Attachment B5 Mini 2007 CATI Questionnaire

ATTACHMENT B5
MINI-N-SSATS CATI QUESTIONNAIRE

Attachment B5 (Mini-N-SSATS CATI Questionnaire)
FORM APPROVED OMB NO.: 0930-XXXX
APPROVAL EXPIRES: XX/XX/XXXX
See OMB burden statement on last page

INTRODUCTION:

1.

Hello, my name is [INTERVIEWER]. I am calling concerning the Substance Abuse and
Mental Health Services Administration’s on-line directory of drug and alcohol abuse
treatment facilities.

INTERVIEWER: IS A FACILITY DIRECTOR OR CONTACT PERSON’S NAME LISTED?
YES

ASK: May I speak with [FACILITY DIRECTOR OR CONTACT PERSON] regarding this facility’s
inclusion in the on-line directory.

NO

ASK: I would like to speak to your facility director regarding this facility’s inclusion in the on-line
directory.
TO CHANGE DIRECTOR’S NAME: ENTER <2> ON MENU SCREEN, RECORD NAME + RETURN TO MENU SCREEN
TO CHANGE CONTACT PERSON: ENTER <1> ON MENU SCREEN, RECORD NAME + RETURN TO MENU SCREEN

2.

•

SPEAKING WITH FACILITY DIRECTOR/APPROPRIATE PERSON

•

CONNECTED TO FACILITY DIRECTOR/APPROPRIATE PERSON

•

FACILITY DIRECTOR NOT AVAILABLE

ENTER <4> ON MENU SCREEN AND FOLLOW INSTRUCTIONS

•

ANSWERING MACHINE

ENTER <4> ON MENU SCREEN AND FOLLOW INSTRUCTIONS

•

REFUSES

ENTER <4> ON MENU SCREEN AND FOLLOW INSTRUCTIONS

GO TO #2 BELOW
REREAD INTRODUCTION AND GO TO #2 BELOW

Recently you were sent a letter signed by Dr. Javaid Kaiser of SAMHSA explaining that this facility has been
approved to be listed in SAMHSA’s on-line Locator for drug and alcohol abuse treatment facilities. The letter also
explains that this facility can be added to the Locator by answering a few questions about the services this facility
provides. Did you receive that letter?
•

YES, RECEIVED LETTER

GO TO #2a BELOW

•

NO, DID NOT RECEIVE LETTER

READ: Would you like me to read you the letter, or perhaps fax it to you?

•

READ LETTER

READ LETTER THEN GO TO #2a BELOW

•

FAX LETTER

READ: I will fax the letter today. You can visit the Locator at the Web address listed on the
letter. If you decide to participate, please call us at the toll-free number given on the letter.

2a. If you would like to be included on the Locator, we can ask you the questions now.
•

RESPONDENT WILL PROCEED WITH INTERVIEW

GO TO #2b BELOW

•

SCHEDULE CALLBACK AT CONVENIENT TIME

ENTER <4> ON MENU SCREEN

•

NO LONGER PROVIDES SUBSTANCE ABUSE TREATMENT

•

NEVER PROVIDED SUBSTANCE ABUSE SERVICES

•

DOES NOT WANT TO BE INCLUDED ON THE LOCATOR

•

SATELLITE FACILITY

ENTER <5> ON MENU SCREEN

2b. I will be asking you questions about [fill FACILITY NAME] at [fill LOCATION ADDRESS].
•

PROCEED WITH INTERVIEW

ENTER ON MENU SCREEN

•

CHANGE FACILITY NAME OR ADDRESS

ENTER<2>ON MENU SCREEN, MAKE CHANGE & RETURN TO MENU SCREEN

1

NATIONAL SURVEY OF SUBSTANCE ABUSE TREATMENT SERVICES

>a1<

[missing ][fill NFRi] MPRID = [fill csid]
Which of the following substance abuse services are offered by this facility, at this
location, that is [fill UFA@NAM1] [fill UFA@NAM2]located at fill LOC@UAD1]
[if LOC@UAD2 gt <> ] [fill LOC@UAD2][endif].
@1
@2
@3

Intake, assessment, or referral,
Detoxification,
Substance abuse treatment, by that we mean services that focus on
initiating and maintaining an individual’s recovery from substance abuse
and on averting relapse?

