Client Instruments Client Instruments

Form Approved
OMB No. ####-####
Expiration Date: ##/##/####

TCE-HIV Multi-Site Evaluation
6-MONTH FOLLOW-UP Client-Level Survey
Funding for data collection supported by the
Center for Substance Abuse Treatment (CSAT)
Substance Abuse and Mental Health Services Administration (SAMHSA)
U.S. Department of Health and Human Services (HHS)

Instructions: These instructions are for program staff administering the TCE-HIV Multi-Site Evaluation
Client-Level Survey. The Client-Level Survey should be administered by program staff at baseline (based
on the program’s definition of baseline), discharge, and 6-months post-baseline to all clients receiving
TCE-HIV services. Please note that this version of the Client-Level Survey is to be used at the 6MONTH FOLLOW-UP (i.e., 6-months post-intake/baseline) only.
The Client-Level Survey includes six sections: Background Information, Risky Behaviors, HIV Testing/HIV
Status, Social Support, Mental Health and Medical Health, and Motivation for Treatment. All questions in
Sections A – F should be asked of the client.
Please read the introduction to each section (in italics) and then read each question to the client as it is
written. For some questions, you will read the response options to clients. Other questions are openended and you will not read the response options to clients. Please see the note in italics next to each
question to determine whether you should read the response options. Some questions require the use of
response options cards. Please provide the response options card to clients when noted.
You may provide clarification to the client to help them in understanding the question, but please do not
change the wording of the questions.

The Client-Level Survey should take approximately 25 minutes to administer.

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, if all items are asked of a client/participant; to the extent that providers already obtain much of this
information as part of their ongoing client/participant intake or follow-up, less time will be required. Send comments regarding this
burden estimate or any other aspect of this collection of information 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 control number for this project is ####-####.

F/U 1

Form Approved
OMB No. ####-####
Expiration Date: ##/##/####

TCE-HIV Multi-Site Evaluation
Client-Level Survey

6-MONTH FOLLOW-UP
Funding for data collection supported by the Center for Substance Abuse Treatment (CSAT)
Substance Abuse and Mental Health Services Administration (SAMHSA)
U.S. Department of Health and Human Services (HHS)

Grantee ID

TI0 ___ ___ ___ ___ ___ ___

Partner ID (if applicable)

TI0 ___ ___ ___ ___ ___ ___ - ___ ___ ___

Client ID ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
(Please use the same Client ID that was assigned to the client for the GPRA)

Date of Administration (mm/dd/yyyy)

___ ___ / ___ ___ / ___ ___ ___ ___

PROGRAM STAFF: Please complete the following client background questions
using information collected from the 6-months post-intake/baseline GPRA.
Client’s Gender

Male

Female

Transgender

Refused

Other (specify) ________________________

Client’s Ethnicity: Is the client
Hispanic or Latino?
Client’s Race

Yes

No

Refused

Alaska Native
American Indian
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Refused

Client’s Age

___ ___

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, if all items are asked of a client/participant; to the extent that providers already obtain much of this
information as part of their ongoing client/participant intake or follow-up, less time will be required. Send comments regarding this
burden estimate or any other aspect of this collection of information 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 control number for this project is ####-####.

F/U 2

Client ID: ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
(Please use the same Client ID that was assigned to the client for the GPRA)

Program Staff: The purpose of these questions is to get more information about how best to provide
services. We are asking these questions because it is a requirement for us from the Federal government
who gave us funding to provide services to you. All your background information and survey answers will
be kept strictly confidential. All survey answers will be provided to the Federal government using only a
number for you so there will be no way they can identify who you are. If you have any questions,
comments, or concerns they can be directed to Resa Matthew, Ph.D. at 240-645-4608.
A. Background Information
Program Staff: First, I am going to ask you some questions about yourself.
A1. What is your marital status? Do not read response options.
1

Never Married/Single

2

Married

3

Living as Married

4

Separated

5

Divorced

6

Widowed

88

Refused

A2. In the past 30 days, with whom or where have you lived? You may say yes to more than one.
Please read response options.

