Form Attachment B2 Attachment B2 2007 Questionnaire

Drug and Alcohol Services Information System

OMB Att-B2 2007 Questionnaire

Drug and Alcohol Services Information System

OMB: 0930-0106

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Attachment B2
N-SSATS 2007 Questionnaire

U.S. Department of Health and Human Services

Attachment B2 (N-SSATS 2007 Questionnaire)
FORM APPROVED:
OMB No. 0930-XXXX
APPROVAL EXPIRES: XX/XX/XXXX
See OMB burden statement on last page

National Survey of
Substance Abuse Treatment Services
(N-SSATS)
March 30, 2007
Substance Abuse and Mental Health Services Administration (SAMHSA)

PLEASE REVIEW THE FACILITY INFORMATION PRINTED ABOVE.
CROSS OUT ERRORS AND ENTER CORRECT OR MISSING INFORMATION.
CHECK ONE

! Information is complete and correct, no changes needed
! All missing or incorrect information has been corrected

PREPARED BY MATHEMATICA POLICY RESEARCH, INC.

PLEASE READ THIS ENTIRE PAGE BEFORE
COMPLETING THE QUESTIONNAIRE

INSTRUCTIONS
•

Most of the questions in this survey ask about “this facility.” By “this facility” we mean the specific
treatment facility or program whose name and location are printed on the front cover. If you have any
questions about how the term “this facility” applies to your facility, please call 1-888-324-8337.

•

Please answer ONLY for the specific facility or program whose name and location are printed on the
front cover, unless otherwise specified in the questionnaire.

•

Return the completed questionnaire in the envelope provided. Please keep a copy for your records.

•

For additional information about this survey or the types of care referred to in the questionnaire,
please visit our website at http://info.nssats.com.

•

If you have any questions or need additional blank forms, contact:

MATHEMATICA POLICY RESEARCH, INC.
1-888-324-8337
If you prefer, you may complete this questionnaire online. See the pink flyer enclosed in your
questionnaire packet for the Internet address and your unique user ID and password. If you need
more information, call the N-SSATS helpline at 1-888-324-8337.

IMPORTANT INFORMATION
* Asterisked questions.

Information from asterisked (*) questions will be published in
SAMHSA’s National Directory of Drug and Alcohol Abuse Treatment Programs and will be
available online at http://findtreatment.samhsa.gov, SAMHSA’s Substance Abuse Treatment
Facility Locator.
Mapping feature in Locator. Complete and accurate name and address information is needed
for the online Treatment Facility Locator so it can correctly map the facility location.
Eligibility for Directory/Locator. Only facilities designated as eligible by their state substance
abuse office will be listed in the National Directory and online Treatment Facility Locator. Your
state N-SSATS representative can tell you if your facility is eligible to be listed in the
Directory/Locator. For the name and telephone number of your state representative, call the
N-SSATS helpline at 1-888-324-8337 or go to http://wwwdasis.samhsa.gov and click on
“DASIS Contacts” then “N-SSATS Contacts by State.”

PREPARED BY MATHEMATICA POLICY RESEARCH, INC.

SECTION A: FACILITY
CHARACTERISTICS

Section A asks about characteristics of individual facilities
and should be completed for this facility only, that is, the
treatment facility or program at the location listed on the
front cover.

*4.
1.

Which of the following substance abuse services
are offered by this facility at this location, that is,
the location listed on the front cover?

1. Intake, assessment, or referral......... 1 !

2. Detoxification ..................................... 1 !

! Yes

! No

SKIP TO Q.41 (PAGE 12)

What is the primary focus of this facility at this
location, that is, the location listed on the front
cover?

! Substance abuse treatment services

! Mental health services

3. Substance abuse treatment

(services that focus on initiating
and maintaining an individual’s
recovery from substance abuse
and on averting relapse) ...................... 1 !

