0920-21DC Survey Year Two/Three

Attachment # 8

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

National Syringe Services Program Evaluation

Survey Years 2-3

Public reporting burden of this collection of information is estimated to average 35 minutes, including the time for reviewing instructions, administering/reading questions, and entering responses. 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 NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

DAVE PURCHASE MEMORIAL SURVEY

QUESTIONNAIRE SECTIONS

Contents

Abbreviations 2

Key Terms 2

PRELIMINARY INFORMATION 2

PROGRAM CHARACTERISTICS 5

CLIENT CHARACTERISTICS 11

COMMUNITY RELATIONS AND CHALLENGES 14

SYRINGE COLLECTION, DISTRIBUTION, AND DISPOSAL 16

PROVISION OF NALOXONE AND OTHER OVERDOSE REVERSAL MEDICATIONS 16

PROVISION OF SERVICES 18

PROCESS EVALUATION 25

OVERVIEW

Abbreviations

R	Respondent
DK	Don't know
REF	Refused to answer
NA	Not applicable (question asked of R but this is a codable response option)
EQ	Equal to
GT	Greater than
GE	Greater than or equal to
LE	Less than or equal to
LT	Less than
NE	Not equal to

Key Terms

Term	Prefix / format	Definition
Calculated variable	CALC_	Item identifier (not prefix for variable name) for variables calculated by the CAPI program that appear in the CRQ.
Message	INTERVIEWER:	Message displayed to the interviewer that is not to be read to R. May be triggered by an edit check. Distinct from Interviewer Instruction. ‘FIELD NOTE’ indicates instructions that will be added as a field note rather than directly included in the question.
Filter question		A question that determines whether the respondent should receive subsequent question or set of questions, typically on a related topic.
Logic Check	Check_	Logic that must be checked (by the CAPI program) in order to determine proper routing to the next item in the CAPI programmed questionnaire.
Interviewer instruction		Instruction to interviewer regarding survey administration. Standard instructions are ‘Give Respondent Flashcard {letter}', ‘READ choices', ‘DO NOT READ choices', & ‘CHECK ALL that apply'.
Introductory statement	INTRO_	Transitional statement read to R at the beginning of a new topic (e.g., Section, set of questions, etc.). Prefix is followed by section abbreviation, series, or first item in set to which it applies.
Range		Range of valid response values for items collecting or computing numeric data. E.g., the valid range of responses to number of sex partners in past 12 months is 0 to 7000.
Section		Section of the Questionnaire. Each section has a unique two letter abbreviation.
Soft Edit Check	SoftEdit_	A check to determine whether the response entered is implausible. If yes, CAPI program displays message to interviewer; program may advance after closing the error message dialog box.

DAVE PURCHASE MEMORIAL SURVEY

PRELIMINARY INFORMATION

INTRO_OMB.

Public reporting burden of this collection of information is estimated to average 35 minutes per survey, including the time for reviewing instructions, administering questions and entering responses. 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 NE, US8-4, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New).

CALC_YR	Hidden variable: Year of recall period. This is the period that the participant will be asked to recall throughout the survey. This needs to be updated manually by survey staff each time the survey is administered. Field note: Must be 4 digits.
YEAR	Recall year
	_ _ _ _

PI1.	Are you completing this survey by yourself or by speaking with an interviewer?
ADMIN	Mode of administration
	Completing survey myself	0
	Completing survey with interviewer	1

Check_INTRO.

If R self-administering survey (PI1 [ADMIN] EQ 0), go to INTRO_SA. Else, go to INTRO_IA.

INTRO_SA.

Thank you for taking the time to complete this program survey. When answering questions, please refer to the period from January 1, [YEAR], to December 31, [YEAR] unless otherwise stated. If program data are not available, please use your best estimate to complete the questions below. If your program only operated during some of the specified time period, please provide information reflective of the time period(s) during which your program did operate. If you need any clarifications about any of the questions in this survey or how this information will be used, please contact [project coordinator name, phone, email]. If you need to step away, PLEASE REMEMBER TO SAVE YOUR SURVEY, as not saving it will result in losing your responses. To save, first click on the save button at the bottom of the screen. You will then be prompted to enter an email address and a link will be sent to you to continue the survey later.

INTRO_IA.

Thank you for taking the time to complete this program survey. When answering questions, please refer to the period from January 1, [YEAR], to December 31, [YEAR] unless otherwise stated. If program data are not available, please use your best estimate to complete the questions below. If your program only operated during some of the specified time period, please provide information reflective of the time period(s) during which your program did operate. If you need any clarifications about any of the questions in this survey or how this information will be used, please let me know. During the survey, you may need to refer to your records to answer some questions. If you are unable to answer a question today, but later find the answer in your records, you can reach us later to provide this additional information by contacting [project coordinator name, phone, email].