88

Alone

With parents

With children alone

With other family members

With significant other alone

With friends

With significant other and children

In jail (short-term)

In prison (long-term)

In a hospital

In residential treatment

Other (specify) _________________

Refused

B. Risky Behaviors

Program Staff: The next set of questions asks about any behaviors that you may engage in that may put
you at risk for substance use disorders or HIV/AIDS. I realize these questions are very personal, but your
open and honest answers are very important. There are no right or wrong answers.
B1. Did you use alcohol or drugs since leaving treatment? Do not read response options.
1

Yes (specify what substances were used since leaving treatment) __________

0

No

88

Refused

66

Don’t Know

Program Staff: If clients reported alcohol or drug use in Question B1 above please skip to
question B3 below. Only ask question B2 below to clients who reported no alcohol or drug
use in Question B1 above.

F/U 3

B2. You reported that since leaving treatment you did not use alcohol or drugs. What were your
reasons for not using any alcohol or drugs? You may say yes to more than one. Please read
response options.
1

In jail/prison

4

Medical hospitalization

2

On probation/parole

5

Inpatient mental health treatment

3

Lack of money

6

Residential substance use treatment

7

Other (specify) ___________________________

77

Not applicable – used alcohol and/or drugs since leaving treatment.

88

Refused

Program Staff: The next set of questions asks about your sexual behaviors. Again, I realize these
questions are very personal, but your open and honest answers are very important.
B3. In the past 30 days, did you engage in unprotected sexual activity with a male partner? Do not
read response options.
1

Yes

0

No

66

Don’t Know

Refused

88

B4. In the past 30 days, did you engage in unprotected sexual activity with a female partner? Do not
read response options.
1

Yes

0

No

66

Don’t Know

Refused

88

B5. In the past 30 days, did you engage in unprotected sexual activity with both a male partner and a
female partner? Do not read response options.
1

Yes

0

No

66

Don’t Know

Refused

88

***Program Staff: Only ask questions B6a – B6j of those clients who reported having unprotected
sexual contact during the past 30 days. If the client did not report having unprotected sexual
contact during the past 30 days, please skip to Question C1 below.
If the client reported having unprotected sexual contact ONLY with a male partner, please ask only
questions B6a, B6c, B6e, B6g, and B6i.
If the client reported having unprotected sexual contact ONLY with a female partner, please ask
questions B6b, B6d, B6f, B6h, and B6j.
If the client reported having unprotected sexual contact with BOTH a male partner and a female
partner please answer all questions in B6a – B6j. ***
B6. In the past 30 days, did you have…
Oral Sex

a. Unprotected
sexual
contact with
a male
partner?

1#

of times ___

0 No
66 Don’t

Vaginal Sex

1#

of times ___

0 No

Know

66 Don’t

Anal Sex

1#

of times ___

0 No

Know

66 Don’t

Did you use any of
the following before
or during… (check all
that apply)
1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

77 N/A

77 N/A

4 Cocaine/ Crack

88 Refused

88 Refused

88 Refused

5 Other

______

66 Don’t

Know

F/U 4

Oral Sex

Vaginal Sex

Anal Sex

Did you use any of
the following before
or during… (check all
that apply)
77 N/A
88 Refused

b. Unprotected
sexual
contact with
a female
partner?

1#

of times ___

0 No
66 Don’t

1#

of times ___

0 No

Know

66 Don’t

1#

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

77 N/A

77 N/A

4 Cocaine/ Crack

88 Refused

88 Refused

88 Refused

5 Other

______

66 Don’t

Know

77 N/A
88 Refused

c.

Unprotected
sex with a
male
partner in
exchange for
money,
drugs, or
shelter?

1#

of times ___

0 No
66 Don’t

1#

of times ___

0 No

Know

66 Don’t

1#

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

77 N/A

77 N/A

4 Cocaine/ Crack

88 Refused

88 Refused

88 Refused

5 Other

______

66 Don’t

Know

77 N/A
88 Refused

d. Unprotected
sex with a
female
partner in
exchange for
money,
drugs, or
shelter?

1#

of times ___

0 No
66 Don’t

1#

of times ___

0 No

Know

66 Don’t

1#

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

77 N/A

77 N/A

4 Cocaine/ Crack

88 Refused

88 Refused

88 Refused

5 Other

______

66 Don’t

Know

77 N/A
88 Refused

e. Unprotected
sex with a
male
partner you
know had, or
suspected of
having a
sexually
transmitted
disease
(STD)?
f. Unprotected
sex with a
female
partner you

1#

of times ___

0 No
66 Don’t

1#

of times ___

0 No

Know

66 Don’t

1#

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

77 N/A

77 N/A

4 Cocaine/ Crack

88 Refused

88 Refused

88 Refused

5 Other

______

66 Don’t

Know

77 N/A
88 Refused
1#

of times ___

0 No
66 Don’t

1#

of times ___

0 No

Know

66 Don’t

1#

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

F/U 5

Oral Sex

know had, or
suspected of
having a
sexually
transmitted
disease
(STD)?
g. Unprotected
sex with a
male
partner you
know had, or
suspected of
having
HIV/AIDS?

