N-SSATS 2013 CATI N-SSATS 2013 CATI Questionnaire

Attachment B4 (N-SSATS 2013 CATI questionnaire)
FORM APPROVED: OMB No. 0930-xxxx
APPROVAL EXPIRES: xx/xx/xxxx
See OMB burden statement on last page

NATIONAL SURVEY OF SUBSTANCE ABUSE TREATMENT SERVICES
2013 N-SSATS
Hello

Hello, my name is [fill interviewer name] and I am calling
concerning the Federal Government's annual survey of substance
abuse treatment providers called N-SSATS or the National Survey
of Substance Abuse Treatment Services. The N-SSATS survey is
sponsored by SAMHSA, the Substance Abuse and Mental Health
Services Administration.

GetDir

May I speak with [fill director name] regarding this facility’s
2013 N-SSATS questionnaire?
USE UpdateInfo TAB TO ENTER A DIFFERENT PHONE NUMBER
<1>
<2>
<3>
<4>
<5>

SPEAKING WITH FACILITY DIRECTOR/APPROPRIATE PERSON
[goto Intro]
CONNECTED TO FACILITY DIRECTOR/APPROPRIATE PERSON
[goto Hello2]
FACILITY DIRECTOR NOT AVAILABLE [goto Callback]
ANSWERING MACHINE [goto Message_Q]
WRONG NUMBER [goto Sorry]

Sorry

I'm sorry. Thank you for your time.

Hello2

Hello, my name is [fill interviewer name] and I am calling
concerning the Federal Government's annual survey of substance
abuse treatment providers called N-SSATS or the National Survey
of Substance Abuse Treatment Services. The N-SSATS survey is
sponsored by SAMHSA, the Substance Abuse and Mental Health
Services Administration.
[goto Intro]

Intro

Recently you were mailed a letter from Dr. Peter J. Delany at
SAMHSA along with a letter from your State or Federal Agency
Substance Abuse Director. Both letters requested the
participation of your facility in the 2013 N-SSATS. We are
calling at this time to complete the survey. Is this a good
time?
<1>
YES, CONTINUE [goto Confirm2]
<2>
SCHEDULE CALLBACK AT CONVENIENT TIME [goto Callback]
<3>
COMPLETING ON THE WEB [Thanks]
<4>
NO LONGER PROVIDES SUBSTANCE ABUSE TREATMENT [goto A1]
<5>
NEVER PROVIDED SUBSTANCE ABUSE SERVICES [goto A1]
<6>
DUPLICATE FACILITY [goto Duplicate]
<7>
MERGED WITH ANOTHER FACILITY [goto Merged]
<8>
FACILITY CLOSED/NO LONGER EXISTS [goto Thanks2]
<9>
SATELLITE FACILITY [goto Satellite]
<10>
REPORTED ELSEWHERE [goto RE1]
<11>
WRONG NUMBER [goto Sorry]
<12>
COMPLETING BY MAIL [goto Thanks]

Confirm2

I will be asking you questions about [fill facility name]
located at
[fill address 1]
[fill address 2]
[fill City],
[fill State]
[fill zip]
IF NOT CORRECT USE THE UpdateInfo TAB TO UPDATE FACILITY
INFORMATION
[goto A1]

RE1

We'll watch for that information to come in. Putting the client
information aside, it is important for every facility to answer
a few questions regarding the specific characteristics of their
facility--even if an administrative unit or parent facility
will report your client information for you. Could I ask you
these few questions now? It will only take about 15 minutes
<1>
<2>
<3>
<4>
<5>

RE3

YES
NO,
NO,
NO,
NO,

[goto A1]
NOT A CONVENIENT TIME [goto Callback]
WILL SEND THEM IN THE MAIL [goto Thanks]
NOT THE PROPER PERSON TO TALK WITH [goto RE3]
WILL COMPLETE ON WEB [goto Thanks]

Who could answer facility-specific questions such as which
types of services are offered at this facility?
USE UpdateInfo TAB TO ENTER A NEW CONTACT NAME