CALC_SDATE		Automatic, hidden variable: Survey date (today)
		Automatic start date
	_ _ / _ _ / _ _ _ _

CALC_START	Automatic, hidden variable: Start time of survey
	Preliminary information: Start time
	__ : __

PI2.	What is the name of your program? [FIELD NOTE: IF REFUSED, LEAVE BLANK]
PROGNAM	Name of program
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

PI3a.	What month and year did the program start? Start by selecting the month. If you do not remember the exact month, please provide your best estimate.
SDATE_M	SDATE month
	January	1
	February	2
	March	3
	April	4
	May	5
	June	6
	July	7
	August	8
	September	9
	October	10
	November	11
	December	12
	Don't Know	99
	Refuse to Answer	77

PI3b.		Enter the year. If you do not remember the exact year, please provide your best estimate. Please enter four digits. [FIELD NOTE: IF REFUSED OR DON’T KNOW, LEAVE BLANK]
SDATE_Y		SDATE year
		---- ---- ---- -----
		Range		1950-[YEAR]

SoftEdit_SDATE_Y

If [SDATE_Y] > [YEAR], then display error message: “The year the SSP started is later than [YEAR]. Please confirm that this year is accurate.”

INTRO_PI.

First, we would like to ask a series of questions about your program and the services your program provided between January 1, [YEAR], and December 31, [YEAR]. Following these questions, we will then ask a few of the same questions about 2020. The COVID-19 pandemic likely impacted program operations and services provided by programs nationwide during 2020, so this information will be extremely important to help understand these impacts and the continuing challenges to programs moving forward.

PI4.	Did your program provide any services at any time between January 1, [YEAR], and December 31, [YEAR]?
OPRCL	Operated during recall period
	No	0
	Yes	1

Check_PI4.

If R did not operate at any time during the recall period (PI4 [OPRCL] EQ 0), go to INTRO_MD1. Else, go to INTRO_PC.

PROGRAM CHARACTERISTICS

INTRO_PC.

The next set of questions is about your program background and overall set-up. All information is important, and we appreciate your time and effort in completing this survey. However, we understand if you cannot answer some of these questions; in these situations, you have an option to select “don’t know” or “refuse to answer” responses, whichever best applies.

S_TIME1	Automatic hidden variable: Respondent start time
	Respondent start time
	__ : __

PC1.	Was your program operated by a… Select all that apply.
OPBY	Program operator
	Community-based organization
	City health department
	County health department
	State health department
	Health care organization
	Academic institution or hospital
	Volunteers only
	Other (please specify)
	Refuse to Answer	7

Check_PC1spec.

If R selected ‘Other (please specify)’ (PC1(7) [OPBY(7)] EQ 1), go to PC1spec [OPBY_S]. Else, go to PC2 [SFUND].

PC1spec.	Specify other program operator.
OPBY_S	Specify other program operator
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

PC2.	What were your program’s sources of funding? Select all that apply.
SFUND	Sources of funding
	City government
	County government
	State government
	Federal government
	Non-profit foundation/organization
	Individual donations
	Personal funds from program managers or staff
	Corporate donation
	Other (please specify)
	Don’t Know	99
	Refuse to Answer	77

Check_PC2spec.

If R selected ‘Other (please specify)’ (PC2(9) [SFUND(9)] EQ 1), go to PC2spec [SFUND_S]. Else, go to PC3 [BUDGET].

PC2spec.	Specify other source of funding.
SFUND_S	Specify other funding source
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

PC3.		What was your total program budget? If your program is part of a larger, multi-service organization, please only provide the budget for your part of the program. Please provide the best estimate to your knowledge.
BUDGET		Total program budget
		Less than $25,000	1
		$25,000–$100,000	2
		$100,001–$250,000	3
		$250,001–$500,000	4
		$500,001–$1 million	5
		Between $1 million and $2 million	6
		$2 million or more	7
		Don’t Know	99
		Refuse to Answer	77

PC4.	Did your program employ any full-time paid staff (that is, those working 30 hours per week or more)?
FTSTAF	Full-time paid staff
	No	0
	Yes	1
	Refuse to Answer	7

PC5.	Did your program have any paid employees who formerly or currently injected drugs? Include paid outreach workers and those paid with stipends or salaries.
PWIDST	Current or former PWID staff
	No	0
	Yes	1
	Don’t Know……………………………………………………………………………….	9
	Refuse to Answer	7

PC6.	Did your program have any volunteers who formerly or currently injected drugs? Include outreach volunteers.
PWIDVL	Current or former PWID volunteers
	No	0
	Yes	1
	Don’t Know……………………………………………………………………………….	9
	Refuse to Answer	7

PC7.		What were your program’s total hours of operation in a typical week? If your program had more than one location (including mobile locations), consider the hours of operation for the overall program. For example, if your program had 3 locations, and each was open from 1-5pm for 5 days per week, that would be 20 hours, not 60 hours, of overall coverage for that week. If you do not know or prefer not to answer, you may leave the response blank.
NUMHRS		Number of hours per week
		__ __ __
		Range	0-168

INTRO_GEO.

To help us understand geographic coverage of syringe services programs, please enter the state and county(ies) where your program operates. If your program has multiple locations, please list counties for all locations. Please also consider mobile units in your responses.

