Screenshots Survey Year One

Confidential

Page 1

Dave Purchase Memorial Survey

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).

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.
PI1. Are you completing this survey by yourself or by
speaking with an interviewer?

__________________________________
(Must be 4 digits.)

Completing survey myself
Completing survey with interviewer

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.
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].
Automatic, hidden variable: Survey date (today)

Automatic, hidden variable: Start time of survey

01/29/2021 1:08pm

__________________________________

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PI2. What is the name of your program?

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.

PI3b. Enter the year. If you do not remember the
exact year, please provide your best estimate.
Please enter four digits.

__________________________________
(IF REFUSED, LEAVE BLANK.)
January
February
March
April
May
June
July
August
September
October
November
December
Don't Know
Refuse to Answer

__________________________________
(IF REFUSED OR DON'T KNOW, LEAVE BLANK.)

Error Message: "The year the program started is later than [year]. Please confirm that this year is accurate."
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]?

Yes
No

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.
Automatic hidden variable: Respondent start time

PC1. Was your program operated by a... Select all
that apply.

PC1spec. Specify other program operator.

01/29/2021 1:08pm

__________________________________
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

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PC2. What were your program's sources of funding?
Select all that apply.

PC2spec. Specify other source 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
Refuse to Answer

__________________________________

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.

Less than $25,000
$25,000-$100,000
$100,001-$250,000
$250,001-$500,000
$500,001-$1 million
Between $1 million and $2 million
$2 million or more
Don't Know
Refuse to Answer

PC4. Did your program employ any full-time paid staff
(that is, those working 30 hours per week or more)?

No
Yes
Refuse to Answer

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.

No
Yes
Don't Know
Refuse to Answer

PC6. Did your program have any volunteers who
formerly or currently injected drugs? Include
outreach volunteers.

No
Yes
Don't Know
Refuse to Answer

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.

__________________________________

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.

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PC8a. Please specify the state or territory where
your program is located: Select all that apply.

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.

01/29/2021 1:08pm

Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
US Virgin Islands
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Refuse to Answer

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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.

Urban
Suburban
Rural
Refuse to Answer

PC10. How did your program deliver services? If your
program had more than one location or service
delivery type, select all that apply.

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
Refuse to Answer

PC10spec. Specify other service delivery type.

__________________________________

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)?

No
Yes
Don't Know
Refuse to Answer

PC12. Please choose the reason(s) for the disruption.
Select all that apply.

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
Refuse to Answer

PC12spec. Specify other reason for disruption(s) to
services.

__________________________________

PC13. Did your program review your program's data for
monitoring or evaluation purposes between January 1,
[year], and December 31, [year]?

No
Yes
Refuse to Answer

PC14. What computer software program did you use to
manage your program's data? Select all that apply.

None
Excel
Access
Neo360
REDCap
Qualtrics
SurveyMonkey
Other (please describe)
Refuse to Answer

PC14spec. Specify other software used to manage
client data.
PC15. Did your program assign each client a unique
ID?

01/29/2021 1:08pm

__________________________________
No
Yes
Refuse to Answer

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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.

__________________________________

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?

No
Yes
Don't Know
Refuse to Answer

PC18. Did your program require clients to provide
identifying documents (for example, a driver's
license) to enroll or receive services?

No
Yes
Don't Know
Refuse to Answer

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
provide services to in [year]? Select all that apply.

CC1spec. Specify other demographic group served.

01/29/2021 1:08pm

Cisgender men
Cisgender women
Transgender 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, or bisexual persons
Other (please describe)
None
Refuse to Answer

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CC2. Which demographic groups in your community did
your program have difficulty reaching in [year]?
Select all that apply.

CC2spec. Specify other demographic group your program
had difficulty reaching.
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.

01/29/2021 1:08pm

Cisgender men
Cisgender women
Transgender 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, or bisexual persons
Other (please describe)
None
Refuse to Answer

__________________________________
Less than 25%
25-50%
51-75%
More than 75%
Don't Know
Refuse to Answer

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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.
None

Less than
25%

25-50%

51-75%

More than
75%

Don't Know

Refuse to
Answer

Heroin, by itself
Speedball, which is heroin and
cocaine together
Goofball, which is heroin and
methamphetamine together
Methamphetamine, by itself,
also known as meth or speed
Fentanyl, by itself or in
combination with other drugs
Powder cocaine, by itself
Crack cocaine, by itself
Painkillers, such as Oxycontin,
Dilaudid, or Percocet
Benzodiazepines or other
downers, such as Valium, Xanax,
or Klonopin
Other 1 (please describe)
Other 2 (please describe)
Other 3 (please describe)
CC4specA. From the previous question, specify 'Other
1' substance injected by clients.

__________________________________

CC4specB. From the previous question, specify 'Other
2' substance injected by clients.

__________________________________

CC4specC. From the previous question, specify 'Other
3' substance injected by clients.

__________________________________

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.

