
|
|
|
Don’t know [HOUSG9_8] |
|
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[HOUSG10]
[PROGRAMMER NOTE: IF HOUSG8= 2, 8] Which of the following are a factor in determining [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “clients’ ”; IF PROGRAM=3 OR 4 INSERT “consumers’ ”] housing options?
[PROGRAMMER NOTE: IF HOUSG8=1] Which of the following are also a factor in determining [PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “clients’ ”; IF PROGRAM=3 OR 4 INSERT “consumers’ ”] housing options? (check all that apply)
Availability of specific housing options [HOUSG10_1]
Specific housing options are affordable to clients [HOUSG10_2]
Criminal justice record [HOUSG10_3]
Probation/parole/court mandate considerations [HOUSG10_4]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client”; IF PROGRAM=3 OR 4 INSERT “Consumer”] must be clean and sober [HOUSG10_5]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client”; IF PROGRAM=3 OR 4 INSERT “Consumer”] must have reached a certain phase of treatment [HOUSG10_6]
[PROGRAMMER NOTE: IF SAMHSA_PROG=1 OR 2 INSERT “Client’s”; IF PROGRAM=3 OR 4 INSERT “Consumer’s”] mental health symptoms must be stable [HOUSG10_7]
Other clinical determinations, specify: [ALLOW 50] [HOUSG10_8]
Other non-clinical determinations, specify: [ALLOW 50] [HOUSG10_9]
None of these [HOUSG10_99]
Don’t know [HOUSG10_88]
[NEW SCREEN]
Grantee Organization: [INSERT NAME OF GRANTEE ORGANIZATION]
Project Name: [INSERT PROJECT NAME]
[CLOSE1]
Finally, please provide any additional information about the SAMHSA CABHI project that you think is important and would like to share. We are especially interested in “lessons learned” – things that went well, or not so well, during grant service delivery that you would like to share (anonymously) with SAMHSA and future grantees.
[ALLOW 1000]
THANK YOU VERY MUCH for participating!
Information from key stakeholders like you will help practitioners, policy makers, researchers and funders better understand the efforts of SAMHSA CABHI projects, including factors contributing to success, which we hope will improve future efforts to reduce homelessness and provide clients and consumers the services they need.
[NEW SCREEN]
[IF STAKEHOLDER, GRANT ORGANIZATION OR PROJECT NAME NOT ACCURATE]
[TERMINATE]
We are sorry for the confusion. A team member from the National Evaluation of SAMHSA’s Homeless Programs will look into the problem and get back to you.
If you have any questions or need to speak with someone about this National Evaluation of SAMHSA’s Homeless Programs or the Stakeholder survey, please contact Jim Trudeau, RTI International Project Director, via email [email protected], or phone, toll-free 1-877-653-1240.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Ariana Napier |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |