Client Screener

Attachment 4. Client Screener Form

Form Approved

OMB No.: 0920-xxxx

Expiration Date: XX/XX/XXXX

Public Reporting burden of this collection of information is estimated at 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  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.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA  30333; Attn:  PRA (0920-XXXX).

1. MAT Study Client ID: _______________________

SF1. Language – completed by Interviewer

How well does this client speak English?

• Very well/Well

• Not well/Not well at all

• Does not speak English

SF2. I can ask my questions in English or Spanish. Which would you prefer?

1. English

2. Spanish

3. Other and cannot/will not proceed in English or Spanish

FI COMPLETE

O Click here to proceed in English

O Click here to proceed in Spanish

O Click here to code out as ineligible due to language skip to end

SCREENER CONSENT FORM

SF3. Now I need to ask you a few screening questions to make sure you are eligible for this study. The study was described to you in the MAT Study brochure given to you by your treatment provider. Do you remember this, or would you like to review it again? Answering these questions does not commit you to being in our study. If you are eligible and want to learn more about participating, we will review a much longer document with more details about the study at a later time, including benefits and risks and the uses of your data. May I continue with the screening questions? As always, you may refuse to answer any question.

• Yes

• No STOP. Go to Programmer Note 6

• Refuse to answer STOP. Go to Programmer Note 6

SF5. What is your current age? ___________

IF AGE <18 STOP. Go to Programmer Note 6

• Refuse to answer STOP. Go to Programmer Note 6

SF6. Did you just start a new treatment for opioid addiction?¹

• Yes

• No STOP. Go to Programmer Note 6

• Refuse to answer STOP. Go to Programmer Note 6

SF7. What type of treatment did you just start:²

1. Methadone, Methadone Therapy

2. Buprenorphine, Suboxone, or Probuphine

3. Naltrexone, Vivitrol, Revia

4. Behavioral therapy/Counseling without any medications

5. None of the above STOP. Go to Programmer Note 6

6. Refuse to answer STOP. Go to Programmer Note 6

SF8. Before this most recent time, have you received [enter answer to SF7] treatment in the last 3 months?

• Yes STOP. Go to Programmer Note 6

• No

• Unknown STOP. Go to Programmer Note 6

• Refuse to answer STOP. Go to Programmer Note 6

CLIENT DEMOGRAPHICS

SF9. What sex were you assigned at birth, on your original birth certificate?

• Female

• Male

SF10. What is your ethnicity?

• Hispanic or Latino

• Not Hispanic or Latino

SF11. What is your race? (check all that apply.)

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or other Pacific Islander

• White

SF12. What is the ZIP code of your current residence?

ZIP Code: _____________

• Unknown

• Refuse to answer

Programmer note 1: Populate RURAL flag. See current RURAL ZIP document for decision rule for assignment of urban/rural designation. RURAL = 1 if Q10 (ZIP) is rural; else 0.

Programmer note2: Populate STUDYARM = Q5 response code. If missing/refused, go to Programmer Note 6.

Programmer note 3: Populate QUOTAMET =0. See current QUOTA TARGET document for decision rule on quota status. QUOTAMET = 1 If quota is exceeded

Programmer note 4: Populate ELIGCLIENT.

ELIGCLIENT=1

If SF6=No or Refuse (not a new treatment episode or refused), ELIGCLIENT = 2

If SF7= “None of the above” or Refuse (not in one of treatments being studied or refused), ELIGCLIENT = 3

If SF2=Other, ELIGCLIENT = 4

If QUOTAMET =1, ELIGCLIENT=5

Programmer note 5: If eligible, transfer ID and ELIGCLIENT to Case Management System.

Programmer note 6: Interviewer should re-ask question to make sure it was heard correctly. Interviewer should encourage client to answer question. If client persists in refusing to answer or gives answer that makes them ineligible, send instruction to interviewer:

I am sorry but [I am unable to screen you for eligibility if you choose not to provide an answer to this question/you are not eligible for the study]. [Do you think you might be able or willing to answer these questions later? I can call back./ Thank you for your time today].

FLASH SCREEN

If ELIGCLIENT=1, flash: Client is eligible for the MAT Study. Go to closing remarks #1.

Else, flash: Client NOT eligible for MAT study today. Go to closing remarks #2.

Closing Remarks #1: It appears you are eligible for the MAT Study. Let me tell you a little more about what comes next, OK? [Explain about making appointment, selecting location, what will happen during visit, informed consent, questionnaire completion, estimated time to complete, incentives payment]

Closing Remarks #2: It appears you are not eligible for the MAT Study. I appreciate you taking this time with me to go over these questions. Thank you.

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1 The exact definition of a new episode may be read to client if needed to clarify.

2 The exact definition of each type of MAT or counseling may be read to client if needed to clarify.