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U.S. Department of Health and Human Services
FORM APPROVED:
OMB No. 0930-XXXX
APPROVAL EXPIRES: XX/XX/XXXX
Welcome to the
NATIONAL SURVEY OF
SUBSTANCE ABUSE TREATMENT SERVICES
(N-SSATS)
March 29, 2013
Sponsored by:
Substance Abuse and Mental Health Services
Administration (SAMHSA)
User ID
Conducted by:
THIS IS A SECURE SITE Mathematica
Policy Research
Password
Log In
If you do not know your User ID and Password, please refer to the pink flyer in the
N-SSATS packet. You can also call our toll free number to obtain the information:
1-888-324-8337.
Public Burden Statement: 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 0930-xxxx. Public reporting burden for this collection of information is estimated to average
40 minutes per respondent, per year, 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, 1 Choke
Cherry Road, Room 2-1057, Rockville, Maryland 20857.
Pledge to respondents
The information you provide will be protected to the fullest extent allowable under the Section 501(n) of the
Public Health Service Act (42 USC 290aa(n)). This law permits the public release of identifiable information
about an establishment only with the consent of that establishment and limits the use of the information to the
purposes for which it was supplied. With the explicit consent of eligible treatment facilities, information
provided in response to survey questions marked with an asterisk will be published in SAMHSA's National
Directory of Drug and Alcohol Abuse Treatment Programs and the Substance Abuse Treatment Facility
Locator. Responses to non-asterisked questions will be published only in statistical summaries so that
individual treatment facilities cannot be identified.
166$76:HE6XUYH\
U.S. Department of Health and Human Services
FORM APPROVED:
OMB No. 0930-XXXX
APPROVAL EXPIRES: XX/XX/XXXX
Welcome to the
NATIONAL SURVEY OF
SUBSTANCE ABUSE TREATMENT SERVICES
(N-SSATS)
March 29, 2013
Sponsored by:
Substance Abuse and Mental Health Services
Administration (SAMHSA)
User ID
Conducted by:
THIS IS A SECURE SITE Mathematica
Policy Research
Password
Log In
Your login attempt was not successful. Please
try again.
The user ID and password that you have
specified are not valid.
If you do not know your User ID and Password, please refer to the pink flyer in the
N-SSATS packet. You can also call our toll free number to obtain the information:
1-888-324-8337.
Public Burden Statement: 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 0930-xxxx. Public reporting burden for this collection of information is estimated to average
40 minutes per respondent, per year, 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, 1 Choke
Cherry Road, Room 2-1057, Rockville, Maryland 20857.
Pledge to respondents
The information you provide will be protected to the fullest extent allowable under the Section 501(n) of the
Public Health Service Act (42 USC 290aa(n)). This law permits the public release of identifiable information
about an establishment only with the consent of that establishment and limits the use of the information to the
purposes for which it was supplied. With the explicit consent of eligible treatment facilities, information
provided in response to survey questions marked with an asterisk will be published in SAMHSA's National
Directory of Drug and Alcohol Abuse Treatment Programs and the Substance Abuse Treatment Facility
Locator. Responses to non-asterisked questions will be published only in statistical summaries so that
individual treatment facilities cannot be identified.
Complete
Substance Abuse and Mental Health Services Administration (SAMHSA)
! " #
If you think this is an error or have any questions about this information, please call the N-SSATS helpline at 1-888-324-8337.
166$76:HE6XUYH\
Welcome to the 2013 National Survey of Substance Abuse Treatment Services (N-SSATS)
questionnaire on the Internet.
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 Facility Name 1, Address 1. 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 Facility Name 1, Address 1, unless otherwise specified in the questionnaire.
Please keep a copy of your completed Web questionnaire for your records. You will be given the opportunity to review and print
your responses at the end of the questionnaire.
For additional information about this survey and definitions of some of the terms used, please visit our website at
http://info.nssats.com/.
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.
For "Helpful Hints" on completing this questionnaire on the Web: Click Here.
To preview the questionnaire: Click Here.
When you are ready to begin, click on the BEGIN QUESTIONNAIRE button below.
BEGIN QUESTIONNAIRE
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If you have immediate problems or questions, you can reach our helpline at 1-888-324-8337. The helpline is staffed Monday-Friday, 8am to 8pm
(Eastern Time). You can leave a message 24 hours a day when staff is not available,
OR
you can send an e-mail to the help desk by clicking on this link http://devnssats2013.mathematica.net/EmailForm.aspx
+HOSIXO
National Survey of Substance Abuse Treatment Services (N-SSATS)
Here are a few tips to help you complete this questionnaire quickly and easily:
To VIEW or move down entire pages -- USE the scroll bar along the right side of your computer screen. Some screens
contain more than one question on a page. By using the scroll bar, you will be able to view all of the questions on a page.
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National Survey of Substance Abuse Treatment Services (N-SSATS)
Substance Abuse and Mental Health Services Administration (SAMHSA)
When you click the BEGIN QUESTIONNAIRE button below,
you will advance to the actual questionnaire.
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BEGIN QUESTIONNAIRE
Preview Questionnaire
National Survey of Substance Abuse Treatment Services (N-SSATS)
Substance Abuse and Mental Health Services Administration (SAMHSA)
Below you will find the information currently on record for this facility.
Yes, the information below is correct as shown.
No, some information below is incorrect or missing. (Make your corrections below)
No, all information below is incorrect. (Make your corrections
ion below)
O
nl
y
ty's informat
Edit or add to the fields below to correct your facility's
information and delete any incorrect information.
State ID: IL103294
Facility Director:
ent FNAME Middle
First Name Respondent
Last Respondent LNAME
e1
Facility Name Line 1 Facility Name
Facility Name 2
y
nl
Address 1
Street Address
ess 2
Address 2
Addre
ev
Street Address
O
ie
Zip 99999
) 999
9
ev
ie
Facility Telephone Number ( 999
) 999
Facility Fax Number ( 999
y
Illinois
- 9999
ext
- 9999
Pr
Title:
Last
Optional information:
)
(
-
Ext
(
)
-
Email Address:
Pr
Fax number (If different from main facility number):
er):
ev
Telephone number (If different from main facility number):
ie
w
Who will be primarily responsible
ble for completing
comp
this questionnaire?
Name: First
nl
State
tate
w
City
C
Pr
City
O
Location Address:
s
w
Line 2
Facility Email Address:
1.
Which of the following substance abuse services are offered by this facility at this location, that is, Facility Name 1 ,
Address 1?
SELECT "YES" OR "NO" FOR EACH
Preview Questionnaire
Yes
No
Intake, assessment, or referral
Detoxification
Substance abuse treatment
(services that focus on initiating and maintaining an
individual's recovery from substance abuse and on
averting relapse)
1a.
O
nl
y
Any other substance abuse services
Does this facility, at this location, offer mental health treatment services
s
(services focused on improving the mental
well-being of individuals with mental disorders and on promoting their recovery)?
Yes
No
2a.
Does this facility detoxify clients from...
...
ACH
SELECT "YES" OR "NO" FOR EACH
ie
ev
O
Benzodiazepiness
Cocaine
e
Other (Please specify:
SELECT ONE ONLY
A private for-profit organization
A private non-profit organization
State government
Local, county, or community government
Tribal government
Federal Government
4a.
Which Federal Government agency?
SELECT ONE ONLY
Department of Veterans Affairs
Department of Defense
y
ev
ie
w
Is this facility operated by…
Pr
Pr
Does this facility routinely use medications during detoxification?
Yes
No
4.
ev
)
nl
ie
Opioids
O
Pr
w
Methamphetamines
Methamphetam
2b.
y
Alcohol
No
nl
w
Yes
Preview Questionnaire
Indian Health Service
Other (Please specify:
5.
)
Is this facility a solo practice, meaning, an office with only one independent practitioner or counselor?
Yes
No
6.
Is this facility affiliated with a religious organization?
Yes
No
Is this facility a jail, prison, or other organization that
exclusively for incarcerated persons or
hat provides treatment
t
juvenile detainees?
O
nl
y
Yes
No
Is this facility a hospital or located in or operated by a hospital?
Yes
No
What type of hospital?
ie
SELECT ONE ONLY
w
8a.
y
8.
nl
7.
General hospital (including VA hospital)
h
ev
O
Psychiatric hospital
pecialty hospital,
hospit for example, alcoholism, maternity, etc.
Other specialty
ase specify:
(Please
)
2. If applicable, enter secondary intake number here: (
)
-
y
ext
ext
ext
Which of the following assessment and pre-treatment services
rvices ar
are pro
provided by this facility at this location, that is,
Facility Name 1, Address 1 ?
SELECT "YES" OR "NO" FOR EACH
Pr
10a.
)
(
ev
1. Enter intake telephone number
here:
um
ext
ie
w
Pr
Alphanumeric Entry
[example: (888) 555 HELP]
-
)
2. If applicable, enter secondary intake
ntake numb
number here: (
nl
)
(
ev
1. Enter intake telephone number here:
O
Numeric Entry
[example: (888) 555-3456]
ie
w
What telephon
telephone number(s) should a potential client call
all to sched
schedule an intake appointment?
Pr
9*.
Yes
Y
Screening for substance abuse
Screening for mental health disorders
Comprehensive substance abuse assessment or
diagnosis
No
Preview Questionnaire
Comprehensive mental health assessment or
diagnosis (for example, psychological or psychiatric
evaluation and testing)
Screening for tobacco use
Outreach to persons in the community who may
need treatment
O
nl
y
Interim services for clients when immediate
admission is not possible
We do not offer any of these assessment and pretreatment services
10b.
Which of the following testing services are provided by this
th facility at this location?
• Include tests performed at this location,
cat
even
en if specimen
spe
is sent to an outside source for chemical analysis.
SELECT "YES" OR "NO" FOR EACH
Yes
No
ie
Drug or alcohol urine screening
ev
Screening for
or Hepatitis B
Pr
Screening
eening for He
Hepatitis C
HIV testin
testing
ev
STD testing
S
ie
Pr
w
ev
O
ie
n
ly
w
O
nl
y
w
Breathalyzer or other blood alcohol testi
testing
TB screening
10c.
Pr
We do not offer any of these
ese testing services
Which of the following
ing transitional s
services are provided by this facility at this
s location?
SELECT "YES" OR "NO"
O" FOR
F
EACH
Discharge planning
Aftercare/continuing care
Yes
No
We do not offer any of these transitional services
10d.
ed by this facility at this location?
Which of the following ancillary services are provided
SELECT "YES" OR "NO" FOR EACH
Yes
Case management services
Social skills development
No
Preview Questionnaire
Mentoring/peer support
Child care for clients' children
Assistance with obtaining social services
(for example, Medicaid, WIC, SSI, SSDI)
Employment counseling or training for clients
O
nl
y
Assistance in locating housing for clients
Domestic violence -- family or partner violence
services (physical, sexual, and emotional abuse)
Early intervention for HIV
w
HIV or AIDS education, counseling,, o
or support
port
ie
Pr
w
ev
O
ie
n
ly
w
O
nl
y
Hepatitis education, counseling,
eling, or support
supp
ie
Health education
n other than HIV
HIV/AIDS or hepatitis
ev
Substance abuse educatio
education
Pr
Transportation
nsportation a
assistance to treatment
Mental health
he
services
ev
Acupuncture
A
* Residential beds for clients' children
n
Pr
Self-help groups (for example,
mple, AA, NA, SMA
SMART
Recovery)
Smoking cessation counseling
nselin
We do not offer any of these ancillary services
10e.
Which of the following other services are provided by this facility
cility at this location?
lo
SELECT "YES" OR "NO" FOR EACH
Yes
Treatment for gambling disorder
Treatment for Internet use disorder
No
Treatment for other addiction disorder (nonsubstance abuse)
We do not offer any of these other services
10f.
Which of the following pharmacotherapies are provided by this facility at this location?
Preview Questionnaire
SELECT "YES" OR "NO" FOR EACH
Yes
No
Disulfiram (Antabuse®)
Naltrexone (oral)
Vivitrol® (injectible Naltrexone)
O
nl
y
Acamprosate (Campral®)
Nicotine replacement
Non-nicotine smoking/tobacco cessation
n
medications (for example, Bupropion, Varenicline)
Var
nl
ie
O
Buprenorphine with
th naloxone (Suboxone®)
(S
Pr
We do not offer any of these pharmacotherapy
services
servic
nl
Does this facility operate an Opioid Treatment Program
ogram (OTP) at this location?
ie
11*.
