Form Attachment 3 Attachment 3 Baseline Patient Survey

Form Approved

OMB No. 0930-XXXX

Expiration Date XX/XX/XXXX

Attachment 3:
Baseline Patient Survey

SBIRT Patient Survey—Baseline

Section A
Education and Employment

These questions are about school and work.

A1. Are you currently enrolled in school or a job training program? (NOMS)

NOT ENROLLED (Please go to Question A2)

ENROLLED, FULL TIME

ENROLLED, PART TIME

OTHER (SPECIFY)

A1a. During the past 30 days, that is, from [DATEFILL] up to and including today, how many whole days of school did you miss because you were sick or injured? (NSDUH)

A1b. During the past 30 days, that is, since [DATEFILL], how many whole days of school did you miss because you skipped or “cut” or just didn’t want to be there? (NSDUH)

A2. Are you currently employed? (NOMS)

Full time—Working 35 hours or more each week; includes members of the uniformed services

Part time—Working fewer than 35 hours each week

Unemployed, looking for work during the past 30 days or on lay off from a job (Please go to Question A4)

Not in labor force—Not looking for work during the past 30 days or a homemaker, student, disabled, retired, or an inmate of an institution (Please go to Question A4)

Other (SPECIFY)

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___________________________________________________

Public reporting burden for this collection of information is estimated to average 25 minutes per response; including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 7-1045, 1 Choke Cherry Road, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The control number for this project is 0930-XXXX.

A2a. How many hours altogether did you work last week at all jobs and businesses? (NSDUH)

____ ____ ____ NUMBER OF HOURS

A2b. During the past 30 days, that is, from [DATEFILL] up to and including today, how many whole days of work did you miss because you were sick or injured? (NSDUH)

A2c. During the past 30 days, that is, from [DATEFILL] up to and including today, how many whole days of work did you miss because you just didn’t want to be there? (NSDUH)

A3. Next, we would like you to describe your work experiences in the past 30 days. For each of the following statements, please choose the response that shows your agreement or disagreement with the statement in describing your work experiences in the past month. (SPS—modified)

A3a. During the past 30 days, the stresses of my job were hard to handle.

1 Strongly disagree

2 Somewhat disagree

3 Are uncertain about your agreement with the statement

4 Somewhat agree

5 Strongly agree

A3b. During the past 30 days, I was able to finish hard tasks in my work.

1 Strongly disagree

2 Somewhat disagree

3 Are uncertain about your agreement with the statement

4 Somewhat agree

5 Strongly agree

A3c. During the past 30 days, I took less pleasure in my work than usual.

1 Strongly disagree

2 Somewhat disagree

3 Are uncertain about your agreement with the statement

4 Somewhat agree

5 Strongly agree

A3d. During the past 30 days, I felt hopeless about finishing certain work tasks.

1 Strongly disagree

2 Somewhat disagree

3 Are uncertain about your agreement with the statement

4 Somewhat agree

5 Strongly agree

A3e. During the past 30 days, I was able to focus on achieving my goals.

1 Strongly disagree

2 Somewhat disagree

3 Are uncertain about your agreement with the statement

4 Somewhat agree

5 Strongly agree

A3f. During the past 30 days, I felt energetic enough to complete my work.

1 Strongly disagree

2 Somewhat disagree

3 Are uncertain about your agreement with the statement

4 Somewhat agree

5 Strongly agree

(Please go to Question A5)

A4. If not in the labor force, what is your status? (NOMS)

Student enrolled in a school or job training program

Homemaker

Retired

Disabled

Inmate of an institution that restrains a person, otherwise able, from the workforce

Other (SPECIFY)

A5. What is the highest grade or year of school that you completed? (NOMS)

Never attended school

1st grade completed

2nd grade completed

3rd grade completed

4th grade completed

5th grade completed

6th grade completed

7th grade completed

8th grade completed

9th grade completed

10th grade completed

11th grade completed

12th grade completed/high school diploma/equivalent

Voc/tech program after high school but no voc/tech diploma

Voc/tech diploma after high school

College or university/1st year completed

College or university/2nd year completed/Associate’s degree (AA, AS)

College or university/3rd year completed

Bachelor’s degree (BA, BS) or higher

Section B
Psychological Distress

B1. These next questions are about how you’ve been feeling and problems you may have experienced during the past 2 weeks. Over the past 2 weeks, how often have you been bothered by any of the following problems? (PHQ-8)