(1) YES (0) NO (d) DON’T KNOW (r) REFUSED
[if @2 eq <1> or @3 eq <1> goto a4] [if @2 eq <0> and @3 eq <0> goto 1a] [goto a1x]

>1a<

[missing ] [fill NFRi] MPRID = [fill csid]
You reported that this facility at this location does not offer detoxification or substance
abuse treatment. Is that correct?
<1> YES, THIS IS CORRECT
<0> NO, THIS IS NOT CORRECT. RETURN TO A1 FOR CORRECTION
DON’T KNOW
REFUSED

[if @ eq <0>][reset @][goto a1][endif] [if @ eq <1> goto a41]

2

>a1x< [missing ][fill NFRi] MPRID = [fill csid]
Could I speak with someone else who may be familiar with the day-to-day operation of
this facility?
(1) ENTER CONTACT PERSON’S NAME
(d) DON’T KNOW
(r) REFUSED
[if @an1 eq or @an1 eq ][skip][endif]
>a1y< [fill NFRi] MPRID = [fill csid]
Could I speak with [fill CPER]?
<1> YES [goto are5]
<2> NOT AVAILABLE - INTERVIEWER: Thank you, I will call back.
<3> CONNECTED TO ANSWERING MACHINE [goto are4_2]

>are4_2< [nodata]
INTERVIEWER: READ ANSWERING MACHINE MESSAGE THEN PRESS
ENTER TO INTERIM STATUS
>are5< [fill NFRi] MPRID = [fill csid]
Hello, my name is _________ and I am calling on behalf of the federal
Government’s annual survey of facilities that provide substance abuse
services. The survey is called the National Survey of Substance Abuse
Treatment Services or N-SSATS for short. I have a few questions I’d like
to ask you.
PROBE: This survey is sponsored by SAMHSA, the Substance Abuse and
Mental Health Services Administration.
<1> CONTINUE
<2> NOT A CONVENIENT TIME

[if @ eq <1> goto a1] [skip]

3

>a4<

[missing ][fill NFRi] MPRID = [fill csid]
What is the primary focus of [fill UFA@NAM1] [fill UFA@NAM2]
located at fill LOC@UAD1][if LOC@UAD2 eq <>]?[endif]
[if LOC@UAD2 gt <> ]fill LOC@UAD2][endif] Is it...
IF RESPONDENT GIVES MORE THAN ONE RESPONSE, PROBE:
Which do you consider the primary focus of this facility?
INTERVIEWER: CODE ONE ONLY
<1> substance abuse treatment services,
<2> mental health services,
<3> a mix of mental health and substance abuse treatment services,
where neither is primary,
<4> general health care, or
<5> something else? (SPECIFY) [specify] END WITH //
DON’T KNOW
REFUSED

>a8<

[missing ][fill NFRi] MPRID = [fill csid]
Is this facility a jail, prison, or other organization that provides
treatment exclusively for incarcerated persons or juvenile detainees?
<1> YES [goto a8a]
<0> NO [goto a10]
DON’T KNOW [goto a10]
REFUSED [goto a10]

>a8a< Just to confirm, this facility provides substance abuse treatment services only to
incarcerated persons or juvenile detainees. Is that correct?
<1> YES, THAT IS CORRECT [goto uloc5]
<0> NO, THAT IS NOT CORRECT [goto a8]

4

>a10< [missing ]
What telephone number or numbers should a potential client call to schedule an intake
appointment?
INTERVIEWER: IF AN ALPHA NUMBER IS REPORTED, RECORD IN THE
ALPHANUMERIC FIELD. ENTER ALL APPROPRIATE
SPACES, DASHES, ETC.
INTERVIEWER: IF R TELLS YOU THE INTAKE NUMBER IS THE SAME AS
THE NUMBER YOU CALLED, YOU MUST CONFIRM THAT
NUMBER. IT IS FILLED AT THE END OF RESPONSE
NUMBER 3 FOR THIS PURPOSE. YOU CANNOT ASSUME R
KNOWS WHICH NUMBER YOU CALLED TO REACH HIM.
(1) TO RECORD INTAKE PHONE NUMBER(S)
(2) DOES NOT APPLY (SPECIFY END WITH //)
(3) SAME NUMBER YOU JUST CALLED [fill AREA]-[fill PRFX:0]-[fill SUFX:0]
(4) SAME NUMBER YOU JUST CALLED [fill AREA]-[fill PRFX:0]-[fill SUFX:0]
PLUS ANOTHER NUMBER
(d) DON’T KNOW
(r) REFUSED
ENTER NUMERIC PHONE NUMBER (OPTIONAL):
ENTER EXTENSION (OPTIONAL)
ENTER NUMERIC PHONE NUMBER (OPTIONAL):
ENTER EXTENSION (OPTIONAL)
OR
ENTER ALPHA PHONE NUMBER:
ENTER EXTENSION (OPTIONAL)
ENTER ALPHA PHONE NUMBER (OPTIONAL):
ENTER EXTENSION (OPTIONAL)