RE4

Could I speak with [fill contact name]?
<1>
<2>
<3>

RE5

Hello, my name is [fill interviewer name] and I am calling on
behalf of the Federal Government's annual survey called the
National Survey of Substance Abuse Treatment Services. This
survey is sponsored by SAMHSA, the Substance Abuse and Mental
Health Services Administration. I have a few questions I'd like
to ask you.
<1>
<2>
<3>
<4>

Duplicate

YES [goto RE5]
NOT AVAILABLE - INTERVIEWER: Thank you, I will call
back. [goto Callback]
CONNECTED TO ANSWERING MACHINE [goto Message_R]

YES, CONTINUE [goto A1]
NO, NOT A CONVENIENT TIME [goto Callback]
NO, WILL SEND THEM IN THE MAIL [goto Thanks]
NO, WILL COMPLETE ON WEB [goto Thanks]

Which facility is a duplicate of this one?
PRESS ENTER TO CHOOSE FROM LIST OR TO ENTER FACILITY INFO
[choose from list of facilities or goto MainFacility]

Merged

Which facility was this one merged with?
PRESS ENTER TO CHOOSE FROM LIST OR TO ENTER FACILITY INFO
[choose from list of facilities or goto MainFacility]

Satellite

Which facility is this one associated with?
For the purpose of this survey a satellite facility is one that
does not have permanent staff on location. Often times staff
will travel from another location to provide treatment on a
limited schedule.
PRESS ENTER TO CHOOSE FROM LIST OR TO ENTER FACILITY INFO
[choose from list of facilities or goto MainFacility]

MainFacility

May I have the name, address and phone number of the facility?
<1>

PhoneNumber

Continue

Please give me the telephone number, area code first?
[goto Thanks]

Message_R

*** REMINDER CALL MESSAGE ***
DID YOU LEAVE THE MESSAGE?
<1>
<2>

Message_Q

Yes
No

*** QUESTIONNAIRE CALL MESSAGE ***
DID YOU LEAVE THE MESSAGE?
<1>
<2>

Yes
No

Thanks

Thank you so much for your time. Your responses are very
important to the study and we look forward to receiving your
completed questionnaire.

Thanks2

Thank you for your time.

Callback

USE THE ‘APPOINTMENT’ TAB ABOVE TO MAKE AN APPOINTMENT.

A1

First, I will ask you about the characteristics of the
individual facility, [fill facility name] located at [fill
LOCATION ADDRESS].
Please answer the following questions referring only to this
substance abuse facility.
Which of the following substance abuse services are offered by
this facility at this location, that is, [fill LOCATION
ADDRESS].
<1>
<2>
<3>

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

<1>
<0>

YES
NO

DON’T KNOW
REFUSED

[ask if A1_2 & A1_3 = <0>]
You reported that this facility at this location does not offer
detoxification or substance abuse treatment.
Is that correct?

A1x

<1>
<0>

YES [go to A34]
NO [BACK UP AND RETURN TO A1 FOR CORRECTION]

DON’T KNOW
REFUSED

[ask if A1_1 to A1_3 ALL = or OR if A1a = or ]
Could I speak with someone else who may be familiar with the
day-to-day operation of this facility?
IF DON'T KNOW OR REFUSED CODE A REFUSAL USING THE BREAKOFF TAB

A1a

<1>

ENTER CONTACT PERSON'S NAME

DON’T KNOW
REFUSED

Does this facility, at this location, offer mental health
treatment services (services focused on improving the mental
well-being of individuals with mental disorders and on
promoting their recovery)?
<1>
<0>

YES
NO

DON’T KNOW
REFUSED

[if A1-2 = yes, goto A2a; if A1-2 NE Yes & A1-3 = yes, go to
A4; else continue]

A2a

A2b

A3

Does this facility detoxify clients from . . .
<1>
<2>
<3>
<4>
<5>
<6>

Alcohol
Benzodiazepines
Cocaine
Methamphetamines
Opioids
Other substances (SPECIFY)