MARK ONE ONLY

MARK “YES” OR “NO” FOR EACH

YES

Did you answer “yes” to substance abuse
treatment in option 3 of question 1?

! Mix of mental health and substance abuse
treatment services (neither is primary)

! General health care

! Other (Specify:

)

4. Any other substance abuse

services .............................................. 1 !

5.
2.

MARK ONE ONLY

Did you answer “yes” to detoxification in option 2
of question 1 above?
1

! Yes

! No

Is this facility operated by . . .

SKIP TO Q.3 (TOP OF NEXT COLUMN)

! A private for-profit organization

! A private non-profit organization

SKIP TO
Q.6

! State government

(PAGE 2)

2a.

Does this facility detoxify clients from . . .
5

! Tribal government

! Federal government

MARK “YES” OR “NO” FOR EACH

YES

2. Opiates ................................................ 1 !

3. Cocaine................................................ 1 !

... 1 !

!
)

2b.

Does this facility routinely use medications
during detoxification?
1

! Yes

! No

SKIP TO Q.4 (NEXT COLUMN)

SKIP TO Q.8
(PAGE 2)

1. Alcohol ................................................. 1 !

4. Other (Specify:

! Local, county, or community
government

5a.

Which federal government agency?
MARK ONE ONLY
1

! Department of Veterans Affairs

! Department of Defense

! Indian Health Service

! Other (Specify:

SKIP TO
Q.8
(PAGE 2)

)

Is this facility a solo practice, meaning, an office
with a single practitioner or therapist?
1

! Yes

! No

*10. What telephone number(s) should a potential
client call to schedule an intake appointment?

INTAKE TELEPHONE NUMBER(S)

(______) ________ - ___________ ext._____

Is this facility affiliated with a religious
organization?
1

! Yes

! No

11.

Is this facility a jail, prison, or other organization
that provides treatment exclusively for
incarcerated persons or juvenile detainees?
1

! Yes

! No

Does this facility operate a hotline that responds
to substance abuse problems?
• A hotline is a telephone service that provides
information, referral, or immediate counseling,
frequently in a crisis situation.

SKIP TO Q.47 (PAGE 12)

• If this facility is part of a group of facilities that
operates a central hotline to respond to substance
abuse problems, you should mark “yes.”
• DO NOT consider 911 or the local police number
a hotline for the purpose of this survey.

9a.

Is this facility located in, or operated by, a
hospital?
1

! Yes

! No

! Yes

! No

SKIP TO Q.12 (PAGE 3)

SKIP TO Q.10 (TOP OF NEXT COLUMN)

What type of hospital?
*11a. Please enter the hotline telephone number(s)
below.

MARK ONE ONLY

! General hospital (including VA hospital)
HOTLINE TELEPHONE NUMBER(S)

! Psychiatric hospital
! Other specialty hospital, for example,
alcoholism, maternity, etc.
(Specify:

)

(______) ________ - ___________ ext._____

12.

Ancillary Services

Which of the following services are provided by
this facility at this location, that is, the location
listed on the front cover?

! Case management services

! Social skills development

! Mentoring/peer support

! Child care for clients’ children

MARK ALL THAT APPLY

Assessment and Pre-Treatment Services
1

! Screening for substance abuse

! Screening for mental health disorders

! Comprehensive substance abuse assessment
or diagnosis

! Outreach to persons in the community that
may need treatment
! Interim services for clients when immediate
admission is not possible

Pharmacotherapies
7

! Antabuse

! Naltrexone

! Campral

! Buprenorphine – Subutex

! Buprenorphine – Suboxone

! Methadone

! Nicotine replacement

! Medications for psychiatric disorders

Testing (Include tests performed at this location,
even if specimen is sent to an outside source for
chemical analysis.)