>V10< [missing ] [fill NFRi] MPRID = [fill csid]
I’ve recorded [fill a10@ac] as the area code for the intake number. Is that correct?
<1> YES
<0> NO, MAKE NECESSARY CHANGE
DON’T KNOW
REFUSED

5

>V10b< [missing ][fill NFRi] MPRID = [fill csid]
I’ve recorded [fill a10@ac2] as the area code for the second intake number.
Is that correct?
<1> YES
<0> NO, MAKE NECESSARY CHANGE
DON’T KNOW
REFUSED

>V10c< [missing ][fill NFRi] MPRID = [fill csid]
I’ve recorded [fill a10@ac3] as the area code for [if a10@phn eq <>]the first[else]the
next[endif] intake number. Is that correct?
<1> YES
<0> NO, MAKE NECESSARY CHANGE
DON’T KNOW
REFUSED

>V10d< [missing ][fill NFRi] MPRID = [fill csid]
I’ve recorded [fill a10@ac4] as the area code for the next intake number.
Is that correct?
<1> YES
<0> NO, MAKE NECESSARY CHANGE
DON’T KNOW
REFUSED

6

>a11< [missing ][fill NFRi] MPRID = [fill csid]
Does this facility operate a hotline that responds to substance abuse problems? Do not
consider 911 or the local police number a hotline for the purpose of this survey.
PROBE: A hotline is a telephone service that provides information, referral, or
immediate counseling, frequently in a crisis situation.
PROBE IF NECESSARY: If this facility is part of a group of facilities that operates a
central hotline to respond to substance abuse problems, you should answer “yes.”
<1> YES [goto a11a]
<0> NO [goto a19]
DON’T KNOW [goto a19]
REFUSED [goto a19]

>a11a< [missing ][fill NFRi] MPRID = [fill csid]
What is this facility’s hotline telephone number or numbers?
INTERVIEWER: IF AN ALPHA NUMBER IS REPORTED, RECORD IN THE
ALPHANUMERIC FIELD. ENTER ALL APPROPRIATE
SPACES, DASHES, ETC.
(1) TO RECORD PHONE NUMBERS
(d) DON’T KNOW
(r) REFUSED
ENTER PHONE NUMBER:
ENTER SECOND OPTIONAL:
ENTER ALPHA NUMBER:

EXT:
EXT:
EXT:

ENTER SECOND ALPHA OPTIONAL:
[goto a12_1]

7

EXT:

>Va11a< [missing ] [fill NFRi] MPRID = [fill csid]
I’ve recorded [fill a11a@ac] as the area code(s) for the hotline.
Is that correct?
<1> YES
<0> NO, MAKE NECESSARY CHANGE
DON’T KNOW
REFUSED

>Va11a2< [missing ][fill NFRi] MPRID = [fill csid]
I’ve recorded [fill a11a@ac2] as the area code for the second hotline.
Is that correct?
<1> YES
<0> NO, MAKE NECESSARY CHANGE
DON’T KNOW
REFUSED

>Va11a3< [missing ][fill NFRi] MPRID = [fill csid]
I’ve recorded [fill a11a@ac3] as the area code for [if a11a@phn gt <>]the next[else] the
first[endif] hotline.
Is that correct?
<1> YES
<0> NO, MAKE NECESSARY CHANGE
DON’T KNOW
REFUSED

8

>Va11a4< [missing ][fill NFRi] MPRID = [fill csid]
I’ve recorded [fill a11a@ac4] as the area code for the next hotline.
Is that correct?
<1> YES [goto a12_1]
<0> NO, MAKE NECESSARY CHANGE
DON’T KNOW [goto a12_1]
REFUSED [goto a12_1]