<1>
<0>

YES
NO

DON’T KNOW
REFUSED

Does this facility routinely use medications during
detoxification?
<1>
<0>

YES
NO

DON’T KNOW
REFUSED

[Go to A4]
DID RESPONDENT ANSWER YES TO SUBSTANCE ABUSE TREATMENT IN
OPTION 3 OF A1?
<1>
<0>

A4

A4a

YES [goto A4]
NO [goto A34]

Is this facility operated by . . .
<1>
<2>
<3>
<4>
<5>
<6>

A private for-profit organization, [goto A5]
A private non-profit organization, [goto A5]
State government, [goto A7]
Local, county, or community government, [goto A7]
Tribal government, or [goto A7]
The Federal Government?

DON’T KNOW
REFUSED

Which Federal Government agency is that? Is it …
<1>
The Department of Veterans Affairs,
<2>
Department of Defense,
<3>
Indian Health Service, or
<4>
Some other Federal Government agency? (SPECIFY)

DON’T KNOW
REFUSED

[goto A7]
A5

Is this facility a solo practice, meaning, an office with only
one independent practitioner or counselor?
<1>
<0>

YES
NO

DON’T KNOW
REFUSED

A6

A7

A7a

Is this facility affiliated with a religious organization?
<1>
<0>

YES
NO

DON’T KNOW
REFUSED

Is this facility a jail, prison, or other organization that
provides treatment exclusively for incarcerated persons or
juvenile detainees?
<1>
<0>

YES
NO [goto A8]

DON’T KNOW
REFUSED

Just to confirm, this facility provides substance abuse
treatment services only to incarcerated persons or juvenile
detainees.
Is that correct?
<1>
<0>

A8

A8a

YES, THAT IS CORRECT [goto A41]
NO, THAT IS NOT CORRECT

Is this facility a hospital or located in or operated by a
hospital?
<1>
<0>

YES
NO [goto A9]

DON’T KNOW
REFUSED

What type of hospital is that...
<1>
<2>
<3>

A general hospital (including a VA hospital),
Psychiatric hospital, or
Some other specialty hospital, for example, alcoholism
or maternity? (SPECIFY)

DON’T KNOW
REFUSED

A9

What telephone number or numbers should a potential client call
to schedule an intake appointment?
INTERVIEWER: IF R TELLS YOU THE INTAKE NUMBER IS THE SAME AS
THE NUMBER YOU CALLED, YOU MUST CONFIRM THAT NUMBER. IT IS
FILLED AT THE END OF RESPONSE NUMBER 3 FOR THIS PURPOSE. YOU
CANNOT ASSUME R KNOWS WHICH NUMBER YOU CALLED TO REACH HIM.
<1>
<2>
<3>
<4>

TO RECORD INTAKE PHONE NUMBER(S)
DOES NOT APPLY
SAME NUMBER YOU JUST CALLED [fill adialphone],
SAME NUMBER YOU JUST CALLED [fill adialphone] PLUS
ANOTHER NUMBER

DON’T KNOW
REFUSED

ENTER
ENTER
ENTER
ENTER

NUMERIC PHONE NUMBER
EXTENSION (OPTIONAL)
NUMERIC PHONE NUMBER
EXTENSION (OPTIONAL)

(OPTIONAL): @phn
@ext
(OPTIONAL): @phn2
@ext2

OR
ENTER
ENTER
ENTER
ENTER
V9

I've recorded [fill A9_p1ac] as the area code for the intake
number. Is that correct?
<1>
<0>

V9b

YES
NO

I've recorded [fill A9_p3ac] as the area code for the alpha
intake number. Is that correct?
<1>
<0>

V9d

YES
NO

I've recorded [fill A9_p2ac] as the area code for the second
intake number. Is that correct?
<1>
<0>

V9c

ALPHA PHONE NUMBER (OPTIONAL): @ac3 @phn3
EXTENSION (OPTIONAL) @ext3
ALPHA PHONE NUMBER (OPTIONAL): @ac4 @phn4
EXTENSION (OPTIONAL) @ext4