PC8a.	Please specify the state(s) or territory(ies) where your program is located: Select all that apply.
SSPSTAT	State(s) or territory(ies)
	Alabama	01
	Alaska	02
	Arizona	04
	Arkansas	05
	California	06
	Colorado	08
	Connecticut	09
	Delaware	10
	District of Columbia	11
	Florida	12
	Georgia	13
	Hawaii	15
	Idaho	16
	Illinois	17
	Indiana	18
	Iowa	19
	Kansas	20
	Kentucky	21
	Louisiana	22
	Maine	23
	Maryland	24
	Massachusetts	25
	Michigan	26
	Minnesota	27
	Mississippi	28
	Missouri	29
	Montana	30
	Nebraska	31
	Nevada	32
	New Hampshire	33
	New Jersey	34
	New Mexico	35
	New York	36
	North Carolina	37
	North Dakota	38
	Ohio	39
	Oklahoma	40
	Oregon	41
	Pennsylvania	42
	Puerto Rico	72
	Rhode Island	44
	South Carolina	45
	South Dakota	46
	Tennessee	47
	Texas	48
	US Virgin Islands	78
	Utah	49
	Vermont	50
	Virginia	51
	Washington	53
	West Virginia	54
	Wisconsin	55
	Wyoming	56
	Refuse to Answer	77

PC8b.	In which counties does your program provide services? Please include brick and mortar locations, mobile services, deliveries, and other ways you provide services. If you do not know or prefer not to answer, you may leave the response blank.
SSPCNTY	County(ies)
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 255}

PC9.	Did your program serve communities that you would consider urban, suburban, or rural? Please consider all the locations in which your program operates and select all that apply.
SRVAREA	Service area type
	Urban
	Suburban
	Rural
	Refuse to Answer	7

PC10.	How did your program deliver services? If your program had more than one location or service delivery type, select all that apply.
SDELIV	Service delivery type
	Brick and mortar building/storefront
	Mobile unit, such as an RV, van, or car
	Tent or outdoor area
	Home delivery
	“Backpack” delivery
	Mail order
	Syringe vending machine
	Other (please describe)
	Don’t Know	99
	Refuse to Answer	77

Check_PC10spec.

If R selected ‘Other (please describe)’ (PC10(8) [SDELIV(8)] EQ 1), go to PC10spec [SDELIV_S]. Else, go to PC11 [DSRPT].

PC10spec.	Specify other service delivery type.
SDELIV_S	Specify other service delivery type
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

PC11.	Did your program have to stop providing services for any period of time between January 1, [YEAR], and December 31, [YEAR] (that is, you did not provide services for at least one day or more when you had expected to be open)?
DSRPT	Stop providing services
	No	0
	Yes	1
	Don’t Know	9
	Refuse to Answer	7

Check_PC12.

If R had to stop providing services (PC11 [DSRPT] EQ 1), go to PC12 [WHYDSRP]. Else, go to PC13 [INEVAL].

PC12.	Please choose the reason(s) for the disruption. Select all that apply.
WHYDSRP	Why services disrupted
	Inadequate funding for materials or supplies
	Inadequate funding for operations
	Lack of personnel to staff the program
	Legal or political intervention
	COVID-19 pandemic
	Other (please describe)
	Don’t Know	9
	Refuse to Answer	7

Check_PC12spec.

If R selected ‘Other (please describe)’ (PC12(6) [WHYDSRP(6)] EQ 1), go to PC12spec [WHYDSRP_S]. Else, go to PC13 [INEVAL].

PC12spec.	Specify other reason for disruption(s) to services.
WHYDSRP_S	Specify other disruption
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

PC13.	Did your program review your program’s data for monitoring or evaluation purposes between January 1, [YEAR], and December 31, [YEAR]?
INEVAL	Did program review internal data
	No	0
	Yes	1
	Refuse to Answer	7

PC14.	What computer software program did you use to manage your program’s data? Select all that apply.
SFTWR	Software to manage client data
	None
	Excel
	Access
	Neo360
	REDCap
	Qualtrics
	SurveyMonkey
	Other (please describe)
	Refuse to Answer	77

Check_PC14spec.

If R selected ‘Other (please describe)’ (PC14 [SFTWR] EQ 8), go to PC14spec [SFTWR_S]. Else, go to PC15 [UNIQID].

PC14spec.	Specify other software used to manage client data.
SFTWR_S	Specify other software
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

PC15.	Did your program assign each client a unique ID?
UNIQID	Did program assign unique ID
	No	0
	Yes	1
	Refuse to Answer	7

PC16.		How many unique clients did your program serve? Please provide the best estimate to your knowledge. If you do not know or prefer not to answer, you may leave the response blank.
NUMCLI		Number of unique clients
		__ __ __ __ __ __ __ __
		Range	0-99999999

PC17.	Did your program have residency restrictions on who could access services, that is, only people from certain geographic locations could receive services from your program?
RESRSTR	Residency restrictions
	No	0
	Yes	1
	Don’t Know	9
	Refuse to Answer	7

PC18.	Did your program require clients to provide identifying documents (for example, a driver’s license) to enroll or receive services?
IDDOC	Require identifying documents
	No	0
	Yes	1
	Don’t Know	9
	Refuse to Answer	7

CLIENT CHARACTERISTICS

INTRO_CC.

The next questions are about the characteristics of the clients served by your program. As a reminder, as you answer these questions, please think about your program’s operations between January 1, [YEAR], and December 31, [YEAR].