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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

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CR1spec. Specify other source of support

CR2. What types of external challenges did your
program face, not including challenges related to
funding? Select all that apply.

CR2spec. Specify other external challenges

CR3. What types of internal challenges did your
program face? Select all that apply.

CR3spec. Specify other internal 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

__________________________________
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

__________________________________

CR4. How would you describe your program's
relationship with your local health department(s)?

Very good
Somewhat good
Neither good nor poor
Somewhat poor
Very poor
Nonexistent
Refuse to Answer

CR5. How would you describe your program's
relationship with law enforcement?

Very good
Somewhat good
Neither good nor poor
Somewhat poor
Very poor
Nonexistent
Refuse to Answer

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.
SYR2. Did your program provide syringes to clients
based on the clients' needs, without any restrictions?

01/29/2021 1:08pm

__________________________________

No
Yes
Refuse to Answer

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SYR3. Did your program provide clients with extra
syringes to distribute to other people in the
community (i.e., secondary exchange or peer delivery)?

No
Yes
Refuse to Answer

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?

No
Yes
Refuse to Answer

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.

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.
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.

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

__________________________________

__________________________________

PN4. In what ways did your program distribute
naloxone kits? Select all that apply.

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

PN5. What barriers, if any, did your program
experience in providing naloxone to your clients?
Select all that apply.

No barriers
High cost of naloxone
Shortage of naloxone
Legal/political climate
Other (please describe)
Don't Know
Refuse to Answer

PN5spec. Specify other barrier in providing naloxone

01/29/2021 1:08pm

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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.

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PS1. For each of the following safer injection and drug use supplies, please indicate the extent
to which the supply was provided.
Fully provided

Partially
provided

Not provided but Not provided and
needed
not needed

Syringes
Cookers
Cottons
Syringe/pill filters like Sterifilt®
Saline or sterile water
Ties/tourniquets
Alcohol pads
Wound care kits
Sharps containers for carrying
used syringes
Fentanyl test strips
Safer smoking kits
Other (please describe)
PS1spec. Specify other injection and drug use
supplies

01/29/2021 1:08pm

__________________________________

projectredcap.org

Refuse to
Answer

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PS2. For each of the following safer sex supplies, please indicate the extent to which the
supply was provided.
Fully provided

Partially
provided

Not provided but Not provided and
needed
not needed

External condoms (male
condoms)
Internal condoms (female
condoms)
Lubricant
Dental dams

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Answer

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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.
Fully provided

Partially
provided

Not provided but Not provided and
needed
not needed

HIV rapid testing
HIV laboratory-based testing
Hepatitis C virus (HCV) rapid
testing
Hepatitis C virus (HCV)
laboratory-based 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)
PS3spec. Specify other onsite testing service

01/29/2021 1:08pm

__________________________________

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Answer

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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.
Fully provided

Partially
provided

Not provided but Not provided and
needed
not needed

Hepatitis A vaccination
Hepatitis B vaccination
Influenza vaccination
COVID-19 vaccination
Other (please describe)
PS4spec. Specify other vaccination

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__________________________________

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Refuse to
Answer

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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.
Fully provided

Partially
provided

Not provided but Not provided and
needed
not needed

HIV treatment
PrEP (pre-exposure prophylaxis)
PEP (post-exposure prophylaxis)
Hepatitis C treatment
STI treatment other than
hepatitis or HIV
Medications for opioid use
disorder (MOUD)
Medications for non-opioid
substance use disorders
Medications for mental health
disorders
Other (please describe)
PS5spec. Specify other medication

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.

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__________________________________
Buprenorphine/naloxone (Suboxone)
Buprenorphine (Subutex)
Methadone
Naltrexone (Vivitrol)
Refuse to Answer

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Answer

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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.
Fully provided

Partially
provided

Not provided but Not provided and
needed
not needed

Refuse to
Answer

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)
PS7spec. Specify other onsite medical services

__________________________________

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.

No
Yes
Refuse to Answer

PS9. What services were covered by your client
navigation/peer navigation program? Select all that
apply.

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

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PS10. For each of the following social and other services, please indicate the extent to which
the service was provided.
Fully provided

Partially
provided

Not provided but Not provided and
needed
not needed

Refuse to
Answer

Case management
Childcare
Drop-in center
Enrollment in Medicaid or other
health insurance
Family violence, domestic
violence, or intimate partner
violence services
Food/meals, including SNAP,
WIC, food pantries, or meal
delivery services
Housing support
Hygiene-related services (e.g.,
laundry, showers)
Job-related services (e.g.,
placement assistance, skills
training)
Legal services/counseling
Substance use counseling
provided by certified addiction
counselors or other recovery
support services
Other (please describe)
PS10spec. Specify other social service

__________________________________

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.

PS11spec. Specify other testing referral

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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

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PS12. What types of referrals for vaccinations did
your program provide? Select all that apply.

PS12spec. Specify other vaccination referral

PS13. What types of referrals to treatment did your
program provide? Select all that apply.