>a19< [missing ] [fill NFRi] MPRID = [fill csid]
Does [fill UFA@NAM1] [fill UFA@NAM2] operate a methadone maintenance or
detoxification program at [fill LOC@UAD1] [if LOC@UAD2 eq <>]?[endif]
[if LOC@UAD2 gt <> ] [fill LOC@UAD2]
<1> YES [goto a19a]
<0> NO
DON’T KNOW
REFUSED
[goto a20]

>a19a< [missing ] [fill NFRi] MPRID = [fill csid]
Is the methadone program at this location a maintenance program, a detoxification
program, or both?
INTERVIEWER: MARK ONE ONLY
<1> MAINTENANCE PROGRAM
<2> DETOXIFICATION PROGRAM
<3> BOTH
DON’T KNOW
REFUSED

9

>a19b< [missing ] [fill NFRi] MPRID = [fill csid]
Are all of the substance abuse clients at this facility currently in the methadone program?
<1> YES
<0> NO
DON’T KNOW
REFUSED

>a20< [missing ] [fill NFRi] MPRID = [fill csid]
Does this facility offer a special program for DUI/DWI or other drunk driver offenders
at this location?
PROBE IF NECESSARY: You should answer “yes” if this facility serves only
DUI/DWI clients or if this facility has a special DUI/DWI program.
<1> YES [goto a20a]
<0> NO [goto a21]
DON’T KNOW [goto a21]
REFUSED [goto a21]
>a20a< [missing ] [fill NFRi] MPRID = [fill csid]
Does this facility serve only DUI/DWI clients?
<1> YES
<0> NO
DON’T KNOW
REFUSED

10

>a21< [missing ] [fill NFRi] MPRID = [fill csid]
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? You should answer “yes” if either a staff counselor or an
on-call interpreter provides this service.
<1> YES
<0> NO
DON’T KNOW
REFUSED

>a22< [missing ] [fill NFRi] MPRID = [fill csid]
Does this facility provide substance abuse treatment services in a language other than
English at this location? You should answer “yes” if either a staff counselor or an oncall interpreter provides this service.
<1> YES [goto a22a]
<0> NO [goto a23]
DON’T KNOW [goto a23]
REFUSED [goto a23]

>a22a< [missing ][fill NFRi] MPRID = [fill csid]
At this facility, who provides substance abuse treatment services in a language other
than English? Is it...
<1> A staff counselor that speaks a language other than English, [goto a22a1]
<2> An on-call interpreter brought in when needed, or [goto a23]
<3> Both a staff counselor and an on-call interpreter? [goto a22a1]
DON’T KNOW [goto a23]
REFUSED [goto a23]

11

>a22a1< [missing ][fill NFRi] MPRID = [fill csid]
Do staff counselors provide substance abuse treatment in Spanish at this facility?
<1> YES [goto a22a2]
<0> NO [goto a22b]
DON’T KNOW [goto a22a2]
REFUSED [goto a22a2]
>a22a2< [missing ][fill NFRi] MPRID = [fill csid]
Do staff counselors at this facility provide substance abuse treatment in any other
languages?
<1> YES [goto a22b]
<0> NO [goto a23]
DON’T KNOW [goto a23]
REFUSED [goto a23]
>a22b< [missing ][fill NFRi] MPRID = [fill csid]
In which of the following languages do staff counselors provide substance abuse
treatment at this facility?
(1) YES (0) NO (d) DON’T KNOW (r) REFUSED
@1 Hopi
@2 Lakota
@3 Navajo
@4 Yupik
@5 Any other American Indian or Alaska Native language (Specify)
@6 Arabic
@7 Chinese
@8 Creole
@9 French
@10 German
@11 Hmong
@12 Korean
@13 Polish
@14 Portuguese
@15 Russian
@17 Vietnamese
@18 Any other language (Specify)