Vaginal Sex

Anal Sex

77 N/A

77 N/A

77 N/A

88 Refused

88 Refused

88 Refused

Did you use any of
the following before
or during… (check all
that apply)
4 Cocaine/ Crack
5 Other

______

66 Don’t

Know

77 N/A
88 Refused
1#

of times ___

0 No
66 Don’t

1#

of times ___

0 No

Know

66 Don’t

1#

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

77 N/A

77 N/A

4 Cocaine/ Crack

88 Refused

88 Refused

88 Refused

5 Other

______

66 Don’t

Know

77 N/A
88 Refused

h. Unprotected
sex with a
female
partner you
know had, or
suspected of
having
HIV/AIDS?

1#

of times ___

0 No
66 Don’t

1#

of times ___

0 No

Know

66 Don’t

1#

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

77 N/A

77 N/A

4 Cocaine/ Crack

88 Refused

88 Refused

88 Refused

5 Other

______

66 Don’t

Know

77 N/A
88 Refused

i.

Unprotected
sex with a
male
partner you
knew was, or
suspected of
being an
injection
drug user?

1#

of times ___

0 No
66 Don’t

1#

of times ___

0 No

Know

66 Don’t

1#

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

77 N/A

77 N/A

4 Cocaine/ Crack

88 Refused

88 Refused

88 Refused

5 Other

______

66 Don’t

Know

77 N/A
88 Refused

j.

Unprotected
sex with a
female
partner you
knew was, or
suspected of
being an
injection
drug user?

1#

of times ___

0 No
66 Don’t

1#

of times ___

0 No

Know

66 Don’t

1#

of times ___

0 No

Know

66 Don’t

1 Alcohol
2 Marijuana

Know

3 Heroin

77 N/A

77 N/A

77 N/A

4 Cocaine/ Crack

88 Refused

88 Refused

88 Refused

5 Other

______

66 Don’t

Know

77 N/A
88 Refused

F/U 6

C. HIV Testing/HIV Status

Program Staff: These questions ask about whether you have ever been tested for HIV and your HIV
status as well as other sexually transmitted infections (STIs).
C1. In that past 12 months, have you been diagnosed with a sexually transmitted infection (STI) other
than HIV? Do not read response options.
1

Yes

0

No

66

Don’t Know

88

Refused

C2. Have you ever tested positive for HIV? Do not read response options.
1

Yes

0

No

66

Don’t Know

88

Refused

****Program Staff: If client answered No, Don’t Know, or Refused to Question C2, please skip to
Question D1****
C3. How long have you known you were HIV positive? Do not read response options.
1

30 days or less

2

Greater than 30 days

66

Don’t Know

77

Not applicable – Not HIV positive.

88

Refused

Program Staff: Next, I am going to ask you some questions about whether you have changed your
behavior since you found out you were HIV positive. I am going to read each answer option and please
use Response Card A to tell me how much you have changed your behavior. Please select only one
choice for each statement. [Please read response options].
Since you found out you were HIV
positive, how much have you changed…

Not at
all

A little
bit

Moderately

Quite
a bit

Extremely

N/A

Refused

C4.

Sharing drug injection equipment
(needles/syringes) without first
cleaning it with anything?

1

2

3

4

5

77

88

C5.

Sharing drug injection equipment
(needles/syringes) with someone
you know had, or suspected of
having HIV/AIDS?

1

2

3

4

5

77

88

C6.

Having unprotected sexual
contact?

1

2

3

4

5

77

88

C7.

Having unprotected sex with
someone in exchange for money,
drugs, or shelter?

1

2

3

4

5

77

88

C8.

Having unprotected sex with a
partner you know had, or
suspected of having a sexually
transmitted disease (STD)?

1

2

3

4

5

77

88

C9.

Having unprotected sex with a
partner you know had, or
suspected of having HIV/AIDS?

1

2

3

4

5

77

88

C10.

Having unprotected sex with

1

2

3

4

5

77

88

F/U 7

Since you found out you were HIV
positive, how much have you changed…

Not at
all

A little
bit

1

2

Moderately

Quite
a bit

Extremely

N/A

Refused

someone you know was, or
suspected of being an injection
drug user?
C11.

