Form Attachment A3 - Au Attachment A3 - Au Attachment A3 - Augmentation screener

Attachment A3
Augmentation screener questionnaire

Attachment A3 (Augmentation screener questionnaire)
OMB No: 0930-xxxx
APPROVAL EXPIRES: xx/xx/xxxx

U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administration

2010 N-SSATS AUGMENTATION SCREENER
Public burden for this collection of information is estimated to average 5 minutes per response. 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.

MPR ID:

DATE: |

|___|___|___|___|___|___|___|

|

|/|

MONTH

FINAL STATUS:

|___|___|___|

|

| 2010

DAY

INT ID#: |___|___|___|___|___|

001 = COMPLETE
004 = PHYSICALLY CLOSED
005 = CAN’T LOCATE
006 = NO PARTICIPATION
(EFFORT ENDED)
007 = REFUSED

008 = INELIGIBLE
024 = DUPLICATE FACILITY
034 = MERGED FACILITY
044 = NO SUBSTANCE
ABUSE TREATMENT

054 = SATELLITE FACILITY
072 = HALFWAY HOUSE ONLY FACILITY

IF NO ANSWER:
BUSY  CALLBACK IN 10 MINUTES
ANSWERING MACHINE (Facility name verified) 

 CALLBACK IN 1 HOUR

ANSWERING MACHINE (Facility name NOT verified) 

 CALLBACK IN 1 HOUR

NON-WORKING/FAX/FUNNY NUMBER  CHECK THIS BOX  AND PLACE IN
LOCATING BASKET

A1.

Hello, this is [INTERVIEWER] calling on behalf of SAMHSA, the federal government‟s Substance Abuse and
Mental Health Services Administration. SAMHSA is currently updating it‟s listing of facilities that provide
substance abuse services. I would like to verify some address information with you.
IF SUBSTANCE ABUSE SERVICES CLEARLY NOT PROVIDED, CHECK THIS BOX  SKIP TO “END” (PAGE 4)
1

 WRONG NUMBER  PLACE IN LOCATING BASKET

2

 APPROPRIATE RESPONDENT; CONTINUE  SKIP TO B1 (PAGE 2)

3

 APPROPRIATE RESPONDENT; NEEDS CALLBACK 

4

 NOT APPROPRIATE RESPONDENT

RECORD BEST TIME TO CALL BACK ON
CONTACT SHEET (INCLUDE DAY, DATE AND
TIME) AND READ:
Thank you very much. I‟ll call back at that time.

A2.

With whom should I speak? RECORD NAME OF CONTACT PERSON BELOW
_________________________________________________________________

A3.

May I speak with [NAME OF CONTACT PERSON]?
1

 AVAILABLE: WHEN RESPONDENT COMES TO PHONE, READ INTRO (A1) GO TO B1 (PAGE 2)

2

 NOT AVAILABLE 

RECORD BEST TIME TO CALL BACK ON CONTACT SHEET (INCLUDE DAY,
DATE AND TIME) AND READ:
Thank you very much. I‟ll call back at that time.

1

B1.

First, I‟d like to confirm that this is [FACILITY NAME], located at [LOCATION ADDRESS]. Is that correct?
IF SUBSTANCE ABUSE SERVICES CLEARLY NOT PROVIDED, CHECK THIS BOX  SKIP TO “END” (PAGE 4)

B2.

1

 YES, NAME AND ADDRESS CORRECT  SKIP TO B3

0

 NO, NAME AND/OR ADDRESS INCORRECT

RECORD CORRECT INFORMATION BELOW:
NAME:
STREET:
CITY/TOWN:

B2a.

B2b.

STATE:

ZIP:

INTERVIEWER: DID THE ADDRESS CHANGE?
1

 YES

0

 NO  SKIP TO B2d

Is there another substance abuse treatment facility in your organization that is currently located at
[LOCATION ADDRESS]?
1

 YES 

0

 NO  SKIP TO B2d

B2b.1 We need to collect information about that specific location. Could
you give me the TELEPHONE number for that location?
(_______) - ___________ -___________ _________

B2c.

INTERVIEWER: SKIP TO END. CROSS OUT RESPONSE TO B2 ON SCREENER. UPDATE CONTACT
SHEET WITH NEW TELEPHONE NUMBER. CALL THIS NUMBER AND BEGIN WITH A1.

B2d.

INTERVIEWER: DID THE FACILITY NAME CHANGE?

B2e.

B2f.

1

 YES

0

 NO  SKIP TO B3

Was this facility ever called [FACILITY NAME]?
1

 YES  SKIP TO B3

0

 NO

Does this facility provide substance abuse treatment services at this location?
1

 YES

0

 NO  GO TO END

2

B2g.

INTERVIEWER: COMPLETE “NEW FACILITY SHEET” WHILE RESPONDENT IS ON THE PHONE. THEN,
SKIP TO END. CODE A1 ON SCREENER AS „WRONG NUMBER‟. PLACE SCREENER AND CONTACT
SHEET IN LOCATING BASKET, AND “NEW FACILITY SHEET” IN RECEIPT CONTROL BASKET.

B3.

Does this facility, that is, the facility located at [LOCATION ADDRESS], have a licensed, certified or
accredited substance abuse treatment program or unit at this address?

B4.

1

 YES

0

 NO  SKIP TO B4a

Which of the following substance abuse services are offered by this facility, that is, the facility located at
[LOCATION ADDRESS]?
PROBE IF NECESSARY: Please report for only this location.
MARK “YES” OR “NO”
FOR EACH

YES

B4a.

B4b.

B5.

B5a.

NO

1.

Intake, assessment, or referral ........................................................ 1 

2.

Detoxification ..................................................................................... 1 


0

3.

Substance abuse treatment, that is services that focus on
initiating and maintaining an individual‟s recovery from
substance abuse and on averting relapse ..................................... 1 

0

0



Does this facility operate a halfway house or other transitional housing for substance abuse clients at this
location?
1

 YES

0

 NO

INTERVIEWER: DID THE RESPONDENT ANSWER “YES” TO DETOXIFICATION OR SUBSTANCE ABUSE
TREATMENT IN B4 ABOVE (CATEGORIES 2 or 3) OR “YES” TO HALFWAY HOUSE IN B4a?
1

 YES

0

 NO  SKIP TO END (FINAL STATUS CODE “044”)

Is [LOCATION ADDRESS] also the mailing address for this facility?
1

 YES  SKIP TO B6

0

 NO

What is the mailing address for [FACILITY NAME] located at [LOCATION ADDRESS]?
NAME:
STREET:
CITY/TOWN:

STATE:

3

ZIP:

B6.

B7.

Does [FACILITY NAME] have a FAX number?
1

 YES 

B6a. What is that FAX number? (_______) - ___________ -___________

0

 NO

_________________

ASK IF NEEDED, OTHERWISE, VERIFY AND RECORD WITHOUT ASKING: Finally, who is the facility
director for [FACILITY]? (RECORD BELOW)

END: Those are all the questions I have. Thank you very much for your time.

INTERVIEWER:

FINAL STATUS AND PLACE IN COMPLETED BASKET.

NOTES:

4