12

>a22_ck< [missing ][fill NFRi] MPRID = [fill csid]
Are all of these languages spoken by a staff counselor? [FILL LANGUAGES]
<1> YES [goto a23]
<0> NO - GO BACK TO a22b FOR CORRECTION [goto a22a1]
DON’T KNOW [goto a23]
REFUSED [goto a23]
>a23<[missing ][fill NFRi] MPRID = [fill csid]
The next series of questions asks if specific types of clients are accepted
into treatment at this location . For each type of client accepted at this
facility, I will ask if this facility has a specially designed substance
abuse treatment program or group exclusively for that type of client.
Does [fill UFA@NAM1] [fill UFA@NAM2]
accept (READ CATEGORY) into treatment at this location?
(1) YES (0) NO (d) DON'T KNOW (r) REFUSED
@a1 Adolescents
READ IF NECESSARY: Adolescents could also be described as "youths" or "teens."
[if @a1 eq <1>]
@b1 Does this facility offer a specially designed substance abuse
treatment program or group exclusively for adolescents?
[else]
@a2 Clients with co-occurring mental and substance abuse disorders
[if @a2 eq <1>]
@b2 Does this facility offer a specially designed substance abuse
treatment program or group exclusively for
clients with co-occurring mental and substance abuse disorders?
[else]
@a3 Criminal justice clients other than DUI/DWI clients
[if @a3 eq <1>]

13

@b3 Does this facility offer a specially designed substance abuse
treatment program or group exclusively for criminal justice clients?
[else]
[fill NFRi] MPRID = [fill csid] Does [fill UFA@NAM1] [fill UFA@NAM2]
accept READ CATEGORY into treatment at this location?
@a4 Persons with HIV or AIDS
[if @a4 eq <1>]
@b4 Does this facility offer a specially designed substance abuse
treatment program or group exclusively for persons with HIV or AIDS?
[else]
@a5 Gays or lesbians
[if @a5 eq <1>]
@b5 Does this facility offer a specially designed substance abuse
treatment program or group exclusively for gays or lesbians?
[else]
@a6 Seniors or older adults
[if @a6 eq <1>]
@b6 Does this facility offer a specially designed substance abuse
treatment program or group exclusively for seniors or older adults?
[else]
@a7 Adult women
[if @a7 eq <1>]
@b7 Does this facility offer a specially designed substance abuse
treatment program or group exclusively for adult women?
[else]
[fill NFRi] MPRID = [fill csid] Does [fill UFA@NAM1] [fill UFA@NAM2]
accept READ CATEGORY into treatment at this location?
@a8 Pregnant or postpartum women
[if @a8 eq <1>]
@b8 Does this facility offer a specially designed substance abuse
treatment program or group exclusively for pregnant or postpartum women?
[else]
14

@a9 Adult men
[if @a9 eq <1>]
@b9 Does this facility offer a specially designed substance abuse
treatment program or group exclusively for adult men?
[else]
@b10 Does this facility offer specially designed substance abuse
treatment programs or groups exclusively for any other types of clients at
this location?
(1) YES (0) NO (d) DON'T KNOW (r) REFUSED

>a23b11< [missing ][fill NFRi] MPRID = [fill csid]
For what other types of clients does this facility offer specially designed substance abuse
treatment programs or groups?
<1> TO LIST [specify]
DON’T KNOW
REFUSED

>a24< [missing ][fill NFRi] MPRID = [fill csid]
Does this facility offer either of the following hospital inpatient substance abuse services
at this location, that is, [fill UFA@NAM1] [fill UFA@NAM2] located at
[fill LOC@UAD1] [if LOC@UAD2 gt <>]
[fill LOC@UAD2]
(1) YES (0) NO (d) DON’T KNOW (r) REFUSED
@1

Hospital inpatient detoxification. This is similar to ASAM levels
IV-D and III.7-D, medically managed or monitored inpatient
detoxification.
READ IF NECESSARY: ASAM is the American Society of Addiction Medicine.

@2

Hospital inpatient treatment. This is similar to ASAM levels
IV and III.7, medically managed or monitored intensive
inpatient treatment.

15

>a25< [missing ][fill NFRi] MPRID = [fill csid]
Does this facility offer any of the following residential non-hospital substance abuse
services at this location?
(1) YES (0) NO (d) DON’T KNOW (r) REFUSED
@1

Residential detoxification. This is similar to ASAM level
III.2-D, clinically managed residential detoxification or
social detoxification.
READ IF NECESSARY: ASAM is the American Society of Addiction Medicine.

@2

Residential short-term treatment. This is similar to ASAM level III.5,
clinically managed high-intensity residential treatment; typically 30 days
or less.

@3

Residential long-term treatment. This is similar to ASAM levels III.3
and III.1, clinically managed medium- or low-intensity residential
treatment; typically more than 30 days.