! Employment counseling or training for clients

! Assistance in locating housing for clients

! Comprehensive mental health assessment or
diagnosis (for example, psychological or
psychiatric evaluation and testing)

! Assistance with obtaining social services
(for example, Medicaid, WIC, SSI, SSDI)

! Domestic violence—family or partner violence
services (physical, sexual, and emotional
abuse)

! Early intervention for HIV

! HIV or AIDS education, counseling, or support

! Health education other than HIV/AIDS

! Substance abuse education

! Transportation assistance to treatment

! Mental health services

! Acupuncture

* 39 ! Residential beds for clients’ children
40

13.

! Self-help groups (for example, AA, NA,
Smart Recovery)

As part of substance abuse treatment, does this
facility employ individual counseling?
1

! Yes

! No

13a. What percent of substance abuse clients receive
individual counseling?

! Breathalyzer or other blood alcohol testing

! Drug or alcohol urine screening

! Screening for Hepatitis B

! Screening for Hepatitis C

! HIV testing

! STD testing

! TB screening

! Yes

Transitional Services

! No

! Discharge planning

! Aftercare/continuing care

SKIP TO Q.14 (BELOW)

PERCENT OF CLIENTS
(IF NONE, ENTER “0”)

14.

As part of substance abuse treatment, does this
facility employ group counseling (with peers)?

SKIP TO Q.15 (TOP OF PAGE 4)

14a. What percent of substance abuse clients receive
group counseling?
PERCENT OF CLIENTS
(IF NONE, ENTER “0”)

15.

17.

As part of substance abuse treatment, does this
facility employ family counseling?
1

! Yes

! No

Are any of the following practices part of this
facility’s standard operating procedures?
MARK “YES” OR “NO” FOR EACH

SKIP TO Q.16 (BELOW)

YES
1. Required continuing education

15a. What percent of substance abuse clients receive
family counseling?
PERCENT OF CLIENTS
(IF NONE, ENTER “0”)

for staff .............................................

2. Periodic drug testing of clients .........

quality review committee..................

5. Outcome follow-up after discharge ..

6. Periodic utilization review.................

3. Regularly scheduled case

review with a supervisor...................
16.

As part of substance abuse treatment, does this
facility employ marital/couples counseling?
1

! Yes

! No

4. Case review by an appointed

SKIP TO Q.17 (TOP OF NEXT COLUMN)

16a. What percentage of substance abuse clients
receive marital/couples counseling?
PERCENT OF CLIENTS
(IF NONE, ENTER “0”)

18.

7. Periodic client satisfaction

surveys conducted by the facility .....

Listed below are a variety of clinical/therapeutic approaches used by substance abuse treatment facilities. For
each, please mark the box that best describes how often the practice is used at this facility.
MARK ONE FREQUENCY FOR EACH
Never

Sometimes

Often

Not Familiar With
This Approach

Substance abuse counseling ............................................

12-step approach ..............................................................

Brief intervention ...............................................................

Cognitive-behavioral therapy ............................................

Contingency management ................................................

Motivational interviewing ...................................................

Trauma-related counseling ...............................................

Anger management...........................................................

Relapse prevention ...........................................................

10. Other treatment approach (Specify: _______________
___________________________________________
__________________________________________ )

Rarely

*19. Does this facility operate a methadone
maintenance or detoxification program at this
location?
1
0

! Yes
! No

•
SKIP TO Q.20 (BELOW)

*19a. Is the methadone program at this location a
maintenance program, a detoxification program,
or both?
MARK ONE ONLY
1
2
3

*22. Does this facility provide substance abuse
treatment services in a language other than
English at this location?

! Maintenance program
! Detoxification program
! Both

! Yes

! No

1
0

MARK ONE ONLY

! Yes
! No

*20. Does this facility offer a special program for
DUI/DWI or other drunk driver offenders at
this location?
Mark “yes” if this facility serves only DUI/DWI
clients OR if this facility has a special
DUI/DWI program.