YES
NO

I've recorded [fill A9_p4ac] as the area code for the second
alpha intake number. Is that correct?
<1>
<0>

YES
NO

A10a

Now I am going to ask you about services provided by [fill
facility name] located at [fill LOCATION ADDRESS].
Which of the following Assessment and Pre-Treatment Services
are provided by this facility at this location, that is, [fill
LOCATION ADDRESS]?
Please answer "Yes" or "No" for each.
<1>
<0>

YES
NO

DON’T KNOW
REFUSED

<1>
<2>
<3>
<4>

Screening for substance abuse
Screening for mental health disorders
Comprehensive substance abuse assessment or diagnosis
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
Interim services for clients when immediate admission
is not possible
We do not offer any of these assessment and pretreatment services

<5>
<6>
<7>
<8>

A10b

A10c

Which of the following Testing services are provided by this
facility at this location? Include tests performed at this
location, even if the specimen is sent to an outside source for
chemical analysis.
<1>
<0>

YES
NO

DON’T KNOW
REFUSED

<9>
<10>
<11>
<12>
<13>
<14>
<15>
<16>

Breathalyzer or other blood alcohol testing
Drug or alcohol urine screening
Screening for Hepatitis B
Screening for Hepatitis C
HIV testing
STD testing
TB screening
We do not offer any of these testing services

Which of the following Transitional Services are provided by
this facility at this location?
<1>
<0>

YES
NO

DON’T KNOW
REFUSED

<17>
<18>
<19>

Discharge planning
Aftercare or continuing care
We do not offer any of these transitional services

A10d

Which of the following Ancillary Services are provided by this
facility at this location?
<1>
<0>

YES
NO

DON’T KNOW
REFUSED

<20>
<21>
<22>
<23>
<24>

Case management services
Social skills development
Mentoring or peer support
Child care for clients' children
Assistance with obtaining social services, for
example, Medicaid, WIC, SSI, SSDI
Employment counseling or training for clients
Assistance in locating housing for clients
Domestic violence, that is, family or partner violence
services for physical, sexual, and emotional abuse
Early intervention for HIV
HIV or AIDS education, counseling, or support
Hepatitis education, counseling or support
Health education other than HIV/AIDS or hepatitis
Substance abuse education
Transportation assistance to treatment
Mental health services
Acupuncture
Residential beds for clients' children
Self-help groups, for example, AA, NA, SMART Recovery
Smoking cessation counseling
We do not offer any of these ancillary services

<25>
<26>
<27>
<28>
<29>
<30>
<31>
<32>
<33>
<34>
<35>
<36>
<37>
<38>
<39>
A10e

Which of the following other services are provided by this
facility at this location, that is, [fill LOCATION ADDRESS ]?
<1>
<0>

YES
NO

DON’T KNOW
REFUSED

<40>
<41>
<42>

Treatment
Treatment
Treatment
abuse)
We do not

<43>
A10f

for gambling disorder
for Internet use disorder
for other addiction disorder (non-substance
offer any of these other services

Which of the following Pharmacotherapies are provided by this
facility at this location, that is, [fill LOCATION ADDRESS]?
<1>
<0>

YES
NO

DON’T KNOW
REFUSED

<44>
<45>
<46>
<47>
<48>
<49>

Disulfiram (Antabuse®)
Naltrexone (oral)
Vivitrol® (injectible Naltrexone)
Acamprosate (Campral®)
Nicotine replacement
Non-nicotine smoking/tobacco cessation medications
(for example, Bupropion, Varenicline)
Medications for psychiatric disorders

<50>

<51>
<52>
<53>
<54>
A11

DID RESPONDENT ANSWER YES TO METHADONE, BUPRENORPHINE WITH
NALOXONE (SUBOXONE®), BUPRENOPRHINE WITHOUT NALOXONE, or
Vivitrol® (injectible Naltrexone)?
<1>
<2>

A11x

Methadone
Buprenorphine with naloxone (Suboxone®)
Buprenorphine without naloxone
We do not offer any of these pharmacotherapy services