Having unprotected sex while you
were under the influence of drugs
or alcohol?

3

4

5

77

88

D. Social Support

Program Staff: Next, I am going to ask you some questions about the important people in your life. I am
going to read each answer option and please indicate how much you agree or disagree with each
statement below using Response Card B. Please select only one choice for each statement. [Please read
response options].
Disagree
Strongly

Disagree

Uncertain

Agree

Agree
Strongly

Refused

D1.

You have people close to you who
motivate and encourage your recovery.

1

2

3

4

5

88

D2.

You have close family members who
help you stay away from drugs.

1

2

3

4

5

88

D3.

You have good friends who do not
use drugs.

1

2

3

4

5

88

D4.

You have people close to you who
can always be trusted.

1

2

3

4

5

88

D5.

You have people close to you who
understand your situation and
problems.

1

2

3

4

5

88

D6.

You work in situations where drug
use is common.

1

2

3

4

5

88

D7.

You have people close to you who
expect you to make positive changes
in your life.

1

2

3

4

5

88

D8.

You have people close to you who
help you develop confidence in
yourself.

1

2

3

4

5

88

D9.

You have people close to you who
respect you and your efforts in this
program.

1

2

3

4

5

88

D10.

In the past 30 days, did you attend any self-help groups for recovery (e.g., NA, AA, SMART
Recovery)? Do not read response options.
1

Yes (specify how many times) __________

0

No

88

Refused

F/U 8

E. Mental Health and Medical Health

Program Staff: These questions ask about different areas of your life such as your emotional and
physical health.
Mental Health
Program Staff: Next I have a list of problems people sometimes have. As I read each one to you, I want
you to tell me how much that problem has distressed or bothered you during the past 30 days including
today using Response Card A. [Please read response options].
During the past 30 days, how much were you
distressed by…

Not at
all

A little
bit

Moderately

Quite
a bit

Extremely

Refused

E1.

Nervousness or shakiness inside

1

2

3

4

5

88

E2.

Thoughts of ending your life

1

2

3

4

5

88

E3.

Suddenly scared for no reason

1

2

3

4

5

88

E4.

Feeling lonely

1

2

3

4

5

88

E5.

Feeling blue

1

2

3

4

5

88

E6.

Feeling no interest in things

1

2

3

4

5

88

E7.

Feeling fearful

1

2

3

4

5

88

E8.

Feeling hopeless about the future

1

2

3

4

5

88

E9.

Feeling tense or keyed up

1

2

3

4

5

88

E10.

Spells of terror or panic

1

2

3

4

5

88

E11.

Feeling so restless you couldn’t sit still

1

2

3

4

5

88

E12.

Feelings of worthlessness

1

2

3

4

5

88

E13.

E14.

E15.

In the past 30 days, how often have you used drugs (including prescription drugs) or alcohol to
help you cope with stressful life events? I am going to read each answer option and please use
Response Card A to provide your answer. [Please read response options].
1

Not at all

2

A little bit

3

Moderately

4

Quite a bit

5

Extremely

88

Refused

During the past 3 months, did you receive services for mental or emotional difficulties (i.e.,
inpatient, outpatient, emergency room)? Do not read response options.
1

Yes (specify how many times) __________

88

Refused

0

No

During the past 3 months, were you prescribed a medication for mental or emotional difficulties
(e.g., Prozac, Cymbalta)?
1

Yes (specify medications) __________

88

Refused

0

No

F/U 9

E16.

E17.

Why did you enroll in this treatment program? Do not read response options.
1

Self-admitted

88

Refused

2

Court Mandated

3

Other (specify) _____________

Which drug(s) did you want to address in this treatment program?
Specify: ______________________________________________________________________
66

E18.

Don’t Know

88

Refused

If you are receiving other substance abuse treatment services, how much of your care is
provided by this agency/organization? Please read response options.
0

I do not receive other substance abuse treatment services

1

I receive most of my care from this agency/organization

2

I receive about half of my care from this agency/organization and half from another
agency/organization

3

I receive most of my care from another agency/organization

Medical Health
E19.

In the past 30 days, did you have any type of health insurance for yourself? Please read
response options.
Yes, private health insurance (e.g., through an employer/union, privately purchased)
Yes, Medicare
Yes, Medicaid
88

E20.

E21.