! Yes

! No

! Staff counselor who speaks a language
GO TO Q.22b (BELOW)
other than English
! On-call interpreter (in person or by phone)
SKIP TO Q.23
brought in when needed
(PAGE 6)

•

SKIP TO Q.23 (PAGE 6)

22a. At this facility, who provides substance abuse
treatment services in a language other than
English?

*19b. Are ALL of the substance abuse clients at this
facility currently in the methadone program?

Mark “yes” if either a staff counselor or an
on-call interpreter provides this service.

! BOTH staff counselor and on-call
GO TO Q.22b (BELOW)
interpreter

*22b. In what other languages do staff counselors
provide substance abuse treatment at this
facility?
MARK ALL THAT APPLY

American Indian or Alaska Native:
1

! Hopi

! Navajo

! Lakota

! Yupik

SKIP TO Q.21 (BELOW)
5

*20a. Does this facility serve only DUI/DWI clients?

! Other American Indian or
Alaska Native language

! Yes

(Specify:

! No

Other Languages:

*21. Does this facility provide substance abuse
treatment services in sign language (for example,
American Sign Language, Signed English, or
Cued Speech) for the hearing impaired at this
location?
• Mark “yes” if either a staff counselor or an

on-call interpreter provides this service.

)

! Arabic

! Korean

! Chinese

! Polish

! Creole

! Portuguese

! French

! Russian

! German

! Spanish

! Hmong

! Vietnamese

! Other language (Specify: _______________

! Yes

____________________________________

! No

____________________________________ )

*23. This question has two parts. Column A asks
about the types of clients accepted into
treatment at this facility. Column B asks whether
this facility offers specially designed treatment
programs or groups for each type of client.

*24. Does this facility offer either of the following
HOSPITAL INPATIENT substance abuse
services at this location, that is, the location
listed on the front cover?
MARK “YES” OR “NO” FOR EACH

Column A - For each type of client listed below:
Indicate whether this facility accepts these clients
into treatment at this location.
Column B - For each “yes” in Column A: Indicate
whether this facility offers a specially designed
substance abuse treatment program or group
exclusively for that type of client at this location.

TYPE OF CLIENT

COLUMN A

COLUMN B

CLIENTS
ACCEPTED
INTO
TREATMENT

OFFERS
SPECIALLY
DESIGNED
PROGRAM OR
GROUP

YES

2. Clients with co-occurring
mental and substance
abuse disorders

3. Criminal justice clients
(other than DUI/DWI)

Hospital inpatient detoxification......... 1 !
(Similar to ASAM Levels IV-D
and III.7-D, medically managed or
monitored inpatient detoxification)

Hospital inpatient treatment .............. 1 !
(Similar to ASAM Levels IV and III.7,
medically managed or monitored
intensive inpatient treatment)

NOTE: ASAM is the American Society of Addiction Medicine.

*25. Does this facility offer any of the following
RESIDENTIAL (non-hospital) substance abuse
services at this location, that is, the location
listed on the front cover?
MARK “YES” OR “NO” FOR EACH

4. Persons with HIV or
AIDS

5. Gays or lesbians

6. Seniors or older adults

7. Adult women

8. Pregnant or postpartum
women

9. Adult men

(Specify:
)

1. Adolescents

10. Specially designed
programs or groups for
any other types of clients

YES

YES
1.

Residential detoxification .................. 1 !
(Similar to ASAM Level III.2-D,
clinically managed residential
detoxification or social detoxification)

Residential short-term treatment....... 1 !
(Similar to ASAM Level III.5,
clinically managed high-intensity
residential treatment; typically
30 days or less)

Residential long-term treatment ........ 1 !
(Similar to ASAM Levels III.3
and III.1, clinically managed mediumor low-intensity residential treatment;
typically more than 30 days)

NO
0

*26. Does this facility offer any of the following
OUTPATIENT substance abuse services at this
location, that is, the location listed on the front
cover?

*28. Does this facility offer treatment at no charge to
clients who cannot afford to pay?
1

! Yes

! No

SKIP TO Q.29 (BELOW)

MARK “YES” OR “NO” FOR EACH

YES
1.