[PROGRAMMER: IF Q25.1 OR 25.2 OR 25.3 EQUALS “YES,” GOTO a12.39]

>a12.39< [missing [fill NFRi] MPRID = [fill csid]
Does this facility provide residential beds for clients’ children?
<1> YES
<0> NO
DON’T KNOW
REFUSED

16

>a26< [missing ][fill NFRi] MPRID = [fill csid]
Does this facility offer any of the following outpatient substance abuse services at this
location?
(1) YES (0) NO (d) DON’T KNOW (r) REFUSED
@1

Outpatient detoxification. This is similar to ASAM levels I-D
and II-D, ambulatory detoxification.
READ IF NECESSARY: ASAM is the American Society of Addiction Medicine.

@2

Outpatient methadone or buprenorphine maintenance, or
opioid maintenance therapy.

@3

Outpatient day treatment or partial hospitalization. This is similar to
ASAM level II.5, defined as 20 or more hours per week.

@4

Intensive outpatient treatment. This is similar to ASAM level II.1,
defined as 9 or more hours per week.

@5

Regular outpatient treatment. This is similar to ASAM level I,
outpatient treatment; non-intensive.

>Va26<[if Va26 eq <1> or Va26 eq <2>][store <> in Va26][endif][fill NFRi]MPRID =
[fill csid]
Two responses I recorded are inconsistent. I just recorded that this facility offers
outpatient methadone or buprenorphine maintenance, but earlier I recorded that it does
not operate a methadone maintenance program. Have I recorded something incorrectly?
<1> THIS FACILITY DOES OPERATE A METHADONE MAINTENANCE
PROGRAM CHANGE 19 AND CHECK FORWARD [goto a19]
<2> THIS FACILITY DOES NOT OFFER METHADONE OR BUPRENORPHINE
MAINTENANCE [goto a26@2] CHANGE 26_2
DON’T KNOW
REFUSED

17

>Va26a1< [missing ][fill NFRi] MPRID = [fill csid]
So, this facility does not offer hospital inpatient, residential, or outpatient substance
abuse care. Is that correct?
<1> YES, THAT IS CORRECT [goto Va26a2]
<0> NO, THAT IS NOT CORRECT - (THIS WILL RETURN TO a24)
DON’T KNOW [goto Va26a2]
REFUSED [goto Va26a2]

>Va26a2< [missing ][fill NFRi] MPRID = [fill csid]
What type of substance abuse treatment does this facility offer?
(1) TO RECORD VERBATIM AND END WITH //
(2) DOES NOT OFFER SUBSTANCE ABUSE TREATMENT SERVICES
(d) DON’T KNOW
(r) REFUSED
<1> [specify] [goto a27]
<2>

>a27< [missing ][fill NFRi] MPRID = [fill csid]
Does this facility use a sliding fee scale?
READ IF NECESSARY: A sliding fee scale adjusts the fee for service based on income
and other factors.
<1> YES [goto a27a]
<0> NO [goto a28]
DON’T KNOW [goto a28]
REFUSED [goto a28]

18

>a27a< [missing ][fill NFRi] MPRID = [fill csid]
Do you want the availability of a sliding fee scale listed in SAMHSA’s online Treatment
Facility Locator?
READ IF NECESSARY: The Locator is an online directory of substance abuse
treatment facilities in the United States and the services they offer. It also has a
mapping feature so clients can find facilities easily.
READ IF NECESSARY: The Locator will explain that sliding fee scales are
based on income and other factors.
<1> YES
<0> NO
DON’T KNOW
REFUSED

>a28< [missing ][fill NFRi] MPRID = [fill csid]
Does this facility offer treatment at no charge to clients who cannot afford to pay?
READ IF NECESSARY: “Treatment at no charge” means there are no out-of-pocket
expenses, or just token out-of-pocket expenses, for clients who cannot afford to pay for
treatment.
<1> YES [goto a28a]
<0> NO [goto a30]
DON’T KNOW [goto a30]
REFUSED [goto a30]

19

>a28a< [missing ][form template][fill NFRi] MPRID = [fill csid]
Do you want the availability of free care for eligible clients listed in SAMHSA’s online
Treatment Facility Locator?
READ IF NECESSARY: The Locator is an online directory of substance abuse
treatment facilities in the United States and the services they offer. It also has a
mapping feature so clients can find facilities easily.
READ IF NECESSARY: The Locator will explain that potential clients should call the
facility for information on eligibility.
<1> YES
<0> NO
DON’T KNOW
REFUSED

>a30< [missing ][fill NFRi] MPRID = [fill csid]
Which of the following types of client payments or insurance are accepted by this
facility for substance abuse treatment?
@1
@2

Cash or self-payment
Medicare
READ IF NECESSARY: Medicare is the federal health insurance program
for people age 65 and older and people with disabilities.