YES [goto A11X]
NO [goto A12]

[ask if A11f46, 51, 52 or 53 = <1>; else goto A12]
Does this facility operate an Opioid Treatment Program (OTP) at
this location, that is [fill LOCATION ADDRESS]?
PROBE: OTPs are certified by SAMHSA’s Center for Substance
Abuse Treatment to use the opioid
drugs methadone, buprenorphine and vivitrol in the
treatment of opioid (narcotic) addiction.
PROBE: Some SAMHSA-certified OTPs use only buprenorphine in
the treatment of opioid (narcotic) addiction.
PROBE:

A11a

A11b

Va11a_38

Physicians with a waiver may prescribe
buprenorphine without being affiliated with
an OTP. Therefore, not all facilities that
prescribe buprenorphine are OTPs.

<1>
<0>

YES
NO [goto A12]

DON’T KNOW
REFUSED

Are all of the substance abuse clients at this facility
currently in the Opioid Treatment Program
<1>
<0>

YES
NO

DON’T KNOW
REFUSED

Does the Opioid Treatment Program at this location provide
maintenance services, detoxification services, or both?
<1>
<2>
<3>

Maintenance services
Detoxification services
Both

DON’T KNOW
REFUSED

Two responses appear to be inconsistent. I recorded that
methadone is not provided by this facility. However, I just
recorded that this facility operates an Opioid Treatment
Program. Have I recorded something incorrectly?
<1>
<2>

RETURN TO a10e_43 TO CORRECT METHADONE PROVIDED BY
THIS FACILITY
RETURN TO a11x TO CORRECT OPIOID TREATMENT PROGRAM

A12_1-A12_4

For each type of counseling listed below, please indicate
approximately what percent of substance abuse clients at this
facility receive that type of counseling as part of their
substance abuse treatment program.
<1>
<2>
<3>
<4>
<5>

A13

Not offered
25% or less
26% to 50%
51% to 75%
More than 75%

<1>
<2>
<3>
<4>

Individual Counseling
Group Counseling
Family Counseling
Marital/Couples Counseling

DON’T KNOW
REFUSED

Next I will read a variety of clinical or therapeutic
approaches used by substance abuse treatment facilities. For
each, please tell me how often the practice is used at this
facility. Is it never, rarely, sometimes, always or often, or
are you not familiar with this approach?
<1>
<2>
<3>
<4>
<5>

Never
Rarely
Sometimes
Always or Often,
Not familiar with this approach

<1>
<2>
<3>
<4>
<5>
<6>
<7>
<8>
<9>
<10>
<11>
<12>
<13>

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 (SPECIFY)

<14>

A14

A15

A15a

A16

Are any of the following practices part of this facility's
standard operating procedures?
<1>
<0>

YES
NO

DON’T KNOW
REFUSED

<1>
<2>
<3>
<4>
<5>
<6>
<7>

Required continuing education for staff
Periodic drug testing of clients
Regularly scheduled case review with a supervisor
Case review by an appointed quality review committee
Outcome follow-up after discharge
Periodic utilization review
Periodic client satisfaction surveys conducted by the
facility

Does this facility, at this location, offer a specially
designed program or group intended exclusively for DUI/DWI or
other drunk driver offenders?
<1>
<0>

YES
NO [goto A16]

DON’T KNOW
REFUSED

Does this facility serve only DUI/DWI clients?
<1>
<0>

YES
NO

DON’T KNOW
REFUSED

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?
READ IF NECESSARY: You should answer "yes" if either a staff
counselor or an on-call interpreter provides this service.

A17

<1>
<0>

YES
NO

DON’T KNOW
REFUSED

Does this facility provide substance abuse treatment services
in a language other than English at this location?
READ IF NECESSARY: You should answer "yes" if either a staff
counselor or an on-call interpreter provides this service.
<1>
<0>

YES
NO [goto A18a]

DON’T KNOW
REFUSED

A17a

At this facility, who provides substance abuse treatment
services in a language other than English? Is it...
<1>

<3>

A staff counselor who speaks a language other than
English,
An on-call interpreter, in person or by phone, brought
in when needed, or [goto A18a]
Both a staff counselor and an on-call interpreter?