		Not at all	Several days	More than half the days	Nearly every day
a.	Little interest or pleasure in doing things	1	2	3	4
b.	Feeling down, depressed, or hopeless	1	2	3	4
c.	Trouble falling or staying asleep, or sleeping too much	1	2	3	4
d.	Feeling tired or having little energy	1	2	3	4
e.	Poor appetite or overeating	1	2	3	4
f.	Feeling bad about yourself—or that you are a failure or have let yourself or your family down	1	2	3	4
g.	Trouble concentrating on things, such as reading the newspaper or watching television	1	2	3	4
h.	Moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual	1	2	3	4

i. How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

1 Not difficult at all

2 Somewhat difficult

3 Very difficult

4 Extremely difficult

Section C
ASSIST

I am going to ask you some questions about your experience with alcohol, tobacco products and other drugs across your lifetime and in the past 3 months. These substances can be smoked, swallowed, snorted, inhaled, injected or taken in pill form. Some of the substances listed may be prescribed by a doctor (like sedatives, pain medications, amphetamines etc.). For this interview, we will not record medications that are used as prescribed by your doctor. However, if you have taken such drugs for reasons other than prescription, or taken them more frequently or at higher doses than prescribed, please let me know. While we are also interested in knowing about your use of various illicit drugs, please be assured that the information on such use will be treated as strictly confidential. (ASSIST)

C1. In your life, which of the following substances have you ever used? (non-medical use only)

		No	Yes
a.	Tobacco products	0	3
b.	Alcoholic beverages	0	3
c.	Marijuana	0	3
d.	Cocaine or Crack	0	3
e.	Amphetamines or Stimulants	0	3
f.	Inhalants	0	3
g.	Sedatives or Sleeping Pills	0	3
h.	Hallucinogens	0	3
i.	Heroin, Morphine, Pain Medication	0	3
j.	Other, specify _____________________	0	3

No to all  (Please go to Section D)

C2. In the past three months, how often have you used the substances mentioned (Only ask for substances answered as “yes” in C1)?

		Never	Once or Twice	Monthly	Weekly	Daily or Almost Daily
a.	Tobacco products	0	2	3	4	6
b.	Alcoholic beverages	0	2	3	4	6
c.	Marijuana	0	2	3	4	6
d.	Cocaine or Crack	0	2	3	4	6
e.	Amphetamines or Stimulants	0	2	3	4	6
f.	Inhalants	0	2	3	4	6
g.	Sedatives or Sleeping Pills	0	2	3	4	6
h.	Hallucinogens	0	2	3	4	6
i.	Heroin, Morphine, Pain Medication	0	2	3	4	6
j.	Other, specify ________________	0	2	3	4	6

Never to all  (Please go to Section D)

If any substance in C2 was used in the previous 3 months  continue with questions C3-C5 for each substance used

C3. During the past three months, how often have you had a strong desire or urge to use (first drug, second drug, etc.)?

		Never	Once or Twice	Monthly	Weekly	Daily or Almost Daily
a.	Tobacco products	0	3	4	5	6
b.	Alcoholic beverages	0	3	4	5	6
c.	Marijuana	0	3	4	5	6
d.	Cocaine or Crack	0	3	4	5	6
e.	Amphetamines or Stimulants	0	3	4	5	6
f.	Inhalants	0	3	4	5	6
g.	Sedatives or Sleeping Pills	0	3	4	5	6
h.	Hallucinogens	0	3	4	5	6
i.	Heroin, Morphine, Pain Medication	0	3	4	5	6
j.	Other, specify	0	3	4	5	6

C4. During the past three months, how often has your use of (first drug, second drug, etc.) led to health, social, legal or financial problems?

		Never	Once or Twice	Monthly	Weekly	Daily or Almost Daily
a.	Tobacco products	0	4	5	6	7
b.	Alcoholic beverages	0	4	5	6	7
c.	Marijuana	0	4	5	6	7
d.	Cocaine or Crack	0	4	5	6	7
e.	Amphetamines or Stimulants	0	4	5	6	7
f.	Inhalants	0	4	5	6	7
g.	Sedatives or Sleeping Pills	0	4	5	6	7
h.	Hallucinogens	0	4	5	6	7
i.	Heroin, Morphine, Pain Medication	0	4	5	6	7
j.	Other, specify ________________	0	4	5	6	7

C5. During the past three months, how often have you failed to do what was normally expected of you because of your use of (first drug, second drug, etc.)?

		Never	Once or Twice	Monthly	Weekly	Daily or Almost Daily
a.	Tobacco products	0	5	6	7	8
b.	Alcoholic beverages	0	5	6	7	8
c.	Marijuana	0	5	6	7	8
d.	Cocaine or Crack	0	5	6	7	8
e.	Amphetamines or Stimulants	0	5	6	7	8
f.	Inhalants	0	5	6	7	8
g.	Sedatives or Sleeping Pills	0	5	6	7	8
h.	Hallucinogens	0	5	6	7	8
i.	Heroin, Morphine, Pain Medication	0	5	6	7	8
j.	Other, specify ________________	0	5	6	7	8

C6. Has a friend or relative or anyone else ever expressed concern about your use of (first drug, second drug, etc.) (Only ask for substances answered as “yes” in C1)?

