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pdfAttachment B3- Between Cycles N-SSATS (N-SSATS BC) (as of 2/25/2019)
OMB No. xxxx-xxxx
APPROVAL EXPIRES: xx/xx/xxxx
See OMB burden statement on last page
National Survey of
Substance Abuse Treatment Services
(N-SSATS)
March 29, 2019
Substance Abuse and Mental Health Services Administration (SAMHSA)
U.S. Department of Health and Human Services (HHS)
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
PLEASE READ THIS ENTIRE PAGE BEFORE
COMPLETING THE QUESTIONNAIRE
Would you prefer to complete this questionnaire online? See the pink flyer enclosed in your
survey 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 surveys, 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), in
SAMHSA’s National Directory of Drug and Alcohol Abuse Treatment Programs, and other publicly-available
listings, unless you designate otherwise in question 28, page 10 of this questionnaire.
Mapping feature in online Locator. Complete and accurate name and address information is needed for
SAMHSA’s online Behavioral Health Treatment Services 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 and that complete this questionnaire will be listed as substance abuse facilities 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 1-888-324-8337.
*1.
Which of the following substance abuse services
are offered by this facility at this location, that is,
the location listed on the front cover?
3.
Did you answer “yes” to substance use treatment
in option 3 of question 1?
1
Yes
0
No
MARK “YES” OR “NO” FOR EACH
YES
NO
1. Intake, assessment, or referral ........ 1
0
2. Detoxification .................................... 1
0
3. Substance use treatment ................. 1
0
(services that focus on initiating and
maintaining an individual’s recovery
from substance abuse and on
averting relapse)
4.
5.
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)?
*6.
Is this facility a jail, prison, or other organization
that provides treatment exclusively for
incarcerated persons or juvenile detainees?
1
Yes
0
No
Substance abuse clients
2
Clients other than substance abuse clients
3
2.
1
Yes
0
No
Is this facility a Federally Qualified Health Center
(FQHC)?
No clients are offered mental health treatment
services
FQHCs include: (1) all organizations that receive
grants under Section 330 of the Public Health
Service Act; and (2) other organizations that do
not receive grants, but have met the requirements
to receive grants under Section 330 according to
the U.S. Department of Health and Human
Services.
For a complete definition of a FQHC, go to:
https://info.nssats.com
Did you answer “yes” to detoxification in option 2
of question 1 above?
1
Yes
0
No
1
Yes
0
No
d
Don’t know
SKIP TO Q.3 (TOP OF NEXT COLUMN)
7.
*2a.
Does this facility detoxify clients from . . .
MARK “YES” OR “NO” FOR EACH
YES
What is the primary focus of this facility at this
location, that is, the location listed on the front
cover?
MARK ONE ONLY
NO
1
Substance use treatment services
2
Mental health services
1. Alcohol ............................................... 1
0
2. Benzodiazepines ............................... 1
0
3. Cocaine ............................................. 1
0
4. Methamphetamines ........................... 1
0
4
General health care
5. Opioids .............................................. 1
0
5
Other (Specify: ___________________ )
6. Other (Specify: ______________ ) .... 1
0
3
*2b.
SKIP TO Q.30 (PAGE 10)
Is this facility a solo practice, meaning, an office
with only one independent practitioner or
counselor?
MARK ALL THAT APPLY
1
SKIP TO Q.25 (PAGE 9)
Mix of mental health and substance use
treatment services (neither is primary)
Does this facility routinely use medications during
detoxification?
1
Yes
0
No
SKIP TO Q.4 (NEXT COLUMN)
1
*8.
Is this facility operated by . . .
*10a. Which of the following RESIDENTIAL services are
offered at this facility?
MARK ONE ONLY
1
A private for-profit organization
2
A private non-profit organization
3
State government
4
5
6
*8a.
MARK “YES” OR “NO” FOR EACH
YES
SKIP TO
Q.9
(BELOW)
Local, county, or community
government
1. Residential detoxification .................... 1
Tribal government
2. Residential short-term treatment ........ 1
Which Federal Government agency?
3. Residential long-term treatment ......... 1
Department of Veterans Affairs
2
Department of Defense
3
Indian Health Service
4
Other (Specify: __________________ )
*11.
Does this facility offer HOSPITAL INPATIENT
substance abuse services at this location, that is,
the location listed on the front cover?
*9a.