DON’T KNOW
REFUSED

<2>

A17a1

A17a2

A17b

Do staff counselors provide substance abuse treatment in
Spanish at this facility?
<1>
<0>

YES
NO [go to A17b]

DON’T KNOW
REFUSED

Do staff counselors at this facility provide substance abuse
treatment in any other languages?
<1>
<0>

YES
NO [goto A18]

DON’T KNOW
REFUSED

In what other languages do staff counselors provide substance
abuse treatment at this facility?

DON’T KNOW
REFUSED

<1>
<2>
<3>
<4>
<5>
<6>

Hopi
Lakota
Navajo
Ojobwa
Yupik
Any other American Indian or Alaska Native language
(SPECIFY THE OTHER LANGUAGE)
Arabic
Any Chinese language
Creole
French
German
Greek
Hmong
Italian
Japanese
Korean
Polish
Portuguese
Russian
Tagalog
Vietnamese
Any other language (SPECIFY THE OTHER LANGUAGE)

<7>
<8>
<9>
<10>
<11>
<12>
<13>
<14>
<15>
<16>
<17>
<18>
<19>
<20>
<21>
<22>

A17e

[ask if number = <1> in A17b is GE 4]
Are all of these languages spoken by a staff counselor? (READ
LIST)
INTERVIEWER - YOU MAY HAVE TO SCROLL DOWN TO SEE ALL OPTIONS.
[fill all Language 1 to Language 20 answered YES]
<0>

A18

NO GO BACK TO a17A1 FOR CORRECTION

ENTER 1 TO CONTINUE
Individuals seeking substance abuse treatment can vary by age,
gender or other characteristics.
Which categories of individuals listed below are served by this
facility, at this location?

18_Col_A

Served by this facility?
<1>
<2>
<3>

Adolescents
Adult Women
Adult Men

<1>
<0>

YES
NO

DON’T KNOW
REFUSED

[If 18_Col_A=1 ask A18_Col_B]
A18_Col_B
This facility serves only
<1>
<2>
<3>

Adolescents
Adult Women
Adult Men

<1>
<0>

YES
NO

DON’T KNOW
REFUSED

[If 18_Col_B=1 ask A18_Col_C]
A18_Col_C
Offers specifically tailored programs or groups
<1>
<2>
<3>

Adolescents
Adult Women
Adult Men

<1>
<0>

YES
NO

DON’T KNOW
REFUSED

READ IF NECESSARY: Adolescents could be described as "youths"
or "teens."

A18_a

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…
<1>
<0>

YES
NO

DON’T KNOW
REFUSED

<1>
<2>
<3>

Pregnant/postpartum women
Seniors or older adults
Lesbian, gay, bisexual, transgender, or questioning
(LGBTQ) clients
Veterans
Active duty military
Members of military families
Criminal justice clients (other than DUI/DWI)
Clients with co-occuring mental and substance abuse
disorders
Persons with HIV or AIDS
Persons who have experienced sexual abuse
Persons who have experienced intimate partner violence
or physical abuse
Persons who have experienced other types of trauma
Specially tailored programs or groups for any other
types of clients (SPECIFY)

<4>
<5>
<6>
<7>
<8>
<9>
<10>
<11>
<12>
<13>
A19

A19a

Does this facility offer Hospital Inpatient substance abuse
services at this location, that is, [fill facility name]
located at [fill LOCATION ADDRESS]?
<1>
<0>

YES
NO [goto A20]

DON’T KNOW
REFUSED

Which of the following Hospital Inpatient services are offered
by this facility?
READ IF NECESSARY: ASAM is the American Society of Addiction
Medicine. ASAM has developed guidelines regarding levels of
care that are now widely used.