CC1.	Which demographic groups did your program reach in [YEAR]? Select all that apply.
DEMSRV	Demographic groups served
	Cisgender women
	Cisgender men
	Transgender women
	Transgender men
	Genderqueer/non-binary persons
	American Indian or Alaska Native persons
	Asian persons
	Black or African American persons
	Hispanic or Latinx persons
	Native Hawaiian or Other Pacific Islander persons
	White persons
	Persons aged <18 years
	Persons aged 18 to 29 years
	Persons aged 30 to 39 years
	Persons aged ≥40 years
	Lesbian, gay, bisexual, or queer persons
	Other (please describe)
	Refuse to Answer	77

Check_CC1spec.

If R selected ‘Other (please describe)’ (CC1 [DEMSRV] EQ 16), go to CC1spec [DEMSRV_S]. Else, go to CC2 [DEMRCH].

CC1spec.	Specify other demographic group reached.
DEMSRV_S	Specify other group
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

CC2.	Which demographic groups in your community did your program have difficulty reaching in [YEAR]? Select all that apply.
DEMRCH	Difficulty reaching demographic groups
	Cisgender men
	Cisgender women
	Transgender men
	Transgender women
	Genderqueer/non-binary persons
	American Indian or Alaska Native persons
	Asian persons
	Black or African American persons
	Hispanic or Latinx persons
	Native Hawaiian or Other Pacific Islander persons
	White persons
	Persons aged <18 years
	Persons aged 18 to 29 years
	Persons aged 30 to 39 years
	Persons aged ≥40 years
	Lesbian, gay, bisexual, or queer persons
	Other (please describe)
	Refuse to Answer	77

Check_CC2spec.

If R selected ‘Other (please describe)’ (CC2 [DEMRCH] EQ 16), go to CC2spec [DEMRCH_S]. Else, go to CC3 [DEMRCH].

CC2spec.	Specify other demographic group your program had difficulty reaching.
DEMRCH_S	Specify other group
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

CC3.		Approximately what percentage of your clients did not have health insurance? Please use your records if available but provide your best estimate if no records are kept or are not readily available.
INSUR		Client insurance
		Less than 25%	1
		25-50%	2
		51-75%	3
		More than 75%	4
		Don’t Know	9
		Refuse to Answer	7

CC4.		For each of the following substances, please indicate the approximate percentage of your clients who were injecting each substance on a weekly or more frequent basis. Please use your records if available but provide your best estimate if no records are kept or are not readily available.
INJDRUG		Substances injected by clients
			None	Less than 25%	25-50%	51-75%		More than 75%	Don’t Know	Refuse to Answer
	INJDRUGA	Heroin, by itself
	INJDRUGB	Speedball, which is heroin and cocaine together
	INJDRUGC	Goofball, which is heroin and methamphetamine together
	INJDRUGD	Methamphetamine, by itself, also known as meth or speed
	INJDRUGE	Fentanyl, by itself or in combination with other drugs
	INJDRUGF	Powder cocaine, by itself
	INJDRUGG	Crack cocaine, by itself
	INJDRUGH	Painkillers, such as Oxycontin, Dilaudid, or Percocet
	INJDRUGI	Benzodiazepines or other downers, such as Valium, Xanax, or Klonopin
	INJDRUGJ	Other 1 (please describe)
	INJDRUGK	Other 2 (please describe)
	INJDRUGL	Other 3 (please describe)

Check_CC4specA.

If R selected ‘Other 1 (please describe)’ (CC4 [INJDRUGJ]), go to CC4specA [INJDRUGJ_S]. Else, go to Check_CC4specB.

CC4specA.	From the previous question, specify ‘Other 1’ substance injected by clients.
INJDRUGJ_S	Specify other substance injected
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

Check_CC4specB.

If R selected ‘Other 2 (please describe)’ (CC4 [INJDRUGK]), go to CC4specB [INJDRUGK_S]. Else, go to Check_CC4specC.

CC4specB.	From the previous question, specify ‘Other 2’ substance injected by clients.
INJDRUGK_S	Specify other substance injected
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

Check_CC4specC.

If R selected ‘Other 3 (please describe)’ (CC4 [INJDRUGL]), go to CC4specC [INJDRUGL_S]. Else, go to INTRO_CR.

CC4specC.	From the previous question, specify ‘Other 3’ substance injected by clients.
INJDRUGL_S	Specify other substance injected
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

COMMUNITY RELATIONS AND CHALLENGES

INTRO_CR.

The next questions are about your program’s relationships with members of the community and any related challenges. As a reminder, as you answer these questions, please think about your program’s operations between January 1, [YEAR], and December 31, [YEAR].

CR1.	Which individuals or types of organizations advocated for your program or provided any type of support? Select all that apply.
SUPADV	Sources of support or advocacy
	Local health officials
	Law enforcement
	HIV or other medical providers
	Religious organizations
	Local politicians
	Local residents
	Drug user unions
	Other community-based organizations
	Other (please describe)
	No advocate support
	Refuse to Answer	77

Check_CR1spec.

If R selected ‘Other (please describe)’ (CR1(8) [SUPADV(8)] EQ 1), go to CR1spec [SUPADV_S]. Else, go to CR2 [CHLNG].