		No, Never	Yes, in the past 3 months	Yes, but not in the past 3 months
a.	Tobacco products	0	6	3
b.	Alcoholic beverages	0	6	3
c.	Marijuana	0	6	3
d.	Cocaine or Crack	0	6	3
e.	Amphetamines or Stimulants	0	6	3
f.	Inhalants	0	6	3
g.	Sedatives or Sleeping Pills	0	6	3
h.	Hallucinogens	0	6	3
i.	Heroin, Morphine, Pain Medication	0	6	3
j.	Other, specify ________________	0	6	3

C7. Have you ever tried and failed to control, cut down or stop using (first drug, second drug, etc.) (Only ask for substances answered as “yes” in C1)?

		No, Never	Yes, in the past 3 months	Yes, but not in the past 3 months
a.	Tobacco products	0	6	3
b.	Alcoholic beverages	0	6	3
c.	Marijuana	0	6	3
d.	Cocaine or Crack	0	6	3
e.	Amphetamines or Stimulants	0	6	3
f.	Inhalants	0	6	3
g.	Sedatives or Sleeping Pills	0	6	3
h.	Hallucinogens	0	6	3
i.	Heroin, Morphine, Pain Medication	0	6	3
j.	Other, specify ________________	0	6	3

C8. Have you ever used any drug by injection? (non medical use only)

No, Never	Yes, in the past 3 months	Yes, but not in the past 3 months
0	2	1

Section D
Health and Health Care Utilization

The next questions are about your health and health care.

D1. In general, would you say your health is excellent, very good, good, fair, or poor? (NLSY-79)

1 Excellent

2 Very good

3 Good

4 Fair

5 Poor

D2. Are you covered by any kind of private or governmental health or hospitalization plans or health maintenance organization (HMO) plans? (PROBE IF NECESSARY:) Examples of health and hospitalization insurance plans include Blue Cross, Blue Shield, [Medicaid or a Medicaid alternative plan such as [name of state Medicaid Program]]. (NLSY-79)

1 Yes

2 No

D3. Have you seen a medical care provider during the past 6 months for routine preventive care, such as a physical examination or checkup? (NVVLS)

1 Yes

2 No

D4. During the past 6 months, did you receive any care or treatment for a physical health problem from a doctor or other medical person (such as a nurse, physician’s assistant, chiropractor, or physical therapist) in an emergency room or emergency department? (NVVLS)

1 Yes

2 No → (Please go to Question D5)

D4a. How many visits have you made to an emergency room or emergency department during the past 6 months because of physical health problems? (NVVLS)

____ ____ ____ VISITS

D5. During the past 6 months, did you receive any care or treatment for a physical health problem from a doctor or other medical person (such as a nurse, physician’s assistant, chiropractor, or physical therapist) in an office or clinic? (NVVLS)

1 Yes

2 No → (Please go to Question D6)

D5a. How many visits have you made to a medical office or clinic during the past 6 months because of physical health problems? (NVVLS)

____ ____ ____ VISITS

D6. During the past 6 months, were you a patient overnight in a hospital, convalescent home, nursing home, rehabilitation center, or similar facility because of any physical health problem? (NVVLS)

1 Yes

2 No → (Please go to Section D7)

D6a. How many times in the past 6 months did you stay at least one night in a hospital, nursing home, or other treatment facility because of your physical health? (NVVLS)

____ ____ ____ TIMES

D6b. Altogether, how many nights did you spend in a hospital or treatment facility in the past 6 months because of your physical health? (NVVLS)

____ ____ ____ NIGHTS

D7. During the past 6 months, did you receive any care or treatment for an alcohol, drug abuse, or mental health related problem from a doctor or other medical person (such as a nurse, physician’s assistant, or counselor) in an emergency room or emergency department?

1 Yes

2 No → (Please go to Question D8)

D7a. How many visits have you made to an emergency room or emergency department during the past 6 months because of substance abuse or mental health problems?

____ ____ ____ VISITS

D8. During the past 6 months, did you receive any care or treatment for an alcohol, drug abuse, or mental health related problem from a doctor or other medical person (such as a nurse, physician’s assistant, or counselor) in an office or clinic?

1 Yes

2 No → (Please go to Question D9)

D8a. How many visits have you made to a medical office or clinic during the past 6 months because of substance abuse or mental health problems?

____ ____ ____ VISITS

D9. During the past 6 months, were you a patient overnight in a hospital, residential program, rehabilitation center, or similar facility because of any substance abuse or mental health problems?

1 Yes

2 No → (Please go to Section E)

D9a. How many times in the past 6 months did you stay at least one night in a hospital, residential program, or other treatment facility because of your substance abuse or mental health problems?