*.
w
ev
Buprenorphine
phine without
withou naloxone
y
Methadone
y
w
Medications for psychiatric disorders
rs
O
ev
• OTPs are certified by SAMHSA’s Center
Substance Abuse Treatment to use the opioid drugs methadon
methadone,
er for Substanc
buprenophine and vivitrol in the treatment
opioid (narcotic) addiction.
ment of op
• Some SAMHSHA-certified OTPs
in the treatment of opioid (narcotic)
Ps use only buprenorphine
bu
c) addiction.
Yes, facility operates
perates an OTP
No
Are ALL of the substance abuse
Treatment Program?
abu clients at this facility currently in the Opioid Treatm
Yes
No
11b*.
Pr
ev
i
11a*.
ew
Pr
• Physicians with a waiver may prescribe buprenorphine without being affiliated with an OTP.
OT Therefore, not all facilities
that prescribe buprenorphine
renorphine are OTPs.
OTPs
Does the Opioid Treatment Program at this location provide
maintenance services, detoxification services, or both?
de maintena
SELECT ONE ONLY
Maintenance services
Detoxification services
Both
12.
For each type of counseling listed below, please indicate approximately what percent of the substance abuse clients at
this facility receive that type of counseling as part of their substance abuse treatment program.
SELECT ONE FOR EACH TYPE OF COUNSELING
Preview Questionnaire
TYPE OF
COUNSELING
RECEIVED BY
25% OR LESS
OF CLIENTS
NOT OFFERED
RECEIVED BY
26% TO 50%
OF CLIENTS
RECEIVED BY
51% TO 75%
OF CLIENTS
RECEIVED BY
MORE THAN
75%
OF CLIENTS
Individual counseling
Group counseling
Family counseling
13.
O
nl
y
Marital/couples
counseling
For each type of clinical/therapeutic approach listed
sted below, pleas
please mark the box that best describes how often that
approach is used at this facility.
• Definitions of these approaches can be found at: http://info.nssats.com
h
CLINICAL/THERAPEUTIC
APPROACHES
HERAPEUTIC A
NEVER
nl
ie
y
w
SELECT "Never", "Rarely", "Sometimes",
s", "Always
"Alway or Often" OR "Not Familiar With This Approach" FOR EACH
APPROACH.
RARELY
RELY
ev
ev
y
nl
ie
Brief intervention
B
O
Pr
w
12-step
step facilitation
facilitatio
Cognitive-behavioral therapy
ALWAYS
OR OFTEN
O
Substance abuse
e counseling
SOMETIMES
SOMET
NOT
FAMILIAR
WITH
THIS
APPROACH
Pr
ie
w
Contingency management/motivational
incentives
t/motivational incen
Anger management
Matrix Model
Community reinforcement plus vouchers
Rational emotive behavioral therapy (REBT)
Pr
Trauma-related counseling
ev
Motivational interviewing
g
Preview Questionnaire
Relapse prevention
Computerized substance abuse treatment
(including Internet, Web, mobile, and desktop
programs)
Other treatment approach
(Please specify:
14.
O
nl
y
)
Are any of the following practices part of this facility's
s standard o
operating procedures?
SELECT "YES" OR "NO" FOR EACH
Yes
No
Required continuing education for staff
y
w
Periodic drug testing of clients
ie
nl
Regularly scheduled case
ase review wit
with a supervisor
ev
O
Case review by an appointed quality
q
review
committee
nl
Pr
Periodic utilization review
y
w
Outcome
me followfollow-up after discharge
O
ie
Periodic client satisfaction surveys conducted
d by the
facility
fa
Yes
No
Does this facility serve only
y DUI/DWI clients?
Yes
No
16*.
Pr
ev
i
15a*.
ew
Does this facility, Facility Name
me 1 , Address 1 , offer a specially designed program or group intended exclusively for
DUI/DWI or other drunk
k driver offenders?
Pr
15*.
ev
None of these practices are part of the standard
operating procedures
Does this facility provide substance abuse treatment services
rvices in sign language at this location for the hearing impaired
(for example, American Sign Language, Signed English,
nglish, or Cued Sp
Speech)?
• Select "yes" if either a staff counselor or an on-call interpreter
interprete provides this service.
Yes
No
17*.
Does this facility provide substance abuse treatment services in a language other than English at this location?
Yes
No
17a.
At this facility, who provides substance abuse treatment services in a language other than English?
SELECT ONE ONLY
Preview Questionnaire
Staff counselor who speaks a language other than English
On-call interpreter (in person or by phone) brought in when needed
BOTH staff counselor and on-call interpreter
17a1*.
Do staff counselors provide substance abuse treatment in Spanish at this facility?
Yes
No
17a2.
Do staff counselors at this facility provide substance abuse treatment in any other languages?
17b*.
O
nl
y
Yes
No
In what other languages do staff counselors provide
abuse treatment at this facility?
vide substance a
SELECT "YES" OR "NO" FOR EACH
IVE
AMERICAN INDIAN OR ALASKA NATIVE:
ev
Navajo
ie
Lakota
w
Hopi
Ojibwa
Pr
Yupik
No
ie
Pr
w
ev
O
ie
n
ly
w
O
nl
y
Yes
OTHER LANGUAGES:
Pr
Arabic
Any Chinese language
ge
Creole
French
German
Greek
Hmong
Italian
Japanese
ev
O
Other
American Indian or Alaska Native language
(Please specify:
)
Yes
No
Preview Questionnaire
Korean
Polish
Portuguese
Russian
Vietnamese
O
nl
y
Tagalog
Any other language (Please specify:
)
Individuals seeking substance abuse treatment can
c vary by age, gender or other characteristics. Which categories of
individuals are served by this facility,
at Address1?
il
Addres
y
Does this facility serve adolescents
scents a
at this location?
ev
ie
w
Does this facility serve only adolescents
at this location?
ad
Yes
No
Yes
No
18C2*.
Does this facility offer
programs or groups for adult women
er specifically tailored
t
men at this location?
lo
Yes
No
18A3.
Does this facility serve adult men at this location?
Yes
No
18B3.
Does this facility serve only adult men at this location?
ocation?
Yes
No
18C3*.
y
Does this facility serve only adult women at this location?
ev
18B2.
ev
ie
Does this facility serve adult women at this
s location?
Pr
18A2.
2
nl
Pr
Yes
No
w
Does
s this facility offer specifically tailored programs or groups
ups for adolescents at this location?
Pr
18C1*.
O
Yes
No
o
O
18B1.
nl
Yes
No
ie
w
18A1.
Does this facility offer specifically tailored programs or groups for adult men at this location?
Yes
No
18a.
Many facilities have clients with one or more of the following characteristics. For which characteristic(s) does this
facility offer a substance abuse treatment program or group specifically tailored for those individuals, at this location?
SELECT "YES" OR "NO" FOR EACH
Preview Questionnaire
Yes
No
Pregnant/postpartum women
Seniors or older adults
Lesbian, gay, bisexual, transgender, or questioning
(LGBTQ) clients
Veterans
O
nl
y
Active duty military
Members of military families
Criminal justice clients (other than DUI/DWI)
Clients with co-occuring mental and substance
bsta
abuse disorders
Persons with HIV or AIDS
y
w
Persons who have experienced
nced sexual abuse
a
ie
nl
Persons who have
ve experienced intimate
intim
partner
violence or physical
sical abuse
O
Pr
)
O
19a*.
ie
Yes
No
nl
Does this facility offer HOSPITAL INPATIENT substance
bstance abuse services at this location, that is, Facility
y Name 1 Facility
Name 2, Address 1?
ev
19*.
*
w
Specifically
ifically tailored
tailo
programs or groups for any
other
(Please specify:
her types of clients
cli
y
ev
Persons who have
ve experie
experienced other types of
trauma
Which of the following HOSPITAL INPATIENT se
services are offered at this facility, that is, Facility
lity Name 1, Address 1 ?
ie
w
Pr
SELECT "YES" OR "NO" FOR EACH
Yes
etoxifica
1. Hospital inpatient detoxification
(Similar to ASAM Levels IV-D and III.7-D, medically managed or
monitored inpatient detoxification)
icati
No
Pr
ev
2. Hospital inpatient treatment
(Similar to ASAM Levels IV and III.7, medically managed or monitored
tored
intensive inpatient treatment)
Note: ASAM is the American Society of Addiction
tion Medic
Medicine
20*.
Does this facility offer RESIDENTIAL (non-hospital)
substance abuse services at this location, that is, Facility Name 1 ,
al) su
Address 1?
Yes
No
20a*.
Which of the following RESIDENTIAL services are offered at this facility, that is, Facility Name 1, Address 1 ?
SELECT "YES" OR "NO" FOR EACH
Preview Questionnaire
Yes
No
1. Residential detoxification
(Similar to ASAM Level III.2-D, clinically managed residential
detoxification or social detoxification)
2. Residential short-term treatment
(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 mediumu or
low-intensity residential treatment, typically more than 30 days))
Does this facility offer OUTPATIENT substance abuse
use services a
at this location, that is, Facility Name 1 , Address 1 ?
O
nl
y
21*.
Yes
No
21a*.
Which of the following OUTPATIENT services are offe
offered at this facility, that is, Facility Name 1, Address 1 ?
SELECT "YES" OR "NO" FOR EACH
3. Outpatient
nt day treatment
treatme or partial hospitalization
(Similar to ASAM Level
Lev II.5, 20 or more hours per week)
ev
No
O
2. Outpatient methadone/buprenorphine
thadone/bupren
maintenance
Yes
nl
y
ie
w
1. Outpatient detoxification
(Similar to ASAM Levels I-D
detoxification)
D and II-D, ambulatory
am
y
nl
Pr
w
4. Intensive outpatient
outp
treatment
(Similar to ASAM Level II.1, 9 or more hours per week)
Do you want the availability
bility of a sliding fee
fe scale published in SAMHSA's Directory/Locator?
/Locator
ie
w
22a.
O
Yes
No
ev
Does this facility use a sliding fee scale?
Pr
22*.
ie
5. Regular outpatient treatment
(Similar to ASAM Level I, outpatient treatment,, non-intensive
non-intensive)
(S
• The Directory/Locator
explain that sliding fee scales are based on income
/Locator will explai
me and other factors.
Yes
No
Yes
No
23a.
ev
Does this facility offer treatment at no charge to clients who cannot
pay?
ot afford to p
Do you want the availability of free care for eligible
published in SAMHSA's Directory/Locator?
ible clients pub
Pr
23*.
ial clien
• The Directory/Locator will explain that potential
clients should call the facility for information on eligibility.
Yes
No
24.
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?
• Do not include Medicare, Medicaid, or federal military insurance. These forms of client payments are included in the next
question.
Yes
Preview Questionnaire
No
Don't Know
25*.
Which of the following types of client payments or insurance are accepted by this facility for substance abuse
treatment?
SELECT "YES," "NO," OR "DON'T KNOW" FOR EACH
Yes
No
Don't
Know
O
nl
y
No payment accepted (free treatment for ALL
clients)
Cash or self-payment
Medicare
Medicaid
nl
y
w
State-financed health insurance
e plan other
o
than
Medicaid
ie
Federal military insurance (e.g., TRICARE)
TR
ev
O
Private health insurance
urance
Other (Please specify:
O
O
)
SELECT ONE METHOD FOR EACH APPROACH.
APPR
Assessment
Treatment plan
Discharge
Referrals
Issue/receive lab results
PAPER
ONLY
ev
Intake
Pr
WORK ACTIVITY
ACT
COMPUTER /
ELECTRONIC
ONLY
ie
w
ev
For each of the following activities, please indicate
indic
if staff members routinely use computer or electron
electronic resources,
paper only, or a combination of both
oth to accomplish
accomp
their work.
Pr
26.
nl
ie
Pr
IHS/638 contract care funds
y
w
Access
ss To Reco
Recovery (ATR) vouchers
BOTH
ELECTRONIC
ELEC
AND
ND PAPER
N/A
Preview Questionnaire
Billing
Outcomes management
Medication prescribing/dispensing
Health records
27.