Outpatient detoxification .................... 1 !
(Similar to ASAM Levels I-D and II-D,
ambulatory detoxification)

Outpatient methadone/
buprenorphine maintenance .............. 1 !
(Opioid maintenance therapy)

NO
0

28a. Do you want the availability of free care for
eligible clients published in SAMHSA’s
Directory/Locator?

•

!
29.

Outpatient day treatment or
partial hospitalization ......................... 1 !
(Similar to ASAM Level II.5,
20 or more hours per week)
Intensive outpatient treatment............ 1 !
(Similar to ASAM Level II.1,
9 or more hours per week)
Regular outpatient treatment ............. 1 !
(Similar to ASAM Level I,
outpatient treatment;
non-intensive)

! Yes

! No

Does this facility receive any funding or grants
from the Federal government, or state, county or
local governments, to support its substance
abuse treatment programs?
•

The Directory/Locator will explain that
potential clients should call the facility for
information on eligibility.

Do not include Medicare, Medicaid, or federal
military insurance. These forms of client payments
will be included in Q.30 below.

! Yes

! No

-1

! Don’t Know

*30. Which of the following types of client payments or
insurance are accepted by this facility for
substance abuse treatment?
MARK “YES,” “NO,” OR “DON’T KNOW” FOR EACH

YES NO

*27. Does this facility use a sliding fee scale?
1.
1

! Yes

! No

2.
SKIP TO Q.28 (TOP OF NEXT COLUMN)

3.
4.
5.

27a. Do you want the availability of a sliding fee
scale published in SAMHSA’s Directory/Locator?
(For information on Directory/Locator eligibility, see
the inside front cover.)
•

The Directory/Locator will explain that sliding
fee scales are based on income and other
factors.

6.
7.
8.

! Yes

! No
9.

No payment accepted (free
treatment for ALL clients)........ 1 !
Cash or self-payment.............. 1 !
Medicare ................................. 1 !
Medicaid ................................. 1 !
A state-financed health
insurance plan other than
Medicaid (for example, State
Children’s Health Insurance
Program (SCHIP) or high risk
insurance pools) ..................... 1 !
Federal military insurance such
as TRICARE or Champ VA..... 1 !
Private health insurance ......... 1 !
Access To Recovery (ATR)
vouchers (to be answered
by facilities in the following
states only: CA, CT, FL, ID,
IL, LA, MO, NJ, NM, TN, TX,
WA, WI, WY)........................... 1 !
Other....................................... 1 !
(Specify:

!
0!
0!
0!
0

0
0

!
!
!

!
0!
0

DON’T
KNOW
!
-1 !
-1 !
-1 !
-1

-1

-1
-1

!
!
!

!
-1 !
-1

)
7

31.

HOSPITAL INPATIENT

Does this facility have agreements or contracts
with managed care organizations for providing
substance abuse treatment services?
33.
•

Managed care organizations have agreements
with certain health care providers who give
services to plan members, usually at discounted
rates. Examples include managed behavioral
healthcare organizations (MBHOs), health
maintenance organizations (HMOs), and
preferred provider organizations (PPOs).

! Yes

! No

-1

! Don’t Know

On March 30, 2007, did any patients receive
HOSPITAL INPATIENT substance abuse services
at this facility?
1

! Yes

! No

33a. On March 30, 2007, how many patients received
the following HOSPITAL INPATIENT substance
abuse services at this facility?
•
•

SECTION B: CLIENT COUNT
INFORMATION
1.

Hospital inpatient detoxification ___________
(Similar to ASAM Levels IV-D
and III.7-D, medically managed or
monitored inpatient detoxification)

Hospital inpatient treatment
___________
(Similar to ASAM Levels IV and III.7,
medically managed or monitored
intensive inpatient treatment)

IF THIS IS A MENTAL HEALTH FACILITY: Include in your
client counts all clients receiving substance abuse treatment,
even if substance abuse is their secondary diagnosis.