PS13spec. Specify other treatment referral

PS14. What types of referrals to other medical
services did your program provide? Select all that
apply.

PS14spec. Specify other medical services referrals

No vaccination referrals provided
Hepatitis A vaccination
Hepatitis B vaccination
Influenza vaccination
COVID-19 vaccination
Other (please describe)
Refuse to Answer

__________________________________
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

__________________________________
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

__________________________________

Next, we would like to ask you a few questions about the services you provided in 2020.
MD1. Did your program provide any services at any
time between January 1, 2020, and December 31, 2020?

Yes
No

The next set of questions is about the services your program provided from January 1, 2020, to December 31, 2020.
To the extent possible, please refer to your records to answer these questions. If your program only operated during
some of this time period, please provide information reflective of the time period(s) during which your program did
operate.

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MD2. How many unique clients did your program serve
between January 1, 2020, and December 31, 2020?
Please provide the best estimate to your knowledge.
If you do not know or prefer not to answer, you may
leave the response blank.
MD3. Between January 1, 2020, and December 31, 2020,
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.

__________________________________

__________________________________

MD4. Between January 1, 2020, and December 31, 2020,
did your program provide syringes to clients based
on the clients' needs, without any restrictions?

No
Yes
Don't Know
Refuse to Answer

MD5. Did your program distribute naloxone kits
between January 1, 2020, and December 31, 2020?

No
Yes
Don't Know
Refuse to Answer

MD6. What was your total program budget between
January 1, 2020, and December 31, 2020? 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.

Less than $25,000
$25,000-$100,000
$100,001-$250,000
$250,001-$500,000
$500,001-$1 million
Between $1 million and $2 million
$2 million or more
Don't Know
Refuse to Answer

MD7. Which of the following testing services were
provided onsite, either by the program itself or by
partners, at the location(s) where your program
operated? Select all that apply.

No testing services were provided onsite
HIV rapid testing
HIV laboratory-based testing
Hepatitis C virus (HCV) rapid testing
Hepatitis C virus (HCV) laboratory-based testing
Don't Know
Refuse to Answer

MD8. Which of the following medications for opioid
use disorder (MOUD) were provided onsite, either by
the program itself or by partners, at the
location(s) where your program operated? Select all
that apply.

No medications were provided onsite
Buprenorphine/naloxone (Suboxone)
Buprenorphine (Subutex)
Methadone
Naltrexone (Vivitrol)
Don't Know
Refuse to Answer

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MD9. Which of the following other medical services
were provided onsite, either by the program itself
or by partners, at the location(s) where your
program operated? Select all that apply.

No other medical services were provided onsite
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
Don't Know
Refuse to Answer

MD10. Did your program provide referrals for
buprenorphine (including Suboxone or Subutex)
between January 1, 2020, and December 31, 2020?

No
Yes
Don't Know
Refuse to Answer

MD11. Between January 1, 2020, and December 31, 2020,
what types of referrals to other medical services
did your program provide? Select all that apply.

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
Don't Know
Refuse to Answer

MD12. How was your program impacted by the COVID-19
pandemic in 2020? Select all that apply.

Reduced hours or days of operation
Reduced funding
Site closure(s)
Staff shortage or loss
Change to a MORE restrictive syringe distribution
model (e.g., from needs-based to 1-for-1)
Changes to a LESS restrictive syringe distribution
model (e.g., from 1-for-1 to needs-based)
Changes in physical space (e.g., moved services
outdoors, markers for social distancing,
plexiglass)
Disruptions in supply of syringes
Disruptions in other supplies
Disruptions in HIV, HCV, or other bloodborne
pathogens testing
Disruptions in substance use disorder treatment
linkage (e.g., stopped services, new regulatory
practices)
Changes in other direct client services, such as
food distribution, showers, housing assistance.
New/increased access to telehealth for clients
Lack of personal protective equipment (PPE)
Other (please specify)
Program was not impacted by COVID-19 in 2020
Don't Know
Refuse to Answer

MD12spec. Specify other ways your program was
impacted by COVID-19.

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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...

Too short
Just right
Too long
Refuse to Answer

PE2. If you were taking the survey again, what format
would you prefer? Select only one.

Self-administered online
Self-administered via an electronic document (Word
or PDF) that can be completed and returned by email
Interviewer-administered to me over the phone
Interviewer-administered to me in person
Refuse to Answer

PE3. What topic(s) were missing from this survey and
need to be added in the future?
PE4. How would you like to see this information used?
Select all that apply.

PE4spec. Specify other use for this information

PE5. Please use the space below for any other
suggestions or comments for improving this survey to
make it useful to programs.

__________________________________
Increase awareness
Increase community support
Increase funding
Inform policy/law
Other (please describe)
Refuse to Answer

__________________________________

__________________________________

You have now completed the survey. Thank you so much for your participation.
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.
Automatic, hidden variable: Interview end date
(today)
End time of interview

01/29/2021 1:08pm

No, data cannot be shared
Yes, data can be shared

__________________________________

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