O
nl
y
Interoperability with other providers (such as primary
care, mental health providers, etc.)
The next questions ask about the number of clients
nts in treatm
treatment
nt at this facility. SAMHSA would prefer to get this
information separately for this facility only.
realize that is not always possible.
y However,
wever, we re
u report will be for…
Please indicate whether the clients you
SELECT ONE ONLY
Only this facility
y
w
This facility plus others
How many facilities
ities will be included
inc
in your client counts?
ie
27a.
nl
Another facility will report this facility's client
cl
counts
O
er of addition
s in the box below
Enter the number
additional facilities included in client counts
below.
ev
For Section
on B, please include all of these facilities in the client counts
ounts that you
y report in questions 28 through 33.
This facility
facility:
1
SELECT ONE ONLY
SE
y
nl
To avoid double-counting clients, we need to know
w which faci
facilities are included in your counts. How willl you report
this information to us?
th
O
27b.
b.
ev
ie
w
Pr
+ ADDITIONAL FACILITIES:
I prefer to enter the information now
Please call me for the list of additional
facilities
nal facilitie
ie
w
Please enter the facility name, location address,
add
and phone number for each of the additional
addition facilities included in your
client counts.
Pr
Please scroll through
entire page, listing all of the additional facilities (do
h the ent
do not list this facility). Also, answer the
question at the bottom of th
the page before pressing the "Submit" button
on to advance.
ev
Facility Name (Line 1)
(Line 2)
Location Address
Street Address
Pr
27c.
Street Address 2
City
State
Facility Phone (
Please Select
)
Zip
-
Ext
Before advancing to the next question, please respond to one of the following statements:
Preview Questionnaire
I have entered all the additional facilities that are included in the client counts reported in this questionnaire.
I did not enter all the additional facilities that are included in the client counts reported in this questionnaire. Please have
someone contact me.
28.
On March 29, 2013, did any patients receive HOSPITAL INPATIENT substance abuse services at this facility?
Yes
No
28a.
On March 29, 2013, how many patients received the following HOSPITAL INPATIENT substance abuse services at this
facility?
O
nl
y
• COUNT a patient in one service only, even if the
both services.
he patient received
re
• DO NOT count family members, friends, or other
er non-treatment
non-treatme patients.
ENTER A NUMBER FOR EACH (IF NONE, ENTER
R "0")
1. Hospital inpatient detoxification
(Similar to ASAM Levels IV-D and III.7-D,, medically managed
or monitored inpatient detoxification)
How many of the 0 HOSPITAL
TAL INPATIE
INPATIENTS you just reported were under the age of 18?
y
28b.
w
2. Hospital inpatient treatment
(Similar to ASAM Levels IV and III.7,
managed or
7, medically
cally ma
monitored intensive inpatient treatment)
men
ie
nl
ENTER A NUMBER (IF
F NONE, ENTER
ENTE "0")
ge 18
Number under age
O
How many off the 0 HOSPITAL
HOSP
INPATIENTS you just reported received:
ei
ev
28c.
nclude pa
on or maintenance
intena
• Include
patients who received these drugs for detoxification
purposes.
y
ev
ie
w
Pr
ENTER A NUMB
NUMBER FOR EACH (IF NONE, ENTER "0")
nl
Methad
1. Methadone
dispensed at this facility
2. Buprenorphine dispensed or prescribed at this facility
2
On March 29, 2013, how many hospital inpatient
atient bed
beds at this facility were specifically designated
nated for substa
substance abuse
treatment?
O
28d.
29.
On March 29, 2013, did any clients re
receive RESIDENTIAL (non-hospital) substance
nce abuse se
services at this facility?
Yes
No
ev
On March 29, 2013, how many clients received the following RESIDENTIAL
substance abuse services at this facility?
DENTIAL sub
• COUNT a client in one service only, even if the client received
services.
eceived multiple
mul
• DO NOT count family members, friends, or other non-treatment
clients.
treatment clien
R "0"
ENTER A NUMBER FOR EACH (IF NONE, ENTER
"0")
1. Residential detoxification
(Similar to ASAM Level III.2-D, clinically managed residential
esiden
detoxification or social detoxification)
Pr
29a.
Pr
Number of beds
ie
w
ENTER A NUMBER (IF NONE, ENTER
TER "0")
2. Residential short-term treatment
(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
medium- or low-intensity residential treatment, typically more
than 30 days)
Preview Questionnaire
29b.
How many of the 0 RESIDENTIAL clients you just reported were under the age of 18?
ENTER A NUMBER (IF NONE, ENTER "0")
Number under age 18
29c.
How many of the 0 RESIDENTIAL clients you just reported received:
• Include clients who received these drugs for detoxification or maintenance purposes.
ENTER A NUMBER FOR EACH (IF NONE, ENTER "0")
1. Methadone dispensed at this facility
29d.
O
nl
y
2. Buprenorphine dispensed or prescribed at this facility
ity
On March 29, 2013, how many residential beds att this facility were
wer specifically designated for substance abuse
treatment?
ENTER A NUMBER (IF NONE, ENTER "0")
Number of beds
During the month of March 2013, d
did any
y clients receive OUTPATIENT substance abuse services at this facility?
nl
How many clients
ts received each of the following OUTPATIENT substance abuse
buse services at this facility during March
2013?
ie
30a.
y
Yes
No
w
30.
O
ev
clients who received treatment in March AND
in treatment on March 29, 2013.
Y INCLUDE
E cli
D were still enrolled
en
• ONLY
• COUNT
client in one service only, even if the client received
NT
T a clien
d multiple services.
se
• DO NOT count
unt family members, friends, or other non-treatment clients.
y
nl
ie
Pr
w
ENTER
FOR EACH (IF NONE, ENTER "0")
NTER A NUMBER
NUMB
1. Outpatient detoxification,
(Similar to ASAM Levels I-D and II-D, ambulatory
detoxification)
detoxifica
Pr
4. Intensive outpatient treatment,
eatment,
el II.1, 9 or mor
(Similar to ASAM Level
more hours per week)
ev
ie
w
3. Outpatient day treatment or partial hospitalization,
hospitalizatio
(Similar to ASAM Level II.5, 20 or more
ore hours per week)
O
ev
2 Outpatient methadone/buprenorphine maintenance
2.
tenance (Coun
(Count
methadone/buprenorphine clients on this line only)
5. Regular outpatient treatment,
reatme
(Similar to ASAM Level I, outp
outpatient treatment, non-intensive)
30b.
How many of the 0 OUTPATIENT clients you just reported were under the age of
o 18?
ENTER A NUMBER (IF NONE, ENTER "0")
Number under age 18
How many of the 0 OUTPATIENT clients you just reported received:
Pr
30c.
detoxif
• Include clients who received these drugs for detoxification
or maintenance purposes.
ENTER A NUMBER FOR EACH (IF NONE, ENTER "0")
1. Methadone dispensed at this facility
2. Buprenorphine dispensed or prescribed at this facility
30d.
On average, during March 2013, were the outpatient substance abuse treatment services at this facility operating over,
under, or at capacity?
Well over capacity (over 120%)
Preview Questionnaire
Somewhat over capacity (106 to 120%)
At or about capacity (95 to 105%)
Somewhat under capacity (80 to 94%)
Well under capacity (under 80%)
31.
This question asks you to categorize the substance abuse treatment clients at this facility into three groups: clients in
treatment for (1) the abuse of both alcohol and drugs other than alcohol; (2) abuse of only alcohol; or (3) abuse of only
drugs other than alcohol.
Enter the percent of clients on March 29, 2013, who were in each of these three groups:
O
nl
y
Clients in treatment for abuse of:
r
The following three responses should total 100%. If not, please reconcile.
1. BOTH alcohol and drugs other
than alcohol
2. ONLY alcohol
%
%
3. ONLY drugs other than alcohol
%
33.
12-m
Using the most recent 12-month
period for which you have data, approximately h
how many substance abuse treatment
ADMISSIONS
facility have?
NS did this fac
ev
ie
Pr
w
ev
O
ie
n
ly
w
O
nl
y
ent of the sub
d at this facility
facili on March 29, 2013, had a
Approximately what percent
substance abuse treatment clients enrolled
diagnosed co-occurring
g mental and substance
s
abuse disorder?
PERCENT OF CLIENTS
TS
%
(IF NONE, ENTER
ER "0")
ie
w
32.
Pr
• OUTPATI
nt, not individual treatment visits. Consider an admission to be
OUTPATIENT CLIENTS: Count admissions into treatment,
the
he initiation
initiati of a treatment program or course of treatment.
tment. C
Count any re-admission as an admission.
nt all admissions
admissio in which clients received substance abuse
se treatment,
• IF THIS IS A MENTAL HEALTH FACILITY: Count
even if substance abuse was their secondary diagnosis.
ev
NUMBER OF SUBSTANCE ABUSE
N
A
ADMISSIONS IN A 12-MONTH PERIOD
Yes
No
35.
ev
Does this facility operate transitional housing
ousing or
o a halfway house for substance abuse clients
ts at this location,
loc
that is,
Facility Name 1 , Address 1?
Pr
34*.
Which statement below
describes this facility's smoking policy?
elow BEST descr
SELECT ONE ONLY
Smoking is not permitted on the property or within any building
Smoking is permitted only outdoors
Smoking is permitted outdoors and in designated indoor area(s)
(s)
Smoking is permitted anywhere without restriction
Other (Please specify:
36.
)
Is this facility or program licensed, certified, or accredited
edite to provide substance abuse services by any of the following
organizations?
• Do not include personal-level credentials or general business licenses such as a food service license.
SELECT "YES," "NO," OR "DON'T KNOW" FOR EACH
Yes
No
Don't
Know
Preview Questionnaire
State substance abuse agency
State mental health department
State department of health
Hospital licensing authority
O
nl
y
The Joint Commission
Commission on Accreditation of Rehabilitation
Facilities (CARF)
Council on Accreditation (COA)
37.
ev
ie
w
Another state or local agency or other o
organization
(Please specify:
)
Does this facility have a National
Nation Provider Identifier (NPI) number?
nl
y
National Committee for Quality Assurance
ce (NCQA)
O
• Do NOT include
clude the NPI numbers of individual practitioners and
nd groups of practitioners.
pract
y
nl
What is the
th NPI number for this facility?
ie
a.
37a.
w
Pr
Yes
Ye
No
N
Yes
No
What is this facility’s website
ite address?
ev
38a*.
ie
w
Does this facility have a website
ite or web page
pa with information about the facility's substance
ubstanc abuse treatment
programs?
Pr
38*.
(NPI is a 10-digit numeric ID)
ev
NPI
O
• If a facility has more than one NPI number,
only the primary number.
ber,
r please provide
pro
39.
Does this facility want to be listed in the National
nal Directory
Directo and
d online Treatment Facility Locator?
Yes
No
40.
Pr
• Enter the address in the box below EXACTLY as it should be entered in o
order to access your site.
• Do not enter "http://" (for example, enter www.yourfacility.com)
com)
Would you like to receive a free copy of the next National Directory of Drug and Alcohol Abuse Treatment Programs
when it is published?
Yes
No
40a.
Would you prefer to receive a CD or paper copy of the Directory?
Preview Questionnaire
CD
Paper
C19.
Thank you for completing the N-SSATS questionnaire.
Would you like to provide us with comments regarding your experience completing this questionnaire?
IMPORTANT NOTE: If you do not wish to report any comments, please submit this page in order to receive your
confirmation number!
Yes
No
Please enter your comments below.
nl
y
C20.
Pr
y
nl
O
ev
Pr
ie
w
ev
ie
Pr
w
ev
IMPORTANT NOTE: Please submit this page in order
confirmation number!
er to receive your
y
166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 0% of your questionnaire!
A. FACILITY CHARACTERISTICS
Below you will find the information currently on record for this facility.
X [ \
]
+[ \
^] (Make your corrections below)
+[ \
] (Make your corrections below)
Edit or add to the fields below to correct your facility's information and delete any incorrect information.
State ID: XX999999
_
` {
_ + _+
| |+
_
` + | } _
+ }
| ~
|
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`
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166$76:HE6XUYH\
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You've completed 1% of your questionnaire!
A. FACILITY CHARACTERISTICS
You have recorded a name change for this facility.