32.

Questions 33 through 38 ask about the
number of clients in treatment at this
facility at specified times.
Please check the option below that best
describes how client counts will be
reported in these questions.
MARK ONE ONLY
1

NEXT COLUMN)
2

! Questions 33 through 38 will
include client counts for this
facility combined with other
SKIP TO Q.33 (TOP OF
facilities
NEXT COLUMN)

HOSPITAL INPATIENT
TOTAL BOX

33b. How many of the patients from the HOSPITAL
INPATIENT TOTAL BOX were under the age
of 18?
ENTER A NUMBER
(IF NONE, ENTER “0”)

Number under age 18

! Client counts for this facility
will be reported by another
facility
SKIP TO Q.41 (PAGE 12)

_____________

33c. How many of the patients from the HOSPITAL
INPATIENT TOTAL BOX received methadone or
buprenorphine dispensed by this facility?
•

! Questions 33 through 38 will
include client counts for this facility
SKIP TO Q.33 (TOP OF
alone

COUNT a patient in one service only, even if the
patient received both services.
DO NOT count family members, friends, or other
non-treatment patients.
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)

IMPORTANT: Questions in Section B ask about different
time periods, e.g., the single day of March 30, 2007, and the
12-month period ending on March 31, 2007. Please pay
special attention to the period specified in each question.

SKIP TO Q.34 (PAGE 9)

Include patients who received these drugs for
detoxification or maintenance purposes.
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)

1. Methadone

_______________

2. Buprenorphine

_______________

33d. On March 30, 2007, how many hospital inpatient
beds at this facility were specifically designated
for substance abuse treatment?
ENTER A NUMBER
(IF NONE, ENTER “0”)

Number of beds

_______________

RESIDENTIAL (NON-HOSPITAL)
34.

34b. How many of the clients from the RESIDENTIAL
TOTAL BOX were under the age of 18?

On March 30, 2007, did any clients receive
RESIDENTIAL (non-hospital) substance abuse
services at this facility?
1

! Yes

! No

Number under age 18

•

_______________

SKIP TO Q.35 (PAGE 10)

34a. On March 30, 2007, how many clients received
the following RESIDENTIAL substance abuse
services at this facility?
•

ENTER A NUMBER
(IF NONE, ENTER “0”)

COUNT a client in one service only, even if the
client received multiple services.
DO NOT count family members, friends, or other
non-treatment clients.

34c. How many of the clients from the RESIDENTIAL
TOTAL BOX received methadone or
buprenorphine dispensed by this facility?
•

Include clients who received these drugs for
detoxification or maintenance purposes.
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)

ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)

1. Residential detoxification

_____________

(Similar to ASAM Level III.2-D,
clinically managed residential
detoxification or social detoxification)
2. Residential short-term treatment

1. Methadone

_______________

2. Buprenorphine

_______________

_____________

(Similar to ASAM Level III.5,
clinically managed high-intensity
residential treatment; typically
30 days or less)
3. Residential long-term treatment

_____________
(Similar to ASAM Levels III.3
and III.1, clinically managed mediumor low-intensity residential treatment;
typically more than 30 days)

34d. On March 30, 2007, how many residential beds
at this facility were specifically designated for
substance abuse treatment?
ENTER A NUMBER
(IF NONE, ENTER “0”)

RESIDENTIAL
TOTAL BOX

Number of beds

_______________

OUTPATIENT
35.

35b. How many of the clients from the OUTPATIENT
TOTAL BOX were under the age of 18?

During the month of March 2007, did any clients
receive OUTPATIENT substance abuse services at
this facility?
1

! Yes

! No

SKIP TO Q.36 (PAGE 11)

ENTER A NUMBER
(IF NONE, ENTER “0”)

Number under age 18

_______________

35a. As of March 30, 2007, how many active clients
were enrolled in each of the following
OUTPATIENT substance abuse services at
this facility?
An active outpatient client is someone
who:
(1)

was seen at this facility for substance
abuse treatment or detoxification at least
once during the month of March 2007
AND

(2)

was still enrolled in treatment on
March 30, 2007.