@3

Medicaid
READ IF NECESSARY: Medicaid is a joint federal and state program
that helps with medical costs for some people with low incomes and limited
resources. Medicaid programs vary from state to state.

@4

@5
@6
@7
@8

A state-financed health insurance plan other than Medicaid,
for example, State Children’s Health Insurance Program (SCHIP) or
high risk insurance pools
Federal military insurance such as TRICARE or Champ-VA
Private health insurance
Access to Recovery, or ATR, vouchers
Is treatment for all clients free of charge, that is, no
payment is required from the clients?

(1) YES (0) NO (d) DON’T KNOW (r) REFUSED

20

>a30a< [missing ][fill NFRi] MPRID = [fill csid]
INTERVIEWER: DO NOT READ. IF OTHER TYPES OF PAYMENT ARE
VOLUNTEERED, RECORD HERE. OTHERWISE, PRESS “0”
TO PROCEED.
<1>

TO RECORD OTHER TYPES OF PAYMENTS ACCEPTED - SPECIFY AND
END WITH //[specify]

<0>

NO OTHER PAYMENTS VOLUNTEERED

>a41< [missing ][fill NFRi] MPRID = [fill csid]
Does this facility operate a halfway house or other transitional housing for substance
abuse clients at this location, that is, fill UFA@NAM1] [fill UFA@NAM2] located at
[fill LOC@UAD1][if LOC@UAD2 eq <>]?[endif] if LOC@UAD2 gt <>]
[fill LOC@UAD2]?
<1> YES
<0> NO
DON’T KNOW
REFUSED
[if a1@2 eq <0> and a1@3 eq <0> and a41 eq <0> goto uloc5]

>a44< [missing ] [if URL ne <> goto a44a] [fill NFRi] MPRID = [fill csid]
Does this facility have a website or web page with information about the facility’s
substance abuse treatment programs?
<1> YES [goto a44b]
<0> NO [goto a45]
DON’T KNOW [goto a45]
REFUSED [goto a45]

21

>a44a< [missing ][fill NFRi] MPRID = [fill csid]
Our records show you have a website at [fill URL]. Is that correct?
<1> YES [goto a45]
<2> NO, CHANGE URL [goto a44b]
<0> NO, DO NOT HAVE A WEBSITE [goto a45]
DON’T KNOW [goto a45]
REFUSED [goto a45]

>a44b< [missing ][fill NFRi] MPRID = [fill csid]
The website address for this facility will appear in the Locator. Please give me the
website address exactly as it should be entered in order to reach your website.
INTERVIEWER:
1) DO NOT RECORD “http://” AT THE BEGINNING OF A WEB ADDRESS.
2) IF “WWW” IS NOT REPORTED AT THE BEGINNING OF THE WEB
ADDRESS, ASK IF IT IS NEEDED AND CHANGE IF NECESSARY.
3) IF AN “AT” SIGN IS REPORTED IN THE WEB ADDRESS, ASK IF THIS IS
REALLY AN E-MAIL ADDRESS. IF SO, DO NOT RECORD HERE.
(1) TO RECORD WEB SITE ADDRESS
(d) DON’T KNOW
(r) REFUSED
[if @an eq <1>]RECORD WEB SITE ADDRESS @web [endif]

>a45< [missing ][fill NFRi] MPRID = [fill csid]
Does this facility want to be listed in SAMHSA’s online Treatment Facility Locator?
READ IF NECESSARY: The Locator is an online Directory listing all the substance
abuse treatment facilities in the United States and the services they offer. It also
includes a mapping feature so clients can find facilities easily.
<1> YES
<0> NO
DON’T KNOW
REFUSED

22

>aM1< [missing ][fill NFRi] MPRID = [fill csid]
Is this facility part of an organization with multiple facilities or sites that provide
substance abuse treatment?
<1> YES [goto aM2]
<0> NO [goto uloc]
DON’T KNOW [goto uloc]
REFUSED [goto uloc]