For confirmation purposes, please select the choice that best describes why you recorded this change.
9 ` ^
]
\
`
_
` + }[
^ ]
\
`
_
` + }
^
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166$76:HE6XUYH\
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A. FACILITY CHARACTERISTICS
Is there another substance abuse treatment facility in your organization that is currently located at Address 1 ?
X
+
5 \
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Suspend
Substance Abuse and Mental Health Services Administration (SAMHSA)
We need to check your new address against our files to determine whether your facility should be
assigned a new ID number.
An N-SSATS administrator will contact you within one working day to discuss your responses, make
corrections to your questionnaire (if necessary), and allow you to complete the remaining questions.
We are sorry for this inconvenience and thank you for starting the N-SSATS questionnaire.
If you have any questions about this information, please call the N-SSATS helpline at }888324-8337.
166$76:HE6XUYH\
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You've completed 2% of your questionnaire!
A. FACILITY CHARACTERISTICS
Who will be primarily responsible for completing this questionnaire?
|
Name: _
Title:
Optional information:
Telephone number (If different from main facility number):
$
Fax number (If different from main facility number):
Email Address:
Facility Email Address:
5 \
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166$76:HE6XUYH\
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A. FACILITY CHARACTERISTICS
1.
Which of the following substance abuse services are offered by this facility at this location, that is, Facility Name 1
Facility Name 2, Address 1?
SELECT "YES" OR "NO" FOR EACH
Yes
No
& ! [ [ \
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166$76:HE6XUYH\
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You've completed 3% of your questionnaire!
A. FACILITY CHARACTERISTICS
You reported that this facility does not offer detoxification or substance abuse treatment.
Is this correct?
X [
]
+[
]
; ^ \
]
5 \
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NSSATS 2013 Web Survey
25%
50%
75%
100%
You've completed 3% of your questionnaire!
A. FACILITY CHARACTERISTICS
1a.
Does this facility, at this location, offer mental health treatment services (services focused on improving the mental wellbeing of individuals with mental disorders and on promoting their recovery)?
Yes
No
Quit for now
Review my answers
Back
If you have immediate problems or questions, you can reach our helpline at 1-888-324-8337. The helpline is staffed Monday-Friday, 8am to 8pm
(Eastern Time). You can leave a message 24 hours a day when staff is not available,
OR
you can send an e-mail to the help desk by clicking on this link http://devnssats2013.mathematica.net/EmailForm.aspx
166$76:HE6XUYH\
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You've completed 4% of your questionnaire!
A. FACILITY CHARACTERISTICS
2a.
Does this facility detoxify clients from...
SELECT "YES" OR "NO" FOR EACH
Yes
No
#
9
9
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166$76:HE6XUYH\
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You've completed 4% of your questionnaire!
A. FACILITY CHARACTERISTICS
2b.
Does this facility routinely use medications during detoxification?
X
+
5 \
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166$76:HE6XUYH\
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You've completed 6% of your questionnaire!
A. FACILITY CHARACTERISTICS
4.
Is this facility operated by…
SELECT ONE ONLY
\\ ^
\ ^
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166$76:HE6XUYH\
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A. FACILITY CHARACTERISTICS
4a.
Which Federal Government agency?
SELECT ONE ONLY
{ \
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166$76:HE6XUYH\
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You've completed 7% of your questionnaire!
A. FACILITY CHARACTERISTICS
5.
Is this facility a solo practice, meaning, an office with only one independent practitioner or counselor?
X
+
5 \
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166$76:HE6XUYH\
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You've completed 8% of your questionnaire!
A. FACILITY CHARACTERISTICS
6.
Is this facility affiliated with a religious organization?
X
+
5 \
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166$76:HE6XUYH\
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You've completed 8% of your questionnaire!
A. FACILITY CHARACTERISTICS
7.
Is this facility a jail, prison, or other organization that provides treatment exclusively for incarcerated persons or juvenile
detainees?
X
+
5 \
; `
#
!
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166$76:HE6XUYH\
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You've completed 9% of your questionnaire!
A. FACILITY CHARACTERISTICS
Just to confirm, this facility provides substance abuse treatment services only to incarcerated persons or juvenile
detainees.
Is that correct?
X [
]
+[
]
; \
]
5 \
; `
#
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166$76:HE6XUYH\
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You've completed 10% of your questionnaire!
A. FACILITY CHARACTERISTICS
8.
Is this facility a hospital or located in or operated by a hospital?
X
+
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166$76:HE6XUYH\
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A. FACILITY CHARACTERISTICS
8a.
What type of hospital?
SELECT ONE ONLY
% LQFOXGLQJ9$KRVSLWDO
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9
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166$76:HE6XUYH\
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A. FACILITY CHARACTERISTICS
9*.
What telephone number(s) should a potential client call to schedule an intake appointment?
Numeric Entry
[example: (888) 555-3456]
}] $ !
~] &\
[
` !
Alphanumeric Entry
[example: (888) 555 HELP]
}] $ !
~] &\
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166$76:HE6XUYH\
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A. FACILITY CHARACTERISTICS
You reported the following telephone number(s) should be called to schedule an intake appointment. Please review the
number(s) below for accuracy and select the choice that best describes the result of your review.
Intake Numbers:
Numeric entry #1:
(999)999-9999
Numeric entry #2:
Alphanumeric entry #1:
Alphanumeric entry #2:
\
]
\
] ;
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]
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A. FACILITY CHARACTERISTICS
10a. Which of the following assessment and pre-treatment services are provided by this facility at this location, that is, Facility
Name 1 Facility Name 2, Address 1?
SELECT "YES" OR "NO" FOR EACH
Yes
No
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A. FACILITY CHARACTERISTICS
10b. Which of the following testing services are provided by this facility at this location?
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No
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A. FACILITY CHARACTERISTICS
10c. Which of the following transitional services are provided by this facility at this location?
SELECT "YES" OR "NO" FOR EACH
Yes
No
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A. FACILITY CHARACTERISTICS
10d. Which of the following ancillary services are provided by this facility at this location?
SELECT "YES" OR "NO" FOR EACH
Yes
No
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A. FACILITY CHARACTERISTICS
10e. Which of the following other services are provided by this facility at this location?
SELECT "YES" OR "NO" FOR EACH
Yes
No
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A. FACILITY CHARACTERISTICS
10f.
Which of the following pharmacotherapies are provided by this facility at this location?
SELECT "YES" OR "NO" FOR EACH
Yes
No
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NSSATS 2013 Web Survey
25%
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A. FACILITY CHARACTERISTICS
11*.
Does this facility operate an Opioid Treatment Program (OTP) at this location?
• OTPs are certified by SAMHSA’s Center for Substance Abuse Treatment to use the opioid drugs methadone,
buprenophine and vivitrol in the treatment of opioid (narcotic) addiction.
• Some SAMHSHA-certified OTPs use only buprenorphine in the treatment of opioid (narcotic) addiction.
• Physicians with a waiver may prescribe buprenorphine without being affiliated with an OTP. Therefore, not all facilities that
prescribe buprenorphine are OTPs.
Yes, facility operates an OTP
No
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(Eastern Time). You can leave a message 24 hours a day when staff is not available,
OR
you can send an e-mail to the help desk by clicking on this link http://devnssats2013.mathematica.net/EmailForm.aspx
166$76:HE6XUYH\
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You've completed 16% of your questionnaire!
A. FACILITY CHARACTERISTICS
Two responses are inconsistent.
Earlier you indicated that you do not offer methadone services, however you just indicated that you operate an Opioid
Treatment Program (OTP) at this location.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
10f. Which of the following pharmacotherapies are provided by this facility at this location?
YOUR RESPONSE:
Methadone: No
11. Does this facility operate an Opioid Treatment Program (OTP) at this location?
YOUR RESPONSE: Yes
Select the choice that best describes your resolution:
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A. FACILITY CHARACTERISTICS
Two responses are inconsistent.
Earlier you indicated that you do not offer buprenorphine services, however you just indicated having buprenorphine
services.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
10f. Which of the following pharmacotherapies are provided by this facility at this location?
YOUR RESPONSE:
Methadone: No
Buprenorphine with naloxone (Suboxone®): No
Buprenorphine without naloxone: No
11. Does this facility operate an Opioid Treatment Program (OTP) at this location?
YOUR RESPONSE: Yes
Select the choice that best describes your resolution:
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A. FACILITY CHARACTERISTICS
11a*. Are ALL of the substance abuse clients at this facility currently in the Opioid Treatment Program?
X
+
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A. FACILITY CHARACTERISTICS
11b*. Does the Opioid Treatment Program at this location provide maintenance services, detoxification services, or both?
SELECT ONE ONLY
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A. FACILITY CHARACTERISTICS
12.
For each type of counseling listed below, please indicate approximately what percent of the substance abuse clients at
this facility receive that type of counseling as part of their substance abuse treatment program.
SELECT ONE FOR EACH TYPE OF COUNSELING
TYPE OF COUNSELING
NOT OFFERED
RECEIVED BY
25% OR LESS
OF CLIENTS
RECEIVED BY
26% TO 50%
OF CLIENTS
RECEIVED BY
51% TO 75%
OF CLIENTS
RECEIVED BY
MORE THAN 75%
OF CLIENTS
&
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NSSATS 2013 Web Survey
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You've completed 19% of your questionnaire!
A. FACILITY CHARACTERISTICS
13.
For each type of clinical/therapeutic approach listed below, please mark the box that best describes how often that
approach is used at this facility.
• Definitions of these approaches can be found at: http://info.nssats.com
SELECT "Never", "Rarely", "Sometimes", "Always or Often" OR "Not Familiar With This Approach" FOR EACH
APPROACH.
CLINICAL/THERAPEUTIC APPROACHES
NEVER
RARELY
SOMETIMES
ALWAYS
OR OFTEN
NOT
FAMILIAR
WITH
THIS
APPROACH
Substance abuse counseling
12-step facilitation
Brief intervention
Cognitive-behavioral therapy
Contingency management/motivational incentives
Motivational interviewing
Trauma-related counseling
Anger management
Matrix Model
Community reinforcement plus vouchers
Rational emotive behavioral therapy (REBT)
Relapse prevention
Computerized substance abuse treatment
(including Internet, Web, mobile, and desktop
programs)
Other treatment approach
(Please specify:
)
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OR
you can send an e-mail to the help desk by clicking on this link http://devnssats2013.mathematica.net/EmailForm.aspx
166$76:HE6XUYH\
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A. FACILITY CHARACTERISTICS
14.
Are any of the following practices part of this facility's standard operating procedures?
SELECT "YES" OR "NO" FOR EACH
Yes
No
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A. FACILITY CHARACTERISTICS
15*.
Does this facility, Facility Name 1 Facility Name 2, Address 1, offer a specially designed program or group intended
exclusively for DUI/DWI or other drunk driver offenders?
X
+
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A. FACILITY CHARACTERISTICS
15a*. Does this facility serve only DUI/DWI clients?
X
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A. FACILITY CHARACTERISTICS
16*.
Does this facility provide substance abuse treatment services in sign language at this location for the hearing impaired
(for example, American Sign Language, Signed English, or Cued Speech)?
6HOHFW\HVLIHLWKHUDVWDIIFRXQVHORURUDQRQFDOOLQWHUSUHWHUSURYLGHVWKLVVHUYLFH
X
+
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A. FACILITY CHARACTERISTICS
17*.
Does this facility provide substance abuse treatment services in a language other than English at this location?
X
+
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A. FACILITY CHARACTERISTICS
17a. At this facility, who provides substance abuse treatment services in a language other than English?
SELECT ONE ONLY
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A. FACILITY CHARACTERISTICS
17a1*. Do staff counselors provide substance abuse treatment in Spanish at this facility?
X
+
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A. FACILITY CHARACTERISTICS
17a2. Do staff counselors at this facility provide substance abuse treatment in any other languages?
X
+
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NSSATS 2013 Web Survey
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You've completed 24% of your questionnaire!
A. FACILITY CHARACTERISTICS
17b*. In what other languages do staff counselors provide substance abuse treatment at this facility?