35c. How many of the clients from the OUTPATIENT
TOTAL BOX received methadone or
buprenorphine dispensed by this facility?
• Include clients who received these drugs for
detoxification or maintenance purposes.
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)

•

COUNT a client in one service only, even if

the client received multiple services.
•

DO NOT count family members, friends, or other
non-treatment clients.

1. Methadone

_______________

2. Buprenorphine

_______________

ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)

1. Outpatient detoxification

_____________

(Similar to ASAM
Levels I-D and II-D,
ambulatory detoxification)
2. Outpatient methadone/

buprenorphine maintenance
(Opioid maintenance therapy)

_____________

3. Outpatient day treatment or

partial hospitalization
(Similar to ASAM Level II.5,
20 or more hours per week)

_____________

4. Intensive outpatient treatment

_____________

(Similar to ASAM Level II.1,
9 or more hours per week)
5. Regular outpatient treatment

(Similar to ASAM Level I,
outpatient treatment;
non-intensive)
OUTPATIENT
TOTAL BOX

35d. Without adding to the staff or space available
in March 2007, what is the maximum number
of clients who could have been enrolled in
outpatient substance abuse treatment on
March 30, 2007? This is generally referred to
as outpatient capacity.
OUTPATIENT CAPACITY
ON MARCH 30, 2007

_____________
This number should not be less
than the number entered in the
OUTPATIENT TOTAL BOX.

36.

Some clients are treated for both alcohol and drug
abuse, while others are treated for only alcohol or
only drug abuse. Approximately what percent of
the substance abuse treatment clients enrolled at
this facility on March 30, 2007, including hospital
inpatient, residential, and/or outpatient, were
being treated for . . .

38a. How many of the 12-month treatment admissions
included in question 38 were funded by ATR
vouchers?
• To be answered by facilities in the following
states only: CA, CT, FL, ID, IL, LA, MO, NJ,
NM, TN, TX, WA, WI, WY

1. BOTH alcohol AND

drug abuse

NUMBER OF ADMISSIONS
FUNDED BY ATR VOUCHERS
(IF NONE, ENTER “0”)

___________%

2. ONLY alcohol abuse

___________%

3. ONLY drug abuse

___________%
TOTAL

39.

How many facilities are included in the client
counts reported in questions 33 through 38?
1

! Only this facility

! This facility plus others

THIS SHOULD TOTAL 100%.
IF NOT, PLEASE RECONCILE.

SKIP TO Q.40 (BELOW)
ENTER NUMBER OF
FACILITIES INCLUDED
IN CLIENT COUNTS:

THIS FACILITY

+ ADDITIONAL FACILITIES
37.

Approximately what percent of the substance
abuse treatment clients enrolled at this facility on
March 30, 2007, had a diagnosed co-occurring
substance abuse and mental health disorder?

= TOTAL FACILITIES

When we receive your questionnaire, we will contact you
for a list of the other facilities included in your client
counts.
PERCENT OF CLIENTS
(IF NONE, ENTER “0”)

38.

In the 12 months beginning April 1, 2006, and
ending March 31, 2007, how many ADMISSIONS
for substance abuse treatment did this facility
have? Count every admission and re-admission
in this 12-month period. If a person was admitted
3 times, count this as 3 admissions.
• FOR OUTPATIENT CLIENTS, consider an
admission to be the initiation of a treatment
program or course of treatment. Count admissions
into treatment, not individual treatment visits.
• IF DATA FOR THIS TIME PERIOD are not
available, use the most recent 12-month period
for which you have data.
• IF THIS IS A MENTAL HEALTH FACILITY, count
all admissions in which clients received substance
abuse treatment, even if substance abuse was
their secondary diagnosis.