CR1spec.	Specify other source of support
SUPADV_S	Specify other source of support
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

CR2.	What types of external challenges did your program face, not including challenges related to funding? Select all that apply.
ECHLNG	Types of external challenges
	Limited/no law enforcement support
	Active police harassment/arrest of program clients
	Program operations disrupted by government or law enforcement
	Local policy/law that restricts program services
	Lack of support from local health officials
	Lack of community support
	Active community harassment
	COVID-19 pandemic
	Other (please describe)
	Did not face external challenges
	Refuse to Answer	77

Check_CR2spec.

If R selected ‘Other (please describe)’ (CR2(9) [ECHLNG(9)] EQ 1), go to CR2spec [ECHLNG_S]. Else, go to CR3 [ICHLNG].

CR2spec.	Specify other external challenges
ECHLNG_S	Specify other external challenges
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 255}

CR3.	What types of internal challenges did your program face? Select all that apply.
ICHLNG	Types of internal challenges
	Staff burnout
	Staff shortage
	Limited/no funding
	Limited/no resources or supplies (other than funding)
	Other (please describe)
	Did not face internal challenges
	Refuse to Answer	77

Check_CR3spec.

If R selected ‘Other (please describe)’ (CR3(5) [ICHLNG(5)] EQ 1), go to CR3spec [ICHLNG_S]. Else, go to CR4 [RLHO].

CR3spec.	Specify other internal challenges
ICHLNG_S	Specify other internal challenges
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 255}

CR4.	How would you describe your program’s relationship with your local health department(s)?
RLHO	Relationship with local health officials
	Very good	1
	Somewhat good	2
	Neither good nor poor	3
	Somewhat poor	4
	Very poor	5
	Nonexistent	6
	Refuse to Answer	7

CR5.	How would you describe your program’s relationship with law enforcement?
RLAW	Relationship with law enforcement
	Very good	1
	Somewhat good	2
	Neither good nor poor	3
	Somewhat poor	4
	Very poor	5
	Nonexistent	6
	Refuse to Answer	7

SYRINGE COLLECTION, DISTRIBUTION, AND DISPOSAL

INTRO_SYR.

The next set of questions pertain to syringe services provided by your program between January 1, [YEAR], and December 31, [YEAR].

SYR1.		How many total sterile syringes did your program provide to clients? Please provide your best estimate if records are not readily available. If you do not know or prefer not to answer, you may leave the response blank.
NUMSYR		Number of sterile syringes provided
		__ __ __ __ __ __ __
		Range	0-9999999

SYR2.	Did your program provide syringes to clients based on the clients’ needs, without any restrictions?
CLINEED	Needs-based provision of syringes
	No	0
	Yes	1
	Refuse to Answer	7

SYR3.	Did your program provide clients with extra syringes to distribute to other people in the community (i.e., secondary exchange or peer delivery)?
SECXCHNG	Secondary exchange
	No	0
	Yes	1
	Refuse to Answer	7

Check_SYR4.

If R selected ‘Yes’ (SYR3 [SECXCHNG] EQ 1), go to SYR4 [SETRAIN]. Else, go to INTRO_PN.

SYR4.	Did your program provide training or other support for clients to distribute new, sterile syringes to others (i.e., secondary exchange) and/or facilitate syringe disposal?
SETRAIN	Secondary exchange training
	No	0
	Yes	1
	Refuse to Answer	7

PROVISION OF NALOXONE AND OTHER OVERDOSE REVERSAL MEDICATIONS

INTRO_PN.

In this section, we will ask you about overdose prevention services your program may have provided, such as overdose prevention training and naloxone distribution. As a reminder, we are asking about services provided by your program between January 1, [YEAR], and December 31, [YEAR].

PN1.	What overdose prevention or treatment services did your program provide? Select all that apply.
WHATOD	What OD prevention or treatment services provided
	None
	Naloxone kits
	Naloxone prescription
	Fentanyl test strips
	Overdose prevention and response training for opioids
	Overdose prevention and response training for drugs other than opioids (e.g., cocaine, methamphetamine)
	Refuse to Answer	77

Check_PN2.

If R provided naloxone kits (PN1 [WHATOD] EQ 1), go to PN2 [NALKIT]. Else, go to INTRO_PS1.

PN2.		How many naloxone kits were distributed by your program? Please provide the number of kits distributed regardless of how many doses were contained in each kit. If your program does not collect these data, please provide your best estimate. If you do not know or prefer not to answer, you may leave the response blank.
NALKIT		Number of naloxone kits distributed
		__ __ __ __
		Range	0-9999

PN3.		How many doses were distributed in each naloxone kit by your program? If you do not know or prefer not to answer, you may leave the response blank.
NALDOS		Number of doses distributed in each naloxone kit
		__ __
		Range	1-99

PN4.	In what ways did your program distribute naloxone kits? Select all that apply.
NALDIS	How distributed naloxone
	Direct distribution from staff to client
	In-person delivery (kit delivered directly to client)
	Mail delivery (kit mailed to client)
	Secondary distribution (client distributes kit to peers)
	Provider referral for prescription or referral to pharmacy
	Offered at community-based overdose education events (open to the public)
	Offered at overdose education events for staff or clients of other organizations
	Refuse to Answer	7

PN5.	What barriers, if any, did your program experience in providing naloxone to your clients? Select all that apply.
BARNAL	Barriers to providing naloxone
	No barriers
	High cost of naloxone
	Shortage of naloxone
	Legal/political climate
	Other (please describe)
	Don’t Know	9
	Refuse to Answer	7

Check_PN5spec.