SELECT "YES" OR "NO" FOR EACH
AMERICAN INDIAN OR ALASKA NATIVE:
Yes
No
Hopi
Lakota
Navajo
Ojibwa
Yupik
Other American Indian or Alaska Native language
(Please specify:
)
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(Eastern Time). You can leave a message 24 hours a day when staff is not available,
OR
you can send an e-mail to the help desk by clicking on this link http://devnssats2013.mathematica.net/EmailForm.aspx
166$76:HE6XUYH\
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A. FACILITY CHARACTERISTICS
OTHER LANGUAGES:
Yes
No
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A. FACILITY CHARACTERISTICS
Are all of the languages indicated below spoken by a staff counselor?
Language1, Language2, Language3, Language4, Language5
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A. FACILITY CHARACTERISTICS
Individuals seeking substance abuse treatment can vary by age, gender or other characteristics. Which categories of individuals
are served by this facility, at Address1?
18A1. Does this facility serve adolescents at this location?
Yes
No
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OR
you can send an e-mail to the help desk by clicking on this link http://devnssats2013.mathematica.net/EmailForm.aspx
166$76:HE6XUYH\
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A. FACILITY CHARACTERISTICS
18B1. Does this facility serve only adolescents at this location?
X
+
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A. FACILITY CHARACTERISTICS
18C1*. Does this facility offer specifically tailored programs or groups for adolescents at this location?
X
+
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A. FACILITY CHARACTERISTICS
18A2. Does this facility serve adult women at this location?
X
+
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A. FACILITY CHARACTERISTICS
18B2. Does this facility serve only adult women at this location?
X
+
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A. FACILITY CHARACTERISTICS
18C2*. Does this facility offer specifically tailored programs or groups for adult women at this location?
X
+
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A. FACILITY CHARACTERISTICS
18A3. Does this facility serve adult men at this location?
X
+
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A. FACILITY CHARACTERISTICS
18B3. Does this facility serve only adult men at this location?
X
+
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A. FACILITY CHARACTERISTICS
18C3*. Does this facility offer specifically tailored programs or groups for adult men at this location?
X
+
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A. FACILITY CHARACTERISTICS
18a. Many facilities have clients with one or more of the following characteristics. For which characteristic(s) does this facility
offer a substance abuse treatment program or group specifically tailored for those individuals, at this location?
SELECT "YES" OR "NO" FOR EACH
Yes
No
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A. FACILITY CHARACTERISTICS
19*.
Does this facility offer HOSPITAL INPATIENT substance abuse services at this location, that is, Facility Name 1 Facility
Name 2, Address 1?
X
+
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A. FACILITY CHARACTERISTICS
19a*. Which of the following HOSPITAL INPATIENT services are offered at this facility, that is, Facility Name 1 Facility Name 2,
Address 1?
SELECT "YES" OR "NO" FOR EACH
Yes
No
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A. FACILITY CHARACTERISTICS
Two responses appear to be inconsistent.
In question 19 you indicated that you offer hospital inpatient substance abuse services and in question 19a you
answered NO to each type of hospital inpatient service offered.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
19. Does this facility offer HOSPITAL INPATIENT substance abuse services at this location, that is, Facility Name 1
Facility Name 2, Address 1?
YOUR RESPONSE: Yes
19a. Which of the following HOSPITAL INPATIENT services are offered at this facility?
YOUR RESPONSE:
Hospital inpatient detoxification (Similar to ASAM Levels IV-D and III.7-D, medically managed or monitored inpatient
detoxification): No
Hospital inpatient treatment (Similar to ASAM Levels IV and III.7, medically managed or monitored intensive inpatient
treatment): No
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
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A. FACILITY CHARACTERISTICS
What type of hospital inpatient substance abuse services do you offer at this location, that is, Facility Name 1 Facility
Name 2, Address 1?
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A. FACILITY CHARACTERISTICS
20*.
Does this facility offer RESIDENTIAL (non-hospital) substance abuse services at this location, that is, Facility Name 1
Facility Name 2, Address 1?
X
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You've completed 47% of your questionnaire!
A. FACILITY CHARACTERISTICS
20a*. Which of the following RESIDENTIAL services are offered at this facility, that is, Facility Name 1 Facility Name 2, Address
1?
SELECT "YES" OR "NO" FOR EACH
Yes
No
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166$76:HE6XUYH\
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You've completed 47% of your questionnaire!
A. FACILITY CHARACTERISTICS
Two responses appear to be inconsistent.
In question 20 you indicated that you offer residential (non-hospital) substance abuse services and in question 20a you
answered NO to every type of residential (non-hospital) service offered.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
20. Does this facility offer RESIDENTIAL (non-hospital) substance abuse services at this location, that is, Facility Name 1
Facility Name 2, Address 1?
YOUR RESPONSE: Yes
20a. Which of the following RESIDENTIAL services are offered at this facility?
YOUR RESPONSE:
Residential detoxification (Similar to ASAM Level III.2-D, clinically managed residential detoxification or social
detoxification): No
Residential short-term treatment (Similar to ASAM Level III.5, clinically managed high-intensity residential treatment,
typically 30 days or less): No
Residential long-term treatment (Similar to ASAM Levels III.3 and III.1, clinically managed medium- or low-intensity
residential treatment, typically more than 30 days): No
Select the choice that best describes your resolution:
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A. FACILITY CHARACTERISTICS
What type of residential substance abuse services do you offer at this location, that is, Facility Name 1 Facility Name 2,
Address 1?
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A. FACILITY CHARACTERISTICS
21*.
Does this facility offer OUTPATIENT substance abuse services at this location, that is, Facility Name 1 Facility Name 2,
Address 1?
X
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You've completed 49% of your questionnaire!
A. FACILITY CHARACTERISTICS
21a*. Which of the following OUTPATIENT services are offered at this facility, that is, Facility Name 1 Facility Name 2, Address
1?
SELECT "YES" OR "NO" FOR EACH
Yes
No
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You've completed 50% of your questionnaire!
A. FACILITY CHARACTERISTICS
Two responses appear to be inconsistent.
In question 21 you indicated that you offer outpatient substance abuse services and in question 21a you answered NO to
every type of outpatient service offered.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
21. Does this facility offer OUTPATIENT substance abuse services at this location, that is, Facility Name 1 Facility Name
2, Address 1?
YOUR RESPONSE: Yes
21a. Which of the following OUTPATIENT services are offered at this facility?
YOUR RESPONSE:
Outpatient detoxification (Similar to ASAM Levels I-D and II-D, ambulatory detoxification): No
Outpatient methadone/buprenorphine maintenance: No
Outpatient day treatment or partial hospitalization (Similar to ASAM Level II.5, 20 or more hours per week): No
Intensive outpatient treatment (Similar to ASAM Level II.1, 9 or more hours per week): No
Regular outpatient treatment (Similar to ASAM Level I, outpatient treatment, non-intensive): No
Select the choice that best describes your resolution:
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You've completed 51% of your questionnaire!
A. FACILITY CHARACTERISTICS
What type of outpatient substance abuse services do you offer at this location, that is, Facility Name 1 Facility Name 2,
Address 1?
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You've completed 51% of your questionnaire!
A. FACILITY CHARACTERISTICS
Two responses appear to be inconsistent.
Earlier you indicated that you operate an Opioid Treatment Program (OTP), however you just indicated that you do not
offer outpatient methadone maintenance at this location.
Please review your responses to the two questions below and select the choice that best describes your resolution.
11b. Does the Opioid Treatment Program at this location provide maintenance services, detoxification services, or both?
YOUR RESPONSE:
Maintenance services: Yes
Detoxification services: No
Both: No
21a. Which of the following OUTPATIENT services are offered at this facility?
YOUR RESPONSE:
1. Outpatient detoxification (Similar to ASAM Levels I-D and II-D, ambulatory detoxification): Yes
2. Outpatient methadone/buprenorphine maintenance: No
3. Outpatient day treatment or partial hospitalization (Similar to ASAM Level II.5, 20 or more hours per week): No
4. Intensive outpatient treatment (Similar to ASAM Level II.1, 9 or more hours per week): Yes
5. Regular outpatient treatment (Similar to ASAM Level I, outpatient treatment, non-intensive): No
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
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You've completed 51% of your questionnaire!
A. FACILITY CHARACTERISTICS
Two responses appear to be inconsistent.
Earlier you indicated that this facility's Opioid Treatment Program (OTP) provides detoxification services at this location,
however you just indicated that you offer outpatient methadone maintenance at this location.
Please review your responses to the two questions below and select the choice that best describes your resolution.
11b. Does the Opioid Treatment Program at this location provide maintenance services, detoxification services, or both?
YOUR RESPONSE:
Maintenance services: No
Detoxification services: Yes
Both: No
21a. Which of the following OUTPATIENT services are offered at this facility?
YOUR RESPONSE:
1. Outpatient detoxification (Similar to ASAM Levels I-D and II-D, ambulatory detoxification): Yes
2. Outpatient methadone/buprenorphine maintenance: Yes
3. Outpatient day treatment or partial hospitalization (Similar to ASAM Level II.5, 20 or more hours per week): No
4. Intensive outpatient treatment (Similar to ASAM Level II.1, 9 or more hours per week): Yes
5. Regular outpatient treatment (Similar to ASAM Level I, outpatient treatment, non-intensive): No
Select the choice that best describes your resolution:
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A. FACILITY CHARACTERISTICS
You reported this facility does not offer hospital inpatient, residential, or outpatient substance abuse services.
Is this correct?
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166$76:HE6XUYH\
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A. FACILITY CHARACTERISTICS
22*.
Does this facility use a sliding fee scale?
X
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A. FACILITY CHARACTERISTICS
22a. Do you want the availability of a sliding fee scale published in SAMHSA's Directory/Locator?
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166$76:HE6XUYH\
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A. FACILITY CHARACTERISTICS
23*.
Does this facility offer treatment at no charge to clients who cannot afford to pay?
X
+
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166$76:HE6XUYH\
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A. FACILITY CHARACTERISTICS
23a. Do you want the availability of free care for eligible clients published in SAMHSA's Directory/Locator?
7KH'LUHFWRU\/RFDWRUZLOOH[SODLQWKDWSRWHQWLDOFOLHQWVVKRXOGFDOOWKHIDFLOLW\IRULQIRUPDWLRQRQHOLJLELOLW\
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166$76:HE6XUYH\
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You've completed 55% of your questionnaire!
A. FACILITY CHARACTERISTICS
24.
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?
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NSSATS 2013 Web Survey
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You've completed 56% of your questionnaire!
A. FACILITY CHARACTERISTICS
25*.
Which of the following types of client payments or insurance are accepted by this facility for substance abuse treatment?
SELECT "YES," "NO," OR "DON'T KNOW" FOR EACH
Yes
No
Don't
Know
No payment accepted (free treatment for ALL
clients)
Cash or self-payment
Medicare
Medicaid
State-financed health insurance plan other than
Medicaid
Federal military insurance (e.g., TRICARE)
Private health insurance
Access To Recovery (ATR) vouchers
IHS/638 contract care funds
Other (Please specify:
)
Quit for now
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Back
If you have immediate problems or questions, you can reach our helpline at 1-888-324-8337. The helpline is staffed Monday-Friday, 8am to 8pm
(Eastern Time). You can leave a message 24 hours a day when staff is not available,
OR
you can send an e-mail to the help desk by clicking on this link http://devnssats2013.mathematica.net/EmailForm.aspx
166$76:HE6XUYH\
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You've completed 56% of your questionnaire!
A. FACILITY CHARACTERISTICS
26.
For each of the following activities, please indicate if staff members routinely use computer or electronic resources,
paper only, or a combination of both to accomplish their work.
SELECT ONE METHOD FOR EACH APPROACH.
COMPUTER /
ELECTRONIC
ONLY
WORK ACTIVITY
PAPER
ONLY
BOTH
ELECTRONIC
AND PAPER
N/A
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166$76:HE6XUYH\
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You've completed 56% of your questionnaire!
B. REPORTING CLIENT COUNTS
27.
The next questions ask about the number of clients in treatment at this facility. SAMHSA would prefer to get this
information separately for this facility only. However, we realize that is not always possible.
Please indicate whether the clients you report will be for…
SELECT ONE ONLY
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166$76:HE6XUYH\
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You've completed 57% of your questionnaire!
B. REPORTING CLIENT COUNTS
27a. How many facilities will be included in your client counts?
Enter the number of additional facilities included in client counts in the box below.