If you prefer, attach a separate piece of paper listing the
name and location address of each facility included in
your client counts.
Please continue with Question 40 (BELOW)

40.

For which of the numbers you just reported did
you provide actual client counts and for which
did you provide your best estimate?
•

Mark “N/A” for any type of care not provided
by this facility on March 30, 2007.
MARK “ACTUAL,” “ESTIMATE,” OR “N/A” FOR EACH
ACTUAL ESTIMATE N/A

1. Hospital inpatient clients
(Q.33a, Pg. 8)........................... 1 !

-4

2. Residential clients

(Q.34a, Pg. 9)........................... 1 !
3. Outpatient clients

(Q.35a, Pg. 10)......................... 1 !
NUMBER OF SUBSTANCE
ABUSE ADMISSIONS IN
12-MONTH PERIOD

4. 12-month admissions

(Q.38) ................................ 1 !

43.

SECTION C:
GENERAL INFORMATION
Section C should be completed for this facility only.

*41. Does this facility operate a halfway house or
other transitional housing for substance abuse
clients at this location, that is, the location listed
on the front cover?

42.

! Yes

! No

Has this facility received a National Provider
Identifier (NPI)?
1

! Yes

! No

43a. What is the NPI for this facility?

NPI

*44. Does this facility have a website or web page
with information about the facility’s substance
abuse treatment programs?

Does this facility or program have licensing,
certification, or accreditation from any of the
following organizations?
•

Only include facility-level licensing,
accreditation, etc., related to the provision of
substance abuse services.

•

Do not include general business licenses, fire
marshal approvals, personal-level credentials,
food service licenses, etc.

45.

! Yes

! No

DON’T
YES NO KNOW
1.

State substance abuse agency...... 1 !

-1

State mental health department..... 1 !

-1

State department of health............. 1 !

-1

Hospital licensing authority ............ 1 !

-1

JCAHO (Joint Commission
on Accreditation of Healthcare
Organizations) ............................... 1 !

-1

CARF (Commission on Accreditation
of Rehabilitation Facilities) ............. 1 !

-1

Another state or local agency or
other organization .......................... 1 !
(Specify:

! Yes

! No

Would you like to receive a free paper copy of
the next National Directory of Drug and Alcohol
Abuse Treatment Programs when it is
published?
1

! Yes

! No

Who was primarily responsible for completing
this form? This information will only be used if we
need to contact you about your responses. It will
not be published.
Name:

COA (Council on Accreditation for

Children & Family Services)........... 1 !
9.

47.

NCQA (National Committee

for Quality Assurance) ................... 1 !
8.

46.

Please check the front cover of this
questionnaire to confirm that the
website address for this facility is
correct EXACTLY as listed. If
incorrect or missing, enter the
correct address.

If eligible, does this facility want to be listed in
the National Directory and Online Treatment
Facility Locator? (See inside front cover for
eligibility information.)

MARK “YES,” “NO,” OR “DON’T KNOW” FOR EACH

SKIP TO Q.44 (BELOW)

Title:
Phone Number: (_____) - _______ -

-1

Fax Number:
)

Email Address:

(_____) - _______ -

NOTES

Thank you for your participation. Please return this questionnaire in the envelope provided.
If you no longer have the envelope, please mail this questionnaire to:

MATHEMATICA POLICY RESEARCH, INC.
ATTN: RECEIPT CONTROL - Project 8945
P.O. Box 2393
Princeton, NJ 08543-2393
Public burden for this collection of information is estimated to average 40 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, including suggestions for
reducing this burden to SAMHSA Reports Clearance Officer, Room 7-1044, 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 OMB number for this project is 0930-XXXX.

File Type	application/pdf
File Title	Microsoft Word - 2007-NSSATS-q12.doc
Author	GGustus
File Modified	2006-08-02
File Created	2006-08-02