If R selected ‘Other (please describe)’ (PN5(5) [BARNAL(5)] EQ 1), go to PN5spec [BARNAL_S]. Else, go to INTRO_PS1.

PN5spec.	Specify other barrier in providing naloxone
BARNAL_S	Specify other barrier in providing naloxone
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 255}

PROVISION OF SERVICES

INTRO_PS1.

The next set of questions are about the services your program provided or needed between January 1, [YEAR], and December 31, [YEAR]. This information will help us understand the services that programs are already providing, trying to expand, or adding to meet client needs. Please indicate next to each service whether your program 1) fully provided the service (that is, the service was provided at a level that fully met client needs), 2) partially provided the service (that is, the service was provided inconsistently or at a level that did not meet client needs), 3) did not provide the service and was not able to meet client needs, or 4) did not provide the service and most clients did not need the service. If service provision varied between January 1, [YEAR], and December 31, [YEAR], choose the option that best describes the provision of services during the majority of time during this period.

PS1.		For each of the following safer injection and drug use supplies, please indicate the extent to which the supply was provided.
INJSUP		Safer injection and drug use supplies
			Fully provided	Partially provided	Not providedbut needed		Not provided and not needed	Refuse to Answer/ Not Applicable
	INJSUPA	Syringes
	INJSUPB	Cookers
	INJSUPC	Cottons
	INJSUPD	Syringe/pill filters like Sterifilt®
	INJSUPE	Saline or sterile water
	INJSUPF	Ties/tourniquets
	INJSUPG	Alcohol pads
	INJSUPH	Wound care kits
	INJSUPI	Sharps containers for carrying used syringes
	INJSUPJ	Fentanyl test strips
	INJSUPK	Safer smoking kits
	INJSUPL	Other (please describe)

Check_PS1spec.

If R selected ‘Other (please describe)’ (PS1 [INJSUPL]), go to PS1spec [INJSUP_S]. Else, go to PS2 [SEXSUP].

PS1spec.	Specify other injection and drug use supplies
INJSUP_S	Specify other injection and drug use supplies
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

PS2.		For each of the following safer sex supplies, please indicate the extent to which the supply was provided.
SEXSUP		Safer sex supplies
			Fully provided	Partially provided	Not providedbut needed		Not provided and not needed	Refuse to Answer
	SEXSUPA	External condoms (male condoms)
	SEXSUPB	Internal condoms (female condoms)
	SEXSUPC	Lubricant
	SEXSUPD	Dental dams

PS3.		For each of the following testing services, please indicate the extent to which the service was provided onsite, either by the program itself or by partners, at the location(s) where your program operated.
ONTEST		Onsite testing services
			Fully provided	Partially provided	Not provided but needed		Not provided and not needed	Refuse to Answer/ Not Applicable
	ONTESTA	HIV rapid testing
	ONTESTB	HIV laboratory-based testing
	ONTESTC	Hepatitis C virus (HCV) rapid testing
	ONTESTD	Hepatitis C virus (HCV) laboratory-based testing
	ONTESTE	STI testing other than hepatitis or HIV
	ONTESTF	TB skin testing or laboratory-based screening for latent TB
	ONTESTG	Pregnancy testing
	ONTESTH	COVID-19 testing
	ONTESTI	Other (please describe)

Check_PS3spec.

If R selected ‘Other (please describe)’ (PS3 [ONTESTI]), go to PS3spec [ONTEST_S]. Else, go to PS4 [ONVAX].

PS3spec.	Specify other onsite testing service
ONTEST_S	Specify other testing
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

PS4.		For each of the following vaccinations, please indicate the extent to which the service was provided onsite, either by the program itself or by partners, at the location(s) where your program operated.
ONVAX		Onsite vaccinations
			Fully provided	Partially provided	Not provided but needed		Not provided and not needed	Refuse to Answer/ Not Applicable
	ONVAXA	Hepatitis A vaccination
	ONVAXB	Hepatitis B vaccination
	ONVAXC	Influenza vaccination
	ONVAXD	COVID-19 vaccination
	ONVAXE	Other (please describe)

Check_PS4spec.

If R selected ‘Other (please describe)’ (PS4 [ONVAXE]), go to PS4spec [ONVAX_S]. Else, go to PS5 [ONMED].

PS4spec.	Specify other vaccination
ONVAX_S	Specify other vaccination
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

PS5.		For each of the following medications, please indicate the extent to which the medication was prescribed and/or dispensed onsite, either by the program itself or by partners, at the location(s) where your program operated.
ONMED		Onsite medications
			Fully provided	Partially provided	Not provided but needed		Not provided and not needed	Refuse to Answer/ Not Applicable
	ONMEDA	HIV treatment
	ONMEDB	PrEP (pre-exposure prophylaxis)
	ONMEDC	PEP (post-exposure prophylaxis)
	ONMEDD	Hepatitis C treatment
	ONMEDE	STI treatment other than hepatitis or HIV
	ONMEDF	Medications for opioid use disorder (MOUD)
	ONMEDG	Medications for non-opioid substance use disorders
	ONMEDH	Medications for mental health disorders
	ONMEDI	Other (please describe)

Check_PS5spec.

If R selected ‘Other (please describe)’ (PS5 [ONMEDI]), go to PS5spec [ONMED_S]. Else, go to Check_PS6.

PS5spec.	Specify other medication
ONMED_S	Specify other medication
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

Check_PS6.

If R provided MOUD (PS5 [ONMEDF] EQ “Fully provided” OR “Partially provided”), go to PS6 [MOUD_S]. Else, go to PS7 [ONMSRV].

PS6.	You indicated that your program provided onsite medications for opioid use disorders (MOUD) between January 1, [YEAR], and December 31, [YEAR]. Which of the following MOUD did your program provide onsite, either by the program itself or by partners, at the location(s) where your program operated? Select all that apply.
MOUD_S	Which MOUD provided
	Buprenorphine/naloxone (Suboxone)
	Buprenorphine (Subutex)
	Methadone
	Naltrexone (Vivitrol)
	Other (please describe)
	Refuse to Answer	7

Check_PS6spec.

If R selected ‘Other (please describe)’ (PS6 [MOUD_S]), go to PS6spec [MOUD_SS]. Else, go to PS7 [ONMSRV].

PS6spec.	Specify other MOUD
MOUD_SS	Specify other MOUD
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

PS7.		For each of the following other medical services, please indicate the extent to which the service was provided onsite, either by the program itself or by partners, at the location(s) where your program operated.
ONMSRV		Other onsite medical services
			Fully provided	Partially provided	Not provided but needed		Not provided and not needed	Refuse to Answer/ Not Applicable
	ONMSRVA	Substance use disorder treatment services (excluding medications)
	ONMSRVB	Wound care/treatment
	ONMSRVC	Mental health services (excluding medications) provided by a licensed physician, psychologist, nurse practitioner, or social worker
	ONMSRVD	General medical care (primary care or urgent care)
	ONMSRVE	Reproductive health care excluding STI testing (e.g., pap smears)
	ONMSRVF	Family planning, contraception, or prenatal care
	ONMSRVG	Other (please describe)

Check_PS7spec.

If R selected ‘Other (please describe)’ (PS7 [ONMSRVG]), go to PS7spec [ONMSRV_S]. Else, go to PS8 [CPNAV].

PS7spec.	Specify other onsite medical services
ONMSRV_S	Specify other onsite medical services
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

PS8.	Did your program provide client navigation services/peer navigation? Client/peer navigation provides individualized support for program clients in accessing and sustaining engagement with health and other services.
CPNAV	Did program provide client/peer navigation services
	No	0
	Yes	1
	Refuse to Answer	7

Check_PS9.

If R provided client/peer navigation services (PS8) [CPNAV] EQ 1), go to PS9 [CPNAV_S]. Else, go to PS10 [SOCSRV].

PS9.	What services were covered by your client navigation/peer navigation program? Select all that apply.
CPNAV_S	Client/peer navigation services
	HIV care
	PrEP (pre-exposure prophylaxis for HIV prevention)
	HCV care
	Medications for opioid use disorder (MOUD)
	Medications for non-opioid substance use disorders
	Legal records (e.g., birth certificate, social security card, state ID/driver’s license)
	Medicaid or other health insurance
	Social support services (e.g., housing)
	Refuse to Answer	77

PS10.		For each of the following social and other services, please indicate the extent to which the service was provided.
SOCSRV		Social and other services
			Fully provided	Partially provided	Not provided but needed		Not provided and not needed	Refuse to Answer/ Not Applicable
	SOCSRVA	Case management
	SOCSRVB	Childcare
	SOCSRVC	Drop-in center
	SOCSRVD	Enrollment in Medicaid or other health insurance
	SOCSRVE	Family violence, domestic violence, or intimate partner violence services
	SOCSRVF	Food/meals, including SNAP, WIC, food pantries, or meal delivery services
	SOCSRVG	Housing support
	SOCSRVH	Hygiene-related services (e.g., laundry, showers)
	SOCSRVI	Job-related services (e.g., placement assistance, skills training)
	SOCSRVJ	Legal services/counseling
	SOCSRVK	Substance use counseling provided by certified addiction counselors or other recovery support services
	SOCSRVL	Other (please describe)

Check_PS10spec.

If R selected ‘Other (please describe)’ (PS10) [SOCSRVL]), go to PS10spec [SOCSRV_S]. Else, go to INTRO_PS2.

PS10spec.	Specify other social service
SOCSRV_S	Specify other social service
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

INTRO_PS11.

The next questions pertain to referrals provided by your program between January 1, [YEAR], and December 31, [YEAR]. By “referral,” we mean directing clients to specific offsite providers where they can receive specific services.

PS11.	What types of referrals to testing services did your program provide? Select all that apply.
REFTEST	Testing referrals
	No testing referrals provided
	HIV testing
	Hepatitis C virus (HCV) testing
	STI testing other than hepatitis or HIV
	TB skin testing or laboratory-based screening for latent TB
	Pregnancy testing
	COVID-19 testing
	Other (please describe)
	Refuse to Answer	77

Check_PS11spec.