For Section B, please include all of these facilities in the client counts that you report in questions 28 through 33.
This facility:
1
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166$76:HE6XUYH\
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You've completed 58% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses are inconsistent.
At question 27 you reported you will include client counts for this facility combined with other facilities, however, at
question 27a you reported the number of additional facilities as zero.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
27. The next questions 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.
YOUR RESPONSE:
This questionnaire will include client counts for this facility combined with other facilities
27a. How many facilities will be included in the client counts reported in this questionnaire?
YOUR RESPONSE:
THIS FACILITY: 1
+ ADDITIONAL FACILITIES: 0
---------------------------------------------------= TOTAL FACILITIES: 1
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
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You've completed 58% of your questionnaire!
B. REPORTING CLIENT COUNTS
27b. To avoid double-counting clients, we need to know which facilities are included in your counts. How will you report this
information to us?
SELECT ONE ONLY
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166$76:HE6XUYH\
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You've completed 59% of your questionnaire!
B. REPORTING CLIENT COUNTS
27c. Please enter the facility name, location address, and phone number for each of the additional facilities included in your
client counts.
Please scroll through the entire page, listing all of the additional facilities (do not list this facility). Also, answer the
question at the bottom of the page before pressing the "Submit" button to advance.
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166$76:HE6XUYH\
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You've completed 60% of your questionnaire!
B. REPORTING CLIENT COUNTS
28.
On March 29, 2013, did any patients receive HOSPITAL INPATIENT substance abuse services at these facilities?
X
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NSSATS 2013 Web Survey
25%
50%
75%
100%
You've completed 60% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses may be inconsistent.
In question 19 you indicated this facility offers hospital inpatient substance abuse services and in question 28 you
reported that no patients received hospital inpatient services on March 29, 2013.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
19. Does this facility offer HOSPITAL INPATIENT substance abuse services at this location, that is, Facility Name 1
Facility Name 2, Address 1?
YOUR RESPONSE: Yes
28. On March 29, 2013, did any patients receive HOSPITAL INPATIENT substance abuse services at these facilities?
YOUR RESPONSE: No
Select the choice that best describes your resolution:
Both question 19 and question 28 are correct
Return to question 19 for correction
Return to question 28 for correction
Return to both question 19 and question 28 for correction
Quit for now
Review my answers
Back
If you have immediate problems or questions, you can reach our helpline at 1-888-324-8337. The helpline is staffed Monday-Friday, 8am to 8pm
(Eastern Time). You can leave a message 24 hours a day when staff is not available,
OR
you can send an e-mail to the help desk by clicking on this link http://devnssats2013.mathematica.net/EmailForm.aspx
166$76:HE6XUYH\
25%
50%
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100%
You've completed 60% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses may be inconsistent.
In question 19 you indicated this facility does not offer hospital inpatient substance abuse services and in question 28
you reported that some patients received hospital inpatient services on March 29, 2013.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
19. Does this facility offer HOSPITAL INPATIENT substance abuse services at this location, that is, Facility Name 1
Facility Name 2, Address 1?
YOUR RESPONSE: No
28. On March 29, 2013, did any patients receive HOSPITAL INPATIENT substance abuse services at this facility?
YOUR RESPONSE: Yes
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
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You've completed 61% of your questionnaire!
B. REPORTING CLIENT COUNTS
28a. On March 29, 2013, how many patients received the following HOSPITAL INPATIENT substance abuse services at these
facilities?
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166$76:HE6XUYH\
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You've completed 62% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses appear to be inconsistent.
In question 28 you indicated that some patients received hospital inpatient substance abuse services on March 29, 2013
and, in question 28a, you reported zero patients received hospital inpatient detoxification or treatment services on March
29, 2013.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
28. On March 29, 2013, did any patients receive HOSPITAL INPATIENT substance abuse services at these facilities?
YOUR RESPONSE: Yes
28a. On March 29, 2013, how many patients received the following HOSPITAL INPATIENT substance abuse services at
these facilities?
YOUR RESPONSE:
Hospital inpatient detoxification (Similar to ASAM Levels IV-D and III.7-D, medically managed or monitored inpatient
detoxification): 0
Hospital inpatient treatment (Similar to ASAM Levels IV and III.7, medically managed or monitored intensive inpatient
treatment): 0
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
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You've completed 62% of your questionnaire!
B. REPORTING CLIENT COUNTS
What type of hospital inpatient substance abuse services did patients receive at these facilities on March 29, 2013?
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166$76:HE6XUYH\
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You've completed 63% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses may be inconsistent. In questions 19a and 28a you indicated this facility...
Does not offer hospital inpatient detoxification, but had patients who received this service on March 29, 2013.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
19a. Which of the following HOSPITAL INPATIENT services are offered at this facility?
YOUR RESPONSE:
Hospital inpatient detoxification (Similar to ASAM Levels IV-D and III.7-D, medically managed or monitored inpatient
detoxification): No
Hospital inpatient treatment (Similar to ASAM Levels IV and III.7, medically managed or monitored intensive inpatient
treatment): Yes
28a. On March 29, 2013, how many patients received the following HOSPITAL INPATIENT substance abuse services at
this facility?
YOUR RESPONSE:
Hospital inpatient detoxification (Similar to ASAM Levels IV-D and III.7-D, medically managed or monitored inpatient
detoxification): 1
Hospital inpatient treatment (Similar to ASAM Levels IV and III.7, medically managed or monitored intensive inpatient
treatment): 0
TOTAL HOSPITAL INPATIENTS: 1
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
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You've completed 63% of your questionnaire!
B. REPORTING CLIENT COUNTS
Your response to question 28a is unusually large, compared to most other hospital inpatient facilities. Please verify your
response.
28a. On March 29, 2013, how many patients received the following HOSPITAL INPATIENT substance abuse services at
these facilities?
YOUR RESPONSE:
Hospital inpatient detoxification (Similar to ASAM Levels IV-D and III.7-D, medically managed or monitored inpatient
detoxification): 100000
Hospital inpatient treatment (Similar to ASAM Levels IV and III.7, medically managed or monitored intensive inpatient
treatment): 100000
TOTAL HOSPITAL INPATIENTS: 200000
Is this correct?
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25%
50%
75%
100%
You've completed 64% of your questionnaire!
B. REPORTING CLIENT COUNTS
28b. How many of the 2 HOSPITAL INPATIENTS you just reported were under the age of 18?
ENTER A NUMBER (IF NONE, ENTER "0")
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 65% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses are inconsistent. You have indicated more hospital inpatients under the age of 18 than total hospital
inpatients.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
28a. On March 29, 2013, how many patients received the following HOSPITAL INPATIENT substance abuse services at
this facility?
YOUR RESPONSE:
Hospital inpatient detoxification (Similar to ASAM Levels IV-D and III.7-D, medically managed or monitored inpatient
detoxification): 1
Hospital inpatient treatment (Similar to ASAM Levels IV and III.7, medically managed or monitored intensive inpatient
treatment): 1
TOTAL HOSPITAL INPATIENTS: 2
28b. How many of the 2 HOSPITAL INPATIENTS you just reported were under the age of 18?
YOUR RESPONSE: 3
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 65% of your questionnaire!
B. REPORTING CLIENT COUNTS
28c. How many of the 2 HOSPITAL INPATIENTS you just reported received:
,QFOXGHSDWLHQWVZKRUHFHLYHGWKHVHGUXJVIRUGHWR[LILFDWLRQRUPDLQWHQDQFHSXUSRVHV
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 66% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses are inconsistent. You have indicated more hospital inpatient methadone or buprenorphine patients than
total hospital inpatients.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
28a. On March 29, 2013, how many patients received the following HOSPITAL INPATIENT substance abuse services at
this facility?
YOUR RESPONSE:
Hospital inpatient detoxification (Similar to ASAM Levels IV-D and III.7-D, medically managed or monitored inpatient
detoxification): 1
Hospital inpatient treatment (Similar to ASAM Levels IV and III.7, medically managed or monitored intensive inpatient
treatment): 1
TOTAL HOSPITAL INPATIENTS: 2
28c. How many of the 2 HOSPITAL INPATIENTS you just reported received methadone or buprenorphine dispensed or
prescribed at this facility?
YOUR RESPONSE:
Methadone: 3
Buprenorphine: 3
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 67% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses appear to be inconsistent.
In question 10f you reported this facility does not provide methadone or buprenorphine, however, at question 28c you
indicated some hospital inpatients received methadone and/or buprenorphine dispensed or prescribed at this facility.
Please review your responses to the two questions below and select the choice that best describes your resolution.
10f. Which of the following pharmacotherapies are provided by this facility at this location?
YOUR RESPONSE:
10f.8 Methadone: No
10f.9 Buprenorphine with naloxone (Suboxone®): No
10f.10 Buprenorphine without naloxone: No
28c. How many of the 2 HOSPITAL INPATIENTS you just reported received methadone or buprenorphine dispensed or
prescribed at this facility?
YOUR RESPONSE:
Methadone: 1
Buprenorphine: 1
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 67% of your questionnaire!
B. REPORTING CLIENT COUNTS
28d. On March 29, 2013, how many hospital inpatient beds at this facility were specifically designated for substance abuse
treatment?
ENTER A NUMBER (IF NONE, ENTER "0")
+ \
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 68% of your questionnaire!
B. REPORTING CLIENT COUNTS
Your response to question 28d is unusually large, compared to the number of patients who received hospital inpatient
services on March 29.
Please verify your responses to the two questions below and then select the choice that best describes your resolution.
28a. On March 29, 2013, how many patients received the following HOSPITAL INPATIENT substance abuse services at
this facility?
YOUR RESPONSE:
Hospital inpatient detoxification (Similar to ASAM Levels IV-D and III.7-D, medically managed or monitored inpatient
detoxification): 1
Hospital inpatient treatment (Similar to ASAM Levels IV and III.7, medically managed or monitored intensive inpatient
treatment): 1
TOTAL INPATIENTS: 2
28d. On March 29, 2013, how many hospital inpatient beds at this facility were specifically designated for substance
abuse treatment?
YOUR RESPONSE: 100
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 69% of your questionnaire!
B. REPORTING CLIENT COUNTS
29.
On March 30, 2013, did any clients receive RESIDENTIAL (non-hospital) substance abuse services at this facility?
X
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 69% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses may be inconsistent.
In question 20 you indicated this facility does not offer residential substance abuse services and in question 29 you
reported that some clients received residential services on March 29, 2013.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
20. Does this facility offer RESIDENTIAL (non-hospital) substance abuse services at this location, that is, Facility Name 1
Facility Name 2, Address 1?
YOUR RESPONSE: No
29. On March 29, 2013, did any clients receive RESIDENTIAL (non-hospital) substance abuse services at this facility?
YOUR RESPONSE: Yes
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 69% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses may be inconsistent.
In question 20 you indicated this facility offers residential substance abuse services and in question 29 you reported that
no clients received residential services on March 29, 2013.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
20. Does this facility offer RESIDENTIAL (non-hospital) substance abuse services at this location, that is, Facility Name 1
Facility Name 2, Address 1?
YOUR RESPONSE: Yes
29. On March 29, 2013, did any clients receive RESIDENTIAL (non-hospital) substance abuse services at this facility?
YOUR RESPONSE: No
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 70% of your questionnaire!
B. REPORTING CLIENT COUNTS
29a. On March 29, 2013, how many clients received the following RESIDENTIAL substance abuse services at this facility?
COUNTDFOLHQWLQone service onlyHYHQLIWKHFOLHQWUHFHLYHGPXOWLSOHVHUYLFHV
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 71% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses appear to be inconsistent.
In question 29 you indicated that some clients received residential (non-hospital) substance abuse services on March 29,
2013 and, in question 29a, you reported zero clients received residential detoxification, residential short-term or
residential long-term treatment services on March 29, 2013.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
29. On March 29, 2013, did any clients receive RESIDENTIAL (non-hospital) substance abuse services at this facility?
YOUR RESPONSE: Yes
29a. On March 29, 2013, how many clients received the following RESIDENTIAL substance abuse services at this facility?