____ ____ ____ TIMES

D9b. Altogether, how many nights did you spend in a hospital or treatment facility in the past 6 months because of your substance abuse or mental health problems?

____ ____ ____ TIMES

Section E
Criminal Justice

E1. In the past 30 days, how many times have you been arrested? (IF NO ARRESTS, GO TO ITEM E3) (NOMS)

|___|___|___|

TIMES

E2. In the past 30 days, how many times have you been arrested for alcohol or drug offenses? (NOMS)

|___|___|___|

TIMES

E3. In the past 30 days, how many nights have you spent in jail/prison? (NOMS)

|___|___|

NIGHTS

E4. During the past 6 months, have you had any automobile accidents, regardless of who is at fault? (COMBINE Form 90—modified)

1 Yes

2 No → (Please go to Question E5)

E4a. In the past 6 months, how many automobile accidents have you had?

____ ____ TIMES

E5. During the past 6 months, have you ever driven an automobile while under the influence of drugs or alcohol? (COMBINE Form 90—modified)

1 Yes

2 No → (Please go to Section F)

E5a. In the past 6 months, how many times have you ever driven an automobile while under the influence of drugs or alcohol?

____ ____ TIMES

Section F
Demographics

Finally, we have a few questions to help us understand the backgrounds of the people completing this questionnaire. (NOMS)

F1. What is your gender?

MALE

FEMALE

TRANSGENDER

OTHER (SPECIFY)

F2. Are you Hispanic or Latino? (NOMS)

YES

NO → (Please go to Question F3)

F2a. If yes, what ethnic group do you consider yourself? (PLEASE SELECT ONE OR MORE) (NOMS)

Central American

Cuban

Dominican

Mexican

Puerto Rican

South American

Other (SPECIFY)

F3. What is your race? (PLEASE SELECT ONE OR MORE) (NOMS)

Alaska Native

American Indian

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

F4. What is your month and year of birth? (NOMS)

|____|____| / |____|____|

MONTH YEAR

F5. Are you now married, widowed, divorced, separated, never married, or living with a partner? (NHIS)

1 Married

2 Widowed

3 Divorced

4 Separated

5 Never married

6 Living with a partner

F6. During 2005, how much income did you receive from wages, salary, commissions, or tips from all jobs, before taxes and other deductions? To answer this question, please do not include any income from other family members. (NVVLS)

01 Nothing

02 Less than $2,000

03 $2,000 – $3,999

04 $4,000 – $5,999

05 $6,000 – $7,999

06 $8,000 – $9,999

07 $10,000 – $11,999

08 $12,000 – $13,999

09 $14,000 – $15,999

10 $16,000 – $17,999

11 $18,000 – $19,999

12 $20,000 – $24,999

13 $25,000 – $29,999

14 $30,000 – $39,999

15 $40,000 – $49,999

16 $50,000 – $59,999

17 $60,000 – $69,999

18 $70,000 – $79,999

19 $80,000 – $99,999

20 $100,000 – $149,999

21 $150,000 or more

F7. During 2005, how much income did your family receive from all sources before taxes and other deductions? To answer this question, please combine the income of everyone in your family who lives at the same residence as you. (NVVLS)

01 Nothing or loss

02 Less than $2,000

03 $2,000 – $3,999

04 $4,000 – $5,999

05 $6,000 – $7,999

06 $8,000 – $9,999

07 $10,000 – $11,999

08 $12,000 – $13,999

09 $14,000 – $15,999

10 $16,000 – $17,999

11 $18,000 – $19,999

12 $20,000 – $24,999

13 $25,000 – $29,999

14 $30,000 – $39,999

15 $40,000 – $49,999

16 $50,000 – $59,999

17 $60,000 – $69,999

18 $70,000 – $79,999

19 $80,000 – $99,999

20 $100,000 – $149,999

21 $150,000 or more

FAMILY AND LIVING CONDITION (DO NOT READ OPTIONS TO CLIENT)

F8. In the past 30 days, where have you been living most of the time? (NOMS)

Homeless—No fixed address; includes shelters

Dependent Living—Dependent children and adults living in a supervised setting such as a halfway house or group home

Independent Living (including on own, self-supported, and non-supervised group homes)

F9. Do you have children?

YES

NO (Please go to Question F10)

F9a. How many children do you have?

|___|___|

F9b. Are any of your children living with someone else due to a child protection court order?

YES

NO (Please go to Question F10)

F9c. If yes, how many of your children are living with someone else due to a child protection court order?

|___|___|

F9d. For how many of your children have you lost parental rights? (The client’s parental rights were terminated.)

|___|___|

F10. IF FEMALE: Are you currently pregnant?

YES

NO

DON’T KNOW

F11. How long did it take you to travel to this facility? (In minutes) (COMBINE Form 90—modified)

|___|___| Minutes

19