0
No
SKIP TO Q.10 (BELOW)
YES
1. Hospital inpatient detoxification .......... 1
2. Hospital inpatient treatment ................ 1
NO
0
1
Yes
0
No
SKIP TO Q.12 (TOP OF NEXT PAGE)
YES
0
NOTE: ASAM is the American Society of Addiction Medicine.
For more information on ASAM please go to https://info.nssats.com.
2
Does this facility offer RESIDENTIAL (non-hospital)
substance abuse services at this location, that is,
the location listed on the front cover?
No
SKIP TO Q.10a (TOP OF NEXT COLUMN)
SKIP TO Q.11 (NEXT COLUMN)
1. Outpatient detoxification ..................... 1
NO
0
0
0
0
0
(similar to ASAM Levels I-D and II-D,
ambulatory detoxification)
2. Outpatient methadone/
(similar to ASAM Levels IV and III.7,
medically managed or monitored
intensive inpatient treatment)
0
MARK “YES” OR “NO” FOR EACH
(similar to ASAM Levels IV-D and
III.7-D, medically managed or
monitored inpatient detoxification)
Yes
0
*11a. Which of the following OUTPATIENT services are
offered at this facility?
Which of the following HOSPITAL INPATIENT
services are offered at this facility?
1
Does this facility offer OUTPATIENT substance
abuse services at this location, that is, the location
listed on the front cover?
MARK “YES” OR “NO” FOR EACH
*10.
0
(similar to ASAM Levels III.3 and III.1,
clinically managed medium- or lowintensity residential treatment,
typically more than 30 days)
1
Yes
(similar to ASAM Level III.5, clinically
managed high-intensity residential
treatment, typically 30 days or less)
Federal Government
1
0
(similar to ASAM Level III.2-D,
clinically managed residential
detoxification or social detoxification)
MARK ONE ONLY
*9.
NO
buprenorphine maintenance or
naltrexone treatment .......................... 1
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
(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)
*12. Which of the following services are offered 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
2
3
4
5
6
7
8
9
Screening for substance abuse
Screening for mental disorders
Comprehensive substance abuse assessment or
diagnosis
Comprehensive mental health assessment or
diagnosis (for example, psychological or
psychiatric evaluation and testing)
Screening for tobacco use
Outreach to persons in the community who may
need treatment
Interim services for clients when immediate
admission is not possible
Professional interventionist/educational consultant
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.)
11
12
13
14
15
16
17
18
19
10
Drug and alcohol oral fluid testing
Breathalyzer or other blood alcohol testing
Drug or alcohol urine screening
Testing for Hepatitis B (HBV)
Testing for Hepatitis C (HCV)
HIV testing
STD testing
TB screening
Testing for metabolic syndrome
We do not offer any of these testing services
Recovery Support Services
28
29
30
31
32
33
34
Education and Counseling Services
35
36
37
38
39
40
41
42
43
44
45
20
21
22
Hepatitis A (HAV) vaccination
Hepatitis B (HBV) vaccination
We do not offer any of these medical services
Transitional Services
23
24
25
26
27
Discharge planning
Aftercare/continuing care
Naloxone and overdose education
Outcome follow-up after discharge
We do not offer any of these transitional services
HIV or AIDS education, counseling, or support
Hepatitis education, counseling, or support
Health education other than HIV/AIDS or Hepatitis
Substance abuse education
Smoking/tobacco cessation counseling
Individual counseling
Group counseling
Family counseling
Marital/couples counseling
Vocational training or educational support (for
example, high school coursework, GED
preparation, etc.)
We do not offer any of these education and
counseling services
Ancillary Services
46
47
48
49
50
Medical Services
Mentoring/peer support
Self-help groups (for example, AA, NA, SMART
Recovery)
Assistance in locating housing for clients
Employment counseling or training for clients
Assistance with obtaining social services (for
example, Medicaid, WIC, SSI, SSDI)
Recovery coach
We do not offer any of these recovery support
services
51
52
53
54
55
Case management services
Social skills development
Child care for clients’ children
Domestic violence—family or partner violence
services (physical, sexual, and emotional abuse)
Early intervention for HIV
Transportation assistance to treatment
Mental health services
Acupuncture
Residential beds for clients’ children
We do not offer any of these ancillary services
Other Services
56
57
58
59
Treatment for gambling disorder
Treatment for Internet use disorder
Treatment for other addiction disorder
(non-substance abuse)
We do not offer any of these other services
3
Pharmacotherapies
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
4
Disulfiram (Antabuse®)
Naltrexone (oral)
Naltrexone (extended-release, injectable, for example, Vivitrol®)
Acamprosate (Campral®)
Nicotine replacement
Non-nicotine smoking/tobacco cessation medications (for example, bupropion, varenicline)
Medications for psychiatric disorders
Methadone
Buprenorphine with naloxone (for example, Suboxone®, Bunavail®, Zubsolv®)
Buprenorphine without naloxone
Buprenorphine sub-dermal implant (Probuphine®)
Buprenorphine (extended-release, injectable, for example, Sublocade®)
Medications for HIV treatment (for example, antiretroviral medications such as tenofovir, efavirenz, emtricitabine,
atazanavir, and lamivudine)
Medications for Hepatitis C (HCV) treatment (for example, sofosbuvir, ledipasvir, interferon, peginterferon, ribavirin)
Lofexidine
Clonidine
We do not offer any of these pharmacotherapy services
*13.