YOUR RESPONSE:
Residential detoxification (Similar to ASAM Level III.2-D, clinically managed residential detoxification or social
detoxification): 0
Residential short-term treatment (Similar to ASAM Level III.5, clinically managed high-intensity residential treatment,
typically 30 days or less): 0
Residential long-term treatment (Similar to ASAM Levels III.3 and III.1, clinically managed medium- or low-intensity
residential treatment, typically more than 30 days): 0
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 71% of your questionnaire!
B. REPORTING CLIENT COUNTS
What type of residential substance abuse services did clients receive at this facility on March 29, 2013?
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 72% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses may be inconsistent. In questions 20a and 29a you indicated this facility...
Does not offer residential detoxification, but had clients who received this service on March 29, 2013.
Does not offer residential short-term treatment, but had clients who received this service on March 29, 2013.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
20a. Which of the following RESIDENTIAL services are offered at this facility?
YOUR RESPONSE:
Residential detoxification (Similar to ASAM Level III.2-D, clinically managed residential detoxification or social
detoxification): No
Residential short-term treatment (Similar to ASAM Level III.5, clinically managed high-intensity residential treatment,
typically 30 days or less): No
Residential long-term treatment (Similar to ASAM Levels III.3 and III.1, clinically managed medium- or low-intensity
residential treatment, typically more than 30 days): Yes
29a. On March 29, 2013, how many clients received the following RESIDENTIAL substance abuse services at this facility?
YOUR RESPONSE:
Residential detoxification (Similar to ASAM Level III.2-D, clinically managed residential detoxification or social
detoxification): 5
Residential short-term treatment (Similar to ASAM Level III.5, clinically managed high-intensity residential treatment,
typically 30 days or less): 5
Residential long-term treatment (Similar to ASAM Levels III.3 and III.1, clinically managed medium- or low-intensity
residential treatment, typically more than 30 days): 0
TOTAL RESIDENTIAL CLIENTS: 10
Select the choice that best describes your resolution:
# ~ ~
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 72% of your questionnaire!
B. REPORTING CLIENT COUNTS
Your response to question 29a is unusually large, compared to most other residential facilities.
Please verify your response.
29a. On March 29, 2013, how many clients received the following RESIDENTIAL substance abuse services at this facility?
YOUR RESPONSE:
Residential detoxification (Similar to ASAM Level III.2-D, clinically managed residential detoxification or social
detoxification): 0
Residential short-term treatment (Similar to ASAM Level III.5, clinically managed high-intensity residential treatment,
typically 30 days or less): 0
Residential long-term treatment (Similar to ASAM Levels III.3 and III.1, clinically managed medium- or low-intensity
residential treatment, typically more than 30 days): 1500
TOTAL RESIDENTIAL CLIENTS: 1500
Is this correct?
Select the choice that best describes your resolution:
X [ ~
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 73% of your questionnaire!
B. REPORTING CLIENT COUNTS
29b. How many of the 1500 RESIDENTIAL clients you just reported were under the age of 18?
ENTER A NUMBER (IF NONE, ENTER "0")
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 74% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses are inconsistent. You have indicated more residential clients under the age of 18 than total residential
clients.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
29a. On March 29, 2013, how many clients received the following RESIDENTIAL substance abuse services at this facility?
YOUR RESPONSE:
Residential detoxification (Similar to ASAM Level III.2-D, clinically managed residential detoxification or social
detoxification): 0
Residential short-term treatment (Similar to ASAM Level III.5, clinically managed high-intensity residential treatment,
typically 30 days or less): 0
Residential long-term treatment (Similar to ASAM Levels III.3 and III.1, clinically managed medium- or low-intensity
residential treatment, typically more than 30 days): 1500
TOTAL RESIDENTIAL CLIENTS: 1500
29b. How many of the 1500 RESIDENTIAL clients you just reported were under the age of 18?
YOUR RESPONSE: 8000
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 74% of your questionnaire!
B. REPORTING CLIENT COUNTS
29c. How many of the 1500 RESIDENTIAL clients you just reported received:
,QFOXGHFOLHQWVZKRUHFHLYHGWKHVHGUXJVIRUGHWR[LILFDWLRQRUPDLQWHQDQFHSXUSRVHV
ENTER A NUMBER FOR EACH (IF NONE, ENTER "0")
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 75% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses are inconsistent. You have indicated more residential methadone or buprenorphine clients than total
residential clients.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
29a. On March 29, 2013, how many clients received the following RESIDENTIAL substance abuse services at this facility?
YOUR RESPONSE:
Residential detoxification (Similar to ASAM Level III.2-D, clinically managed residential detoxification or social
detoxification): 0
Residential short-term treatment (Similar to ASAM Level III.5, clinically managed high-intensity residential treatment,
typically 30 days or less): 0
Residential long-term treatment (Similar to ASAM Levels III.3 and III.1, clinically managed medium- or low-intensity
residential treatment, typically more than 30 days): 1500
TOTAL RESIDENTIAL CLIENTS: 1500
29c. How many of the 1500 RESIDENTIAL clients you just reported received methadone or buprenorphine dispensed or
prescribed at this facility?
YOUR RESPONSE:
Methadone: 2000
Buprenorphine: 5
Select the choice that best describes your resolution:
; ~ \
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 76% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses appear to be inconsistent.
In question 10f you reported this facility does not provide methadone or buprenorphine, however, at question 29c you
indicated some residential (non-hospital) clients received methadone and/or buprenorphine dispensed or prescribed at
this facility.
Please review your responses to the two questions below and select the choice that best describes your resolution.
10f. Which of the following pharmacotherapies are provided by this facility at this location?
YOUR RESPONSE:
10f.8 Methadone: No
10f.9 Buprenorphine with naloxone (Suboxone®): No
10f.10 Buprenorphine without naloxone: No
29c. How many of the 1500 RESIDENTIAL clients you just reported received methadone or buprenorphine dispensed or
prescribed at this facility?
YOUR RESPONSE:
Methadone: 5
Buprenorphine: 5
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 76% of your questionnaire!
B. REPORTING CLIENT COUNTS
29d. On March 29, 2013, how many residential beds at this facility were specifically designated for substance abuse
treatment?
ENTER A NUMBER (IF NONE, ENTER "0")
+ \
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 77% of your questionnaire!
B. REPORTING CLIENT COUNTS
Your response to question 29d is unusually large, compared to the number of clients who received residential services
on March 29.
Please verify your responses to the two questions below and then select the choice that best describes your resolution.
29a. On March 29, 2013, how many clients received the following RESIDENTIAL substance abuse services at this facility?
YOUR RESPONSE:
Residential detoxification (Similar to ASAM Level III.2-D, clinically managed residential detoxification or social
detoxification): 0
Residential short-term treatment (Similar to ASAM Level III.5, clinically managed high-intensity residential treatment,
typically 30 days or less): 0
Residential long-term treatment (Similar to ASAM Levels III.3 and III.1, clinically managed medium- or low-intensity
residential treatment, typically more than 30 days): 1500
TOTAL RESIDENTIAL CLIENTS: 1500
29d. On March 29, 2013, how many residential beds at this facility were specifically designated for substance abuse
treatment?
YOUR RESPONSE: 8000
Select the choice that best describes your resolution:
# ~ ~
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 78% of your questionnaire!
B. REPORTING CLIENT COUNTS
To avoid duplication in counting substance abuse patients/clients who received services on March 29, each patient/client
should be reported as receiving services in only one type of setting on that day…either HOSPITAL INPATIENT or
RESIDENTIAL (non-hospital).
Please review your responses to the questions below to make sure that the same patients/clients are not reported twice,
and then select the choice that best describes your resolution.
28. On March 29, 2013, did any patients receive HOSPITAL INPATIENT substance abuse services at this facility?
YOUR RESPONSE: Yes
28a. On March 29, 2013, how many patients received the following HOSPITAL INPATIENT substance abuse services at
this facility (hospital inpatient detoxification; hospital inpatient treatment)?
YOUR TOTAL RESPONSE: 10
29. On March 29, 2013, did any clients receive RESIDENTIAL (non-hospital) substance abuse services at this facility?
YOUR RESPONSE: Yes
29a. On March 29, 2013, how many clients received the following RESIDENTIAL substance abuse services at this facility
(residential detoxification; residential short-term treatment; residential long-term treatment)?
YOUR TOTAL RESPONSE: 10
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 78% of your questionnaire!
B. REPORTING CLIENT COUNTS
30.
During the month of March 2013, did any clients receive OUTPATIENT substance abuse services at this facility?
X
+
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 79% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses may be inconsistent.
In question 21 you indicated this facility offers outpatient substance abuse services and in question 30 you reported that
no clients received outpatient services during the month of March 2013.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
21. Does this facility offer OUTPATIENT substance abuse services at this location, that is, Facility Name 1 Facility Name
2, Address 1?
YOUR RESPONSE: Yes
30. During the month of March 2013, did any clients receive OUTPATIENT substance abuse services at this facility?
YOUR RESPONSE: No
Select the choice that best describes your resolution:
# ~}
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 79% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses may be inconsistent.
In question 21 you indicated this facility does not offer outpatient substance abuse services and in question 30 you
reported that some clients received outpatient services during the month of March 2013.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
21. Does this facility offer OUTPATIENT substance abuse services at this location, that is, Facility Name 1 Facility Name
2, Address 1?
YOUR RESPONSE: No
30. During the month of March 2013, did any clients receive OUTPATIENT substance abuse services at this facility?
YOUR RESPONSE: Yes
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
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You've completed 79% of your questionnaire!
B. REPORTING CLIENT COUNTS
30a. How many clients received each of the following OUTPATIENT substance abuse services at this facility during March
2013?
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166$76:HE6XUYH\
25%
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You've completed 80% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses appear to be inconsistent.
In question 30 you indicated that some clients received outpatient substance abuse services during the month of March
2013. And in question 30a you reported that, as of March 29, 2013, zero clients were enrolled in outpatient detoxification,
methadone/buprenorphine maintenance, day treatment or partial hospitalization, intensive or regular outpatient treatment
services.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
30. During the month of March 2013, did any clients receive OUTPATIENT substance abuse services at this facility?
YOUR RESPONSE: Yes
30a. How many clients received each of the following OUTPATIENT substance abuse services at this facility during
March 2013?
YOUR RESPONSE:
Outpatient detoxification (Similar to ASAM Levels I-D and II-D, ambulatory detoxification): 0
Outpatient methadone/buprenorphine maintenance: 0
Outpatient day treatment or partial hospitalization (Similar to ASAM Level II.5, 20 or more hours per week): 0
Intensive outpatient treatment, (Similar to ASAM Level II.1, 9 or more hours per week): 0
Regular outpatient treatment (Similar to ASAM Level I, outpatient treatment, non-intensive): 0
Select the choice that best describes your resolution:
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NSSATS 2013 Web Survey
25%
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You've completed 81% of your questionnaire!
B. REPORTING CLIENT COUNTS
What type of outpatient substance abuse services were clients enrolled in, at this facility, on March 29, 2013?
Quit for now
Review my answers
Back
If you have immediate problems or questions, you can reach our helpline at 1-888-324-8337. The helpline is staffed Monday-Friday, 8am to 8pm
(Eastern Time). You can leave a message 24 hours a day when staff is not available,
OR
you can send an e-mail to the help desk by clicking on this link http://devnssats2013.mathematica.net/EmailForm.aspx
166$76:HE6XUYH\
25%
50%
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You've completed 81% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses may be inconsistent. In questions 21a and 30a you indicated this facility...
Does not offer methadone/buprenorphine maintenance, but had clients enrolled in this service on March 29, 2013.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
21a. Which of the following OUTPATIENT services are offered at this facility?
YOUR RESPONSE:
Outpatient detoxification (Similar to ASAM Levels I-D and II-D, ambulatory detoxification): No
Outpatient methadone/buprenorphine maintenance: No
Outpatient day treatment or partial hospitalization (Similar to ASAM Level II.5, 20 or more hours per week): No
Intensive outpatient treatment (Similar to ASAM Level II.1, 9 or more hours per week): No
Regular outpatient treatment (Similar to ASAM Level I, outpatient treatment, non-intensive): No
30a. How many clients received each of the following OUTPATIENT substance abuse services at this facility during
March 2013?