>aM2< [missing ][fill NFRi] MPRID = [fill csid]
What is the name, address, and phone number of the facility that is the parent, or master
site, of the organization?
FACILITY NAME:
@nam1
FACILITY NAME (CONT): @nam2
ADDRESS 1:
@ad1
ADDRESS 2:
@ad2
CITY/STATE/ZIP: @cit @st @zip5 - @zip4
FACILITY PHONE: @phn
Extension: @

>uloc< [missing ]
I’d like to make a final verification of the name, address, and phone number that will be
listed in the Treatment Facility Locator [endif] for this facility:
[fill UFA@NAM1]
[fill UFA@NAM2]
[FILL LOC@UAD1]
[FILL LOC@UAD2]
[FILL LOC@UCTY], [FILL LOC@UST] [FILL LOC@UZP5:0]-[FILL LOC@UZP4]
And the facility’s main telephone number is: ([fill FARE]) [fill FPRF:0]-[fill FSUX:0]
EXT: [fill FACN@PEXT]
(1) YES, FACILITY NAME, ADDRESS & PHONE NUMBER ARE CORRECT
(0) NO, MAKE CORRECTIONS (d) DON’T KNOW (r) REFUSED
FACILITY NAME:
FACILITY NAME (CONT):
ADDRESS 1:
ADDRESS 2:
CITY/STATE/ZIP:
FACILITY PHONE:
Extension:

23

>other_1< [missing ][fill NFRi] MPRID = [fill csid]
I’ve recorded [fill uloc@ac] as the area code. Is that correct?
<1> YES [goto other2]
<0> NO, MAKE NECESSARY CHANGE
d> DON’T KNOW [goto other2]
REFUSED [goto other2]

>other2< [fill NFRi] MPRID = [fill csid]
Is there another substance abuse treatment facility in your organization that is currently
located at [fill LOC@UAD1] fill LOC@UAD2] [fill LOC@UCTY], [fill LOC@UST]
[fill LOC@UZP5:0]-[fill LOC@UZP4:0]
<1> YES
<0> NO
<3> The location address has been edited but it is the same address

>uloc2< [missing ][fill NFRi] MPRID = [fill csid]
I would also like to verify this facility’s fax number. Our records show: ([fill fac])
[fill fexc:0]-[fill fnum:0]. Is that correct?
<1> YES, FAX NUMBER IS CORRECT [goto uloc5]
<0> NO, FAX NUMBER IS NOT CORRECT, MAKE CHANGES [goto uloc4]
<2> NO LONGER HAVE FAX MACHINE [goto uloc5]
DON’T KNOW [goto uloc5]
REFUSED [goto uloc5]

>uloc3< [missing ][fill NFRi] MPRID = [fill csid]
Does this facility have a fax machine?
<1> YES
<0> NO [goto uloc5]
DON’T KNOW [goto uloc5]
REFUSED [goto uloc5]

24

>uloc4< [fill NFRi] MPRID = [fill csid]
What is your fax number:
ENTER FAX NUMBER:

>other_3< [missing ][fill NFRi] MPRID = [fill csid]
I’ve recorded [fill uloc4@ac] as the area code for the fax number.
Is that correct?
<1> YES [goto uloc5]
<0> NO, MAKE NECESSARY CHANGE
DON’T KNOW [goto uloc5]
REFUSED [goto uloc5]
[goto uloc4]

>uloc5< [fill NFRi] MPRID = [fill csid]
INTERVIEWER: ENTER RESPONDENT’S NAME. IF NOT KNOWN, ASK.

>uloc1a2< [fill NFRi] MPRID = [fill csid]
I may need to call you back regarding your new address. A note on my computer
indicates there may be duplicate information in our database.
ENTER <1> TO CONTINUE
ENTER CALL BACK DATE AND TIME IN SUPERVISOR NOTES
<2> SUPERVISOR APPROVED

INTERVIEWER: ARE THERE ANY REASONS/PROBLEMS WITH THIS CASE
THAT A SUPERVISOR SHOULD REVIEW BEFORE IT IS
FINAL STATUS?
<1> YES, SUPERVISOR REVIEW
<0> NO PROBLEMS, FINAL STATUS

25

Public 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, 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.

26