<1>

<1>
<0>

Hospital Inpatient detoxification, which is similar to
ASAM Levels IV-D and III.7-D. (Medically managed or
monitored inpatient detoxification)
Hospital Inpatient treatment, which is similar to ASAM
Levels IV and III.7. (Medically managed or monitored
intensive inpatient treatment)
YES
NO

DON’T KNOW
REFUSED

<2>

Va19_1

Two responses appear to be inconsistent. I recorded that this
facility offers Hospital Inpatient substance abuse services.
However, I just recorded that this facility offers neither
Hospital Inpatient detoxification nor Hospital Inpatient
treatment. Have I recorded something incorrectly?
<1>
<2>
<3>
<4>

Va19_2

What kind of Hospital Inpatient services are offered by this
facility?
<1>
<2>

A20

A20a

ALL a19, a19a_1 AND a19a_2 ARE CORRECT AS REPORTED
[goto Va23_2]
DOES NOT OFFER HOSPITAL INPATIENT TREATMENT SERVICES
RETURN TO a20a_1 TO CORRECT HOSPITAL INPATIENT
DETOXIFICATION
RETURN TO a20a_2 TO CORRECT HOSPITAL INPATIENT
TREATMENT

TO RECORD VERBATIM
DOES NOT OFFER SUBSTANCE ABUSE TREATMENT SERVICES

Does this facility offer Residential, non-hospital, substance
abuse services at this location?
<1>
<0>

YES
NO [goto A21]

DON’T KNOW
REFUSED

Which of the following Residential services are offered by this
facility?
READ IF NECESSARY: ASAM is the American Society of Addiction
Medicine. ASAM has developed guidelines regarding levels of
care that are now widely used.
<1>

<1>
<0>

Residential detoxification, which is similar to ASAM
Level III.2-D. (Clinically managed residential
detoxification or social detoxification)
Residential short-term treatment, which is similar to
ASAM Level III.5. (Clinically managed high-intensity
residential treatment, typically 30 days or less)
Residential long-term treatment, which is similar to
ASAM Levels III.3 and III.1. (Clinically managed
medium-or low-intensity residential treatment,
typically more than 30 days)
YES
NO

DON’T KNOW
REFUSED

<2>
<3>

Va20_1

Two responses appear to be inconsistent. I recorded that this
facility offers Residential, non-hospital, substance abuse
services. However, I just recorded that this facility does not
offer Residential detoxification, Residential short-term
treatment or Residential long-term treatment. Have I recorded
something incorrectly?
<1>
<2>
<3>
<4>
<5>

Va20_2

What kind of Residential services are offered by this facility?
<1>
<2>

A21

A21a

ALL a20, a20a_1, a20a_2 AND a20a_3 ARE CORRECT AS
REPORTED
DOES NOT OFFER RESIDENTIAL TREATMENT SERVICES [goto
Va20_2]
RETURN TO a20a_1 TO CORRECT RESIDENTIAL NON-HOSPITAL
DETOXIFICATION
RETURN TO a20a_2 TO CORRECT RESIDENTIAL NON-HOSPITAL
SHORT-TERM TREATMENT
RETURN TO a20a_3 TO CORRECT RESIDENTIAL NON-HOSPITAL
LONG-TERM TREATMENT"

TO RECORD VERBATIM
DOES NOT OFFER SUBSTANCE ABUSE TREATMENT SERVICES

Does this facility offer Outpatient substance abuse services at
this location?
<1>
<0>

YES
NO [goto A22]

DON’T KNOW
REFUSED

Which of the following Outpatient services are offered by this
facility?
READ IF NECESSARY: ASAM is the American Society of Addiction
Medicine. ASAM has developed guidelines regarding levels of
care that are now widely used.
<1>
<0>

YES
NO

DON’T KNOW
REFUSED

<1>

Outpatient detoxification, which is similar to ASAM
Levels I-D and II-D. (Ambulatory detoxification)
Outpatient methadone/buprenorphine maintenance.
(Opioid maintenance therapy)
Outpatient day treatment or partial hospitalization,
which is similar to ASAM Level II.5. (20 or more hours
per week)
Intