Form 0920-21DC Survey Year Two/Three

National Syringe Services Program (SSP) Evaluation

Attachment 8_Survey_Year 2 and 3

National Syringe Services Program Evaluation

OMB: 0920-1359

Document [docx]
Download: docx | pdf

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































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




Shape3 Shape2 Shape1

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



__ : __







File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorPitasi, Marc (CDC/DDID/NCHHSTP/DHPSE)
File Modified0000-00-00
File Created2022-03-02

© 2024 OMB.report | Privacy Policy