Facilities may treat a range of substance use disorders. The next series of questions focuses only on how this
facility treats opioid use disorder.
How does this facility treat opioid use disorder?
Medication assisted treatment (MAT) includes the use of methadone, buprenorphine and/or naltrexone for the
treatment of opioid use disorder. For this question, MAT refers to any or all of these medications unless specified.
MARK ALL THAT APPLY
1
2
3
4
5
6
7
This facility does not treat opioid use disorder.
This facility uses methadone or buprenorphine for pain management, emergency
cases, or research purposes. It is NOT a federally-certified Opioid Treatment
Program (OTP).
This facility treats opioid use disorder, but it does not use medication assisted
treatment (MAT), nor does it accept clients using MAT to treat opioid use disorder.
SKIP TO
Q.14
(TOP OF NEXT
PAGE)
This facility accepts clients using MAT, but the medications originate from or are
prescribed by another entity. (The medications may or may not be
stored/delivered/monitored onsite.)
This facility administers naltrexone to treat opioid use disorder. Naltrexone use is
authorized through any medical staff who have prescribing privileges.
This facility prescribes buprenorphine to treat opioid use disorder. Buprenorphine
use is authorized through a DATA 2000 waivered physician, physician assistant, or
nurse practitioner.
SKIP TO
Q.13b
(BELOW)
This facility is a federally-certified Opioid Treatment Program (OTP). (Most OTPs
administer/dispense methadone; some only use buprenorphine.)
*13a. From where do these clients obtain their medications?
MARK ALL THAT APPLY
1
The prescribing entity is in our network.
2
There is a business, contractual, or formal referral relationship with the prescribing entity.
3
The client obtains their prescription/medication from their personal physician/health care provider.
4
Other (Specify: ______________________________________________________ )
*13b. Does this facility serve only opioid use disorder clients?
1
Yes
0
No
*13c. Which of the following medication services does this program provide?
MARK ALL THAT APPLY
1
Maintenance services with methadone or buprenorphine
2
Maintenance services with medically-supervised withdrawal (or taper) after a period of stabilization
3
Detoxification from opioids of abuse with methadone or buprenorphine
4
Detoxification from opioids of abuse with lofexidine or clonidine
5
Relapse prevention with naltrexone
6
Other (Specify: ______________________________________________________ )
7
We do not offer any of these medication services
5
*14.
Facilities may treat a range of substance use disorders. The next series of questions focuses only on how this
facility treats alcohol use disorder.
How does this facility treat alcohol use disorder?
These medications have been approved by FDA to treat alcohol use disorder: Naltrexone, acamprosate, and
disulfiram. For this question, MAT refers to any or all of these three medications.
MARK ALL THAT APPLY
1
2
3
4
This facility does not treat alcohol use disorder.
SKIP TO Q.15 (TOP OF NEXT PAGE)
This facility treats alcohol use disorder, but it does not use medication assisted
treatment (MAT) for alcohol use disorder, nor does it accept clients using MAT to
treat alcohol use disorder.
SKIP TO Q.14b (BELOW)
This facility accepts clients using MAT for alcohol use disorder, but the medications
originate from or are prescribed by another entity.
This facility administers/prescribes at least one of Disulfiram (Antabuse®), naltrexone, and/or
acamprosate (Campral®) for alcohol use disorder.
SKIP TO Q.14b (BELOW)
*14a. From where do these clients obtain their medications?
MARK ALL THAT APPLY
1
The prescribing entity is in our network.
2
There is a business, contractual, or formal referral relationship with the prescribing entity.
3
The client obtains their prescription/medication from their personal physician/health care provider.
4
Other (Specify: ______________________________________________________ )
*14b. Does this facility serve only alcohol use disorder clients?