YOUR RESPONSE:
Outpatient detoxification (Similar to ASAM Levels I-D and II-D, ambulatory detoxification): 0
Outpatient methadone/buprenorphine maintenance: 10
Outpatient day treatment or partial hospitalization (Similar to ASAM Level II.5, 20 or more hours per week): 0
Intensive outpatient treatment (Similar to ASAM Level II.1, 9 or more hours per week): 0
Regular outpatient treatment (Similar to ASAM Level I, outpatient treatment, non-intensive): 0
TOTAL OUTPATIENTS: 10
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 83% of your questionnaire!
B. REPORTING CLIENT COUNTS
The clients reported in outpatient methadone/buprenorphine maintenance and the clients reported in regular outpatient
treatment appear to be duplicated. Please review your answers below.
Only count methadone/buprenorphine maintenance clients in one category, even if they received multiple services.
30a. How many clients received each of the following OUTPATIENT substance abuse services at this facility during
March 2013?
YOUR RESPONSE:
Outpatient detoxification (Similar to ASAM Levels I-D and II-D, ambulatory detoxification): 0
Outpatient methadone/buprenorphine maintenance: 10
Outpatient day treatment or partial hospitalization (Similar to ASAM Level II.5, 20 or more hours per week): 0
Intensive outpatient treatment (Similar to ASAM Level II.1, 9 or more hours per week): 0
Regular outpatient treatment (Similar to ASAM Level I, outpatient treatment, non-intensive): 10
TOTAL OUTPATIENTS: 20
Are the 10 methadone/buprenorphine maintenance clients the same clients as the 10 regular outpatient treatment
clients?
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 83% of your questionnaire!
B. REPORTING CLIENT COUNTS
Your response to question 30a is unusually large, compared to most other outpatient facilities. Please verify your
response.
30a. How many clients received each of the following OUTPATIENT substance abuse services at this facility during
March 2013?
YOUR RESPONSE:
Outpatient detoxification (Similar to ASAM Levels I-D and II-D, ambulatory detoxification): 0
Outpatient methadone/buprenorphine maintenance: 0
Outpatient day treatment or partial hospitalization (Similar to ASAM Level II.5, 20 or more hours per week): 0
Intensive outpatient treatment (Similar to ASAM Level II.1, 9 or more hours per week): 5000
Regular outpatient treatment (Similar to ASAM Level I, outpatient treatment, non-intensive): 0
TOTAL OUTPATIENTS: 5000
Please consider the following:
Do not count clients who were discharged on or before March 29
Do not count a client's support group, such as relatives and friends who may have received support counseling
Do not count clients who were not seen at least once during March 2013 for a substance abuse treatment service
Do not count clients in more than one category
Count individual clients…not number of visits
The number you report should represent the outpatient caseload or “census” at this facility as of March 29
Considering the above, is your response to question 30a correct?
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166$76:HE6XUYH\
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You've completed 85% of your questionnaire!
B. REPORTING CLIENT COUNTS
30b. How many of the 165 OUTPATIENT clients you just reported were under the age of 18?
ENTER A NUMBER (IF NONE, ENTER "0")
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 85% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses are inconsistent. You have indicated more outpatient clients under the age of 18 than total outpatients.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
30a. How many clients received each of the following OUTPATIENT substance abuse services at this facility during
March 2013?
YOUR RESPONSE:
Outpatient detoxification (Similar to ASAM Levels I-D and II-D, ambulatory detoxification): 5
Outpatient methadone/buprenorphine maintenance: 80
Outpatient day treatment or partial hospitalization (Similar to ASAM Level II.5, 20 or more hours per week): 0
Intensive outpatient treatment (Similar to ASAM Level II.1, 9 or more hours per week): 0
Regular outpatient treatment (Similar to ASAM Level I, outpatient treatment, non-intensive): 80
TOTAL OUPATIENTS: 165
30b. How many of the 165 OUTPATIENT clients you just reported were under the age of 18?
YOUR RESPONSE: 200
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
25%
50%
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100%
You've completed 86% of your questionnaire!
B. REPORTING CLIENT COUNTS
30c. How many of the 165 OUTPATIENT clients you just reported received:
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 87% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses are inconsistent. You have indicated more outpatient methadone or buprenorphine clients than total
outpatients.
Please review your responses to the two questions below and then select the choice that best describes your resolution.
30a. How many clients received each of the following OUTPATIENT substance abuse services at this facility during
March 2013?
YOUR RESPONSE:
Outpatient detoxification (Similar to ASAM Levels I-D and II-D, ambulatory detoxification): 5
Outpatient methadone/buprenorphine maintenance: 80
Outpatient day treatment or partial hospitalization (Similar to ASAM Level II.5, 20 or more hours per week): 0
Intensive outpatient treatment (Similar to ASAM Level II.1, 9 or more hours per week): 0
Regular outpatient treatment (Similar to ASAM Level I, outpatient treatment, non-intensive): 80
TOTAL OUPATIENTS: 165
30c. How many of the 165 OUTPATIENTS you just reported received methadone or buprenorphine dispensed or
prescribed at this facility?
YOUR RESPONSE:
Methadone: 200
Buprenorphine: 15
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 87% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses are inconsistent. You have indicated fewer outpatients received methadone and buprenorphine than
outpatients enrolled in a methadone/buprenorphine maintenance program.
Please review your answers to the two questions below and then select the choice that best describes your resolution.
30a. How many clients received each of the following OUTPATIENT substance abuse services at this facility during
March 2013?
YOUR RESPONSE:
Outpatient detoxification (Similar to ASAM Levels I-D and II-D, ambulatory detoxification): 5
Outpatient methadone/buprenorphine maintenance: 80
Outpatient day treatment or partial hospitalization (Similar to ASAM Level II.5, 20 or more hours per week): 0
Intensive outpatient treatment (Similar to ASAM Level II.1, 9 or more hours per week): 0
Regular outpatient treatment (Similar to ASAM Level I, outpatient treatment, non-intensive): 80
TOTAL OUPATIENTS: 165
30c. How many of the 165 OUTPATIENTS you just reported received methadone or buprenorphine dispensed or
prescribed at this facility?
YOUR RESPONSE:
Methadone: 0
Buprenorphine: 0
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 88% of your questionnaire!
B. REPORTING CLIENT COUNTS
Two responses appear to be inconsistent.
In question 10f you reported this facility does not provide methadone or buprenorphine, however, at question 30c you
indicated some outpatients received methadone and/or buprenorphine dispensed or prescribed at this facility.
Please review your responses to the two questions below and select the choice that best describes your resolution.
10f. Which of the following pharmacotherapies are provided by this facility at this location?
YOUR RESPONSE:
10f.8 Methadone: No
10f.9 Buprenorphine with naloxone (Suboxone®): No
10f.10 Buprenorphine without naloxone: No
30c. How many of the 165 OUTPATIENTS you just reported received methadone or buprenorphine dispensed or
prescribed at this facility?
YOUR RESPONSE:
Methadone: 80
Buprenorphine: 15
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 88% of your questionnaire!
B. REPORTING CLIENT COUNTS
Your responses appear to be inconsistent.
Earlier you indicated that this facility operates an Opioid Treatment Program (OTP), however you have reported that none
of the clients enrolled at this facility on March 29, 2013 received methadone.
Please review your responses to the questions below and select the choice that best describes your resolution.
11. Does this facility operate an Opioid Treatment Program (OTP) at this location?
YOUR RESPONSE: Yes
28c. How many of the 10 HOSPITAL INPATIENTS you just reported received methadone or buprenorphine dispensed or
prescribed at this facility?
YOUR RESPONSE:
Methadone: 0
Buprenorphine: 0
30c. How many of the 165 OUTPATIENT clients you just reported received methadone or buprenorphine dispensed or
prescribed at this facility?
YOUR RESPONSE:
Methadone: 0
Buprenorphine: 80
Select the choice that best describes your resolution:
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 89% of your questionnaire!
B. REPORTING CLIENT COUNTS
30d. On average, during March 2013, were the outpatient substance abuse treatment services at this facility operating over,
under, or at capacity?
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NSSATS 2013 Web Survey
25%
50%
75%
100%
You've completed 90% of your questionnaire!
B. REPORTING CLIENT COUNTS
31.
This question asks you to categorize the substance abuse treatment clients at this facility into three groups: clients in
treatment for (1) the abuse of both alcohol and drugs other than alcohol; (2) abuse of only alcohol; or (3) abuse of only
drugs other than alcohol.
Enter the percent of clients on March 29, 2013, who were in each of these three groups:
Clients in treatment for abuse of:
The following three responses should total 100%. If not, please reconcile.
1. BOTH alcohol and drugs other
than alcohol
%
2. ONLY alcohol
%
3. ONLY drugs other than alcohol
%
Quit for now
Review my answers
Back
If you have immediate problems or questions, you can reach our helpline at 1-888-324-8337. The helpline is staffed Monday-Friday, 8am to 8pm
(Eastern Time). You can leave a message 24 hours a day when staff is not available,
OR
you can send an e-mail to the help desk by clicking on this link http://devnssats2013.mathematica.net/EmailForm.aspx
166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 90% of your questionnaire!
B. REPORTING CLIENT COUNTS
32.
Approximately what percent of the substance abuse treatment clients enrolled at this facility on March 29, 2013, had a
diagnosed co-occurring mental and substance abuse disorder?
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166$76:HE6XUYH\
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100%
You've completed 91% of your questionnaire!
B. REPORTING CLIENT COUNTS
33.
Using the most recent 12-month period for which you have data, approximately how many substance abuse treatment
ADMISSIONS did this facility have?
OUTPATIENT CLIENTS:&RXQWDGPLVVLRQVLQWRWUHDWPHQWQRWLQGLYLGXDOWUHDWPHQWYLVLWV&RQVLGHUDQDGPLVVLRQWREHWKH
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IF THIS IS A MENTAL HEALTH FACILITY:&RXQWDOODGPLVVLRQVLQZKLFKFOLHQWVUHFHLYHGVXEVWDQFHDEXVHWUHDWPHQW
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166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 92% of your questionnaire!
B. REPORTING CLIENT COUNTS
Your response to question 33 is unusually large, compared to the number of clients enrolled at this facility on March 29,
2013.
Please verify your response to question 33.
33. Using the most recent 12-month period for which you have data, approximately how many substance abuse treatment
ADMISSIONS did this facility have?
YOUR RESPONSE:
Number of Substance Abuse Admissions in a 12-month period: 10000
Is this correct?
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166$76:HE6XUYH\
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100%
You've completed 92% of your questionnaire!
C. GENERAL INFORMATION
34*.
Does this facility operate transitional housing or a halfway house for substance abuse clients at this location, that is,
Facility Name 1 Facility Name 2, Address 1?
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166$76:HE6XUYH\
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You've completed 93% of your questionnaire!
C. GENERAL INFORMATION
35.
Which statement below BEST describes this facility's smoking policy?
SELECT ONE ONLY
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NSSATS 2013 Web Survey
25%
50%
75%
100%
You've completed 94% of your questionnaire!
C. GENERAL INFORMATION
36.
Is this facility or program licensed, certified, or accredited to provide substance abuse services by any of the following
organizations?
• Do not include personal-level credentials or general business licenses such as a food service license.
SELECT "YES," "NO," OR "DON'T KNOW" FOR EACH
Yes
No
Don't
Know
State substance abuse agency
State mental health department
State department of health
Hospital licensing authority
The Joint Commission
Commission on Accreditation of Rehabilitation
Facilities (CARF)
National Committee for Quality Assurance (NCQA)
Council on Accreditation (COA)
Another state or local agency or other organization
(Please specify:
)
Quit for now
Review my answers
Back
If you have immediate problems or questions, you can reach our helpline at 1-888-324-8337. The helpline is staffed Monday-Friday, 8am to 8pm
(Eastern Time). You can leave a message 24 hours a day when staff is not available,
OR
you can send an e-mail to the help desk by clicking on this link http://devnssats2013.mathematica.net/EmailForm.aspx
166$76:HE6XUYH\
25%
50%
75%
100%
You've completed 94% of your questionnaire!
C. GENERAL INFORMATION
37.
Does this facility have a National Provider Identifier (NPI) number?
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| File Type | application/pdf |
| File Title | Attachment B3 - N-SSATS 2013 web screens for on-line questionnaire_55.pdf |
| Author | LocalAdmin |
| File Modified | 2012-10-15 |
| File Created | 2012-10-15 |