Yes, other Government health insurance
0

No

Refused

During the past 30 days, did you receive medical treatment (not including substance abuse
treatment) for physical illness or injury (i.e., inpatient, outpatient, emergency room)? Do not read
response options.
1

Yes (specify how many times) __________

88

Refused

0

No

During the past 30 days, for about how many days did poor physical health keep you from doing
your usual activities, such as self-care, work, or recreation? Do not read response options.
Number of days __________

88

Refused

F/U 10

F. Motivation for Treatment

Program Staff: The following questions ask about your attitudes toward substance abuse treatment.
Each of the following statements describes a way that you might (or might not) feel about your drug use.
For each statement, I am going to read each answer option and please use Response Card C to indicate
how much you agree or disagree with each statement right now. [Please read response options].
Note: If the client’s primary substance of choice is alcohol, please replace underlined words with the
wording changes suggested in [ ] below.
Strongly
Disagree
1

Disagree

Undecided
or Unsure
3

Agree

Strongly
Agree
5

Refused

F1.

I have already started making
some changes in my use of
drugs [drinking].

F2.

I was using drugs [drinking] too
much at one time, but I’ve
managed to change that [my
drinking].

1

2

3

4

5

88

F3.

I’m not just thinking about
changing my drug use [drinking],
I’m already doing something
about it.

1

2

3

4

5

88

F4.

I have already changed my drug
use [drinking], and I am looking
for ways to keep from slipping
back to my old pattern.

1

2

3

4

5

88

F5.

I am actively doing things now to
cut down or stop my use of drugs
[drinking].

1

2

3

4

5

88

F6.

I want help to keep from going
back to the drug [drinking]
problems that I had before.

1

2

3

4

5

88

F7.

I am working hard to change my
drug use [drinking].

1

2

3

4

5

88

F8.

I have made some changes in
my drug use [drinking], and I
want some help to keep from
going back to the way I used [to
drink] before.

1

2

3

4

5

88

2

4

88

End of 6-MONTH FOLLOW-UP Client Level Survey
Thank you for your time!

F/U 11

RESPONSE CARD A

RESPONSE CARD B

RESPONSE CARD C

1 = Not at all

1 = Disagree Strongly

1 = Strongly Disagree

2 = A little bit

2 = Disagree

2 = Disagree

3 = Moderately

3 = Uncertain

3 = Undecided or Unsure

4 = Quite a bit

4 = Agree

4 = Agree

5 = Extremely

5 = Agree Strongly

5 = Strongly Agree

F/U 12

Attachment 1b: Document 2 - Client Data Sheet
Form Approved
OMB No. ####-####
Expiration Date: ##/##/####

TCE-HIV Multi-Site Evaluation
Client Focus Group Participant Information
CSAT would like to learn more about you and your involvement with this organization/program. Please take a
few minutes to answer these questions before the focus group begins. Your help in answering these questions is
greatly appreciated and your answers will be held in confidence.
Grantee ID Number: _______________________

Date: ____________________

1. How long have you been a client of the program? _________________
2. Is this your first time in a substance abuse treatment program?

Yes

No

If no, how many times have you been in treatment? __________________
3. What is your gender?

Male

Female

Transgender

4. What is your age? _____________ years old
5. Are you Hispanic or Latino?

Yes

No

6. If yes, what ethnic group do you consider yourself? Please answer yes or no for each of the
following. You may say yes to more than one.
Central American
Yes
No
Cuban
Yes
No
Dominican
Yes
No
Mexican
Yes
No
Puerto Rican
Yes
No
South American
Yes
No
Other
Yes
No
(If Yes in “Other”, please specify)_______________________________
7. What is your race? Please answer yes or no for each of the following. You may check all that
apply.
Alaska Native
Yes
No
American Indian
Yes
No
Asian
Yes
No
Black or African American
Yes
No
Native Hawaiian
Yes
No
Other Pacific Islander
Yes
No
White
Yes
No
Other
Yes
No
(If Yes in “Other”, please specify)_____________________
8. Education (Highest Completed):
Some High School
High School Diploma/GED
Some vocational/technical training
Vocational technical diploma

Associate’s Degree
Bachelor’s Degree
Other (please specify) ___________

THANK YOU!

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Attachment 1b: Document 2 - Client Data Sheet

Notice to Respondents
Public reporting time for this collection is estimated to average 60 minutes, 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 OMB Officer, 1
Choke Cherry Road Room 7-1044, Rockville, MD 20850. 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 control number for this project is XXXX-XXXX.

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