6
1
Yes
0
No
*15. Which of the following clinical/therapeutic approaches listed below are used frequently at this facility?
MARK ALL THAT APPLY
3
4
5
6
7
8
9
10
11
12
13
14
15
16
1
2
Substance abuse counseling
12-step facilitation
Brief intervention
Cognitive behavioral therapy
Dialectical behavior therapy
Contingency management/motivational incentives
Motivational interviewing
Trauma-related counseling
Anger management
Matrix Model
Community reinforcement plus vouchers
Rational emotive behavioral therapy (REBT)
Relapse prevention
Telemedicine/telehealth (including Internet, Web, mobile, and desktop programs)
Other treatment approach (Specify: _________________________________________________ )
We do not use any of these clinical/therapeutic approaches
7
*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.
*18b. In what other languages do staff counselors
provide substance use treatment at this facility?
Do not count languages provided only by on-call
interpreters.
MARK ALL THAT APPLY
American Indian or Alaska Native:
Yes
1
Hopi
1
No
2
Lakota
0
3
Navajo
4
Ojibwa
5
Yupik
Does this facility provide substance use
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)?
6
Mark “yes” if either a staff counselor or an on-call
interpreter provides this service.
*18.
(Specify: ___________________________ )
1
Yes
Other Languages:
0
No
7
Arabic
8
Any Chinese language
9
Creole
Does this facility provide substance use
treatment services in a language other than
English at this location?
1
Yes
0
No
SKIP TO Q.19 (TOP OF NEXT PAGE)
18a. At this facility, who provides substance use
treatment services in a language other than
English?
MARK ONE ONLY
1
2
Staff counselor who speaks a language other
than English
On-call interpreter (in person or by phone)
brought in when needed
SKIP TO Q.19
(TOP OF NEXT
PAGE)
3
BOTH staff counselor and on-call interpreter
*18a1. Do staff counselors provide substance use
treatment in Spanish at this facility?
1
Yes
0
No
SKIP TO Q.18b (TOP OF NEXT COLUMN)
18a2. Do staff counselors at this facility provide
substance use treatment in any other
languages?
8
Other American Indian or Alaska Native
language
1
Yes
GO TO Q.18b (TOP OF NEXT COLUMN)
0
No
SKIP TO Q.19 (TOP OF NEXT PAGE)
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: ___________________________ )
*19. Individuals seeking substance use treatment can vary by age, gender or other characteristics. Which
categories of individuals listed below are served by this facility, at this location?
Indicate only the highest or lowest age the facility would accept. Do not indicate the highest or lowest age
currently receiving services in the facility.
MARK “YES” OR “NO” FOR
EACH CATEGORY
TYPE OF CLIENT
1. Female
1
1
2. Male
IF SERVED, WHAT IS
THE LOWEST AGE SERVED
SERVED BY THIS FACILITY
Yes
Yes
0
0
No
| | |
YEARS
No
| | |
YEARS
*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
use 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
1
Adolescents
2
Young adults
3
Adult women
4
Pregnant/postpartum women
5
Adult men
6
Seniors or older adults
7
Veterans
9
Active duty military
10
Members of military families
11
Criminal justice clients (other than DUI/DWI)
13
Clients with co-occurring mental and substance
abuse disorders
Clients with co-occurring pain and substance
use
14
Clients with HIV or AIDS
15
Clients who have experienced sexual abuse
16
17
18
19
0
*20.
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
No minimum age
| | |
YEARS
0
No maximum age
No minimum age
| | |
YEARS
0
No maximum age
Does this facility use a sliding fee scale?
Sliding fee scales are based on income and other
factors.
1
Yes
0
No
SKIP TO Q.21 (BELOW)
20a. Do you want the availability of a sliding fee scale
published in SAMHSA’s online Locator and
Directory?
The online Locator and Directory will explain that
potential clients should call the facility for
information on eligibility.
*21.
Lesbian, gay, bisexual, transgender (LGBT)
clients
8
12
0
IF SERVED, WHAT IS
THE HIGHEST AGE SERVED
1
Yes
0
No
Does this facility offer treatment at no charge or
minimal payment (for example, $1) to clients who
cannot afford to pay?
1
Yes
0
No
SKIP TO Q.22 (BELOW)
21a. Do you want the availability of treatment at no
charge or minimal payment (for example, $1) for
eligible clients published in SAMHSA’s online
Locator and Directory?
The online Locator and Directory will explain that
potential clients should call the facility for
information on eligibility.
*22.