If R selected ‘Other (please describe)’ (PS11(8) [REFTEST(8)] EQ 1), go to PS11spec [REFTEST_S]. Else, go to PS12 [RCOVAX].

PS11spec.	Specify other testing referral
REFTEST_S	Specify other testing referral
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

PS12.	What types of referrals for vaccinations did your program provide? Select all that apply.
REFVAX	Vaccination referral
	No vaccination referrals provided
	Hepatitis A vaccination
	Hepatitis B vaccination
	Influenza vaccination
	COVID-19 vaccination
	Other (please describe)
	Refuse to Answer	77

Check_PS12spec.

If R selected ‘Other (please describe)’ (PS12(6) [REFVAX(6)] EQ 1), go to PS12spec [REFVAX_S]. Else, go to PS13 [REFMED].

PS12spec.	Specify other vaccination referral
REFVAX_S	Specify other vaccination referral
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

PS13.	What types of referrals to treatment did your program provide? Select all that apply.
REFMED	Referrals to treatment
	No treatment referrals provided
	HIV treatment
	PrEP (pre-exposure prophylaxis)
	PEP (post-exposure prophylaxis)
	Hepatitis C treatment
	STI treatment other than hepatitis or HIV
	Buprenorphine (including Suboxone or Subutex)
	Medications for opioid use disorder (MOUD) other than buprenorphine
	Naloxone
	Medications for non-opioid substance use disorders
	Medications for mental health disorders
	Other (please describe)
	Refuse to Answer	77

Check_PS13spec.

If R selected ‘Other (please describe)’ (PS13(12) [REFMED(12)] EQ 1), go to PS13spec [REFMED_S]. Else, go to PS14 [RMSRV].

PS13spec.	Specify other treatment referral
REFMED_S	Specify other treatment referral
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

PS14.	What types of referrals to other medical services did your program provide? Select all that apply.
RMSRV	Other medical services referrals
	No referrals to other medical services provided
	Substance use disorder treatment services (excluding medications)
	Wound care/treatment
	Mental health services (excluding medications) provided by a licensed physician, psychologist, nurse practitioner, or social worker
	General medical care (primary care or urgent care)
	Reproductive health care excluding STI testing (e.g., pap smears)
	Family planning, contraception, or prenatal care
	Other (please describe)
	Refuse to Answer	77

Check_PS14spec.

If R selected ‘Other (please describe)’ (PS14(8) [RMSRV(8)] EQ 1), go to PS14spec [RMSRV_S]. Else, go to INTRO_PE.

PS14spec.	Specify other medical services referrals
RMSRV_S	Specify other medical services referrals
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

PROCESS EVALUATION

INTRO_PE.

We value your input and would like to ask you a few questions about your experience taking this survey so that we can improve it and ensure that the information you provide is useful.

PE1.	The length of the survey was…
SLNGTH	Survey length
	Too short	1
	Just right	2
	Too long	3
	Refuse to Answer	7

PE2.	If you were taking the survey again, what format would you prefer? Select only one.
PREFMT	Preferred survey format
	Self-administered online	1
	Self-administered via an electronic document (Word or PDF) that can be completed and returned by email	2
	Interviewer-administered to me over the phone	3
	Interviewer-administered to me in person	4
	Refuse to Answer	7

PE3.	What topic(s) were missing from this survey and need to be added in the future?
MISTOP	Missing topics
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 255}

PE4.	How would you like to see this information used? Select all that apply.
HOWUSE	How this information used
	Increase awareness
	Increase community support
	Increase funding
	Inform policy/law
	Other (please describe)
	Refuse to Answer	7

Check_PE4spec.

If R selected ‘Other (please describe)’ (PE4(5) [HOWUSE(5)] EQ 1), go to PE4spec [HOWUSE_S]. Else, go to PE5 [OTHSUG].

PE4spec.	Specify other use for this information
HOWUSE_S	Specify other use for this information
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 100}

PE5.	Please use the space below for any other suggestions or comments for improving this survey to make it useful to programs.
OTHSUG	Other suggestions or comments
	__ __ __ __ __ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __ __ ____ __ __ __ ____ __ __ __ ____ __ __ __
	{text response; max characters = 255}

DATA_PE.

You have now completed the survey. Thank you so much for your participation. Once you submit your survey, you will not be able to go back to previous questions or change any of your answers, so please make sure you are ready before proceeding.   Before we end, we would like to document your preference on how information about your program is shared with others aside from the survey team. Others could include, for example, researchers, health department staff, and other syringe services programs. The survey team includes staff at the North American Syringe Exchange Network (NASEN), the University of Washington (UW), New York University (NYU), and the Centers for Disease Control and Prevention (CDC). As a reminder, data from this survey will only be reported in aggregate (that is, your responses will be grouped with those from other programs) in formats like presentations, publications and reports. Program names and any other information that could potentially identify a program, such as the state or county where a program operates, will never be reported.

PE6.	Would you be willing to share your data with others aside from the survey team? Please remember that identifying information will never be reported.
DATASHR	Individual data sharing preference
	No, data cannot be shared	0
	Yes, data can be shared	1

CALC_EDATE	Automatic, hidden variable: Interview end date (today)
EDATE	End date
	_ _ / _ _ / _ _ _ _

CALC_END	End time of interview
END	End time
	__ : __