1
Yes
0
No
Does this facility receive any funding or grants
from the Federal Government, or state, county or
local governments, to support its substance use
treatment programs?
Do not include Medicare, Medicaid, or federal
military insurance. These forms of client
payments are included in Q.23.
(Specify: ___________________________)
1
Yes
No specifically tailored programs or groups are
offered
0
No
d
Don’t know
9
*23.
Which of the following types of client payments or
insurance are accepted by this facility for
substance use treatment?
*26.
Which of the following statements BEST describes
this facility’s smoking policy for clients?
MARK ONE ONLY
MARK “YES,” “NO,” OR “DON’T KNOW” FOR EACH
YES
NO
1
DON’T
KNOW
1. No payment accepted (free
Not permitted to smoke anywhere outside or
within any building
2
Permitted in designated outdoor area(s)
treatment for ALL clients) ............. 1
0
d
3
Permitted anywhere outside
2. Cash or self-payment ................... 1
0
d
4
Permitted in designated indoor area(s)
3. Medicare ...................................... 1
0
d
5
Permitted anywhere inside
4. Medicaid ....................................... 1
0
d
6
Permitted anywhere without restriction
0
d
(e.g., TRICARE) ........................... 1
0
d
7. Private health insurance .............. 1
0
d
8. IHS/Tribal/Urban (ITU) funds ....... 1
0
d
9. Other ............................................ 1
0
d
5. State-financed health insurance
plan other than Medicaid.............. 1
6. Federal military insurance
*27.
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
(Specify: ______________________________)
*24.
Is this facility a hospital or located in or operated
by a hospital?
1
Yes
0
No
SKIP TO Q.25 (BELOW)
*24a. What type of hospital?
MARK ONE ONLY
DON’T
KNOW
1. State substance abuse agency ... 1
0
d
2. State mental health department .. 1
0
d
3. State department of health .......... 1
0
d
4. Hospital licensing authority ......... 1
0
d
5. The Joint Commission................. 1
0
d
0
d
6. Commission on Accreditation of
Rehabilitation Facilities (CARF) .. 1
General hospital (including VA hospital)
2
Psychiatric hospital
7. National Committee for
Quality Assurance (NCQA) ......... 1
0
d
Other specialty hospital, for example,
alcoholism, maternity, etc.
8. Council on Accreditation (COA) .. 1
0
d
0
d
0
d
(Specify: ___________________________)
10
NO
1
3
*25.
YES
Does this facility operate transitional housing, a
halfway house, or a sober home for substance
abuse clients at this location, that is, the location
listed on the front cover?
1
Yes
0
No
9. Healthcare Facilities
Accreditation Program (HFAP) ... 1
10. Other national organization or
federal, state, or local agency ..... 1
(Specify: _____________________________ )
28.
If eligible, does this facility want to be listed in the Directory and the online Locator? (See inside front cover
for eligibility information)
The Directory will be available at https://www.samhsa.gov/data/substance-abuse-facilities-data-nssats
The Locator can be found at: https://findtreatment.samhsa.gov
1
Yes
0
No
SKIP TO Q.29 (BELOW)
28a. To increase public awareness of behavioral health services, SAMHSA may be sharing facility contact
information with large commercially available Internet search engines, such as Google, Bing, Yahoo!, etc. Do
you want your facility information shared on these Internet search engines?
Information to be shared would be: facility name, location address, telephone number, and website address.
29.
1
Yes
0
No
Is this facility part of an organization with multiple facilities or sites that provide substance use treatment?
1
Yes
0
No
SKIP TO Q.30 (BELOW)
29a. What is the name, address, and phone number of the facility that is the parent, or master site, of the
organization?
Name: ____________________________________________________________________________________
Address: ___________________________________________________________________________________
__________________________________________________________________________________________
Phone Number:
30.
(_____) _______ - _________
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.
MARK ONE ONLY
1
Ms
2
Mrs
3
Mr
4
Dr
5
Other (Specify: ___________________________________ )
Name: ____________________________________________________________________________________
Title: ______________________________________________________________________________________
Phone Number:
(_____) _______ - _________
Fax Number:
(_____) _______ - _________
Ext. ________
Email Address: _____________________________________________________________________________
Facility Email Address: _______________________________________________________________________
11
ANY ADDITIONAL COMMENTS
PLEDGE TO RESPONDENTS: The information you provide will be protected to the fullest extent allowable under the Public Health Service Act (42 USC
290aa(p)). 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 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 publicly-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 50345
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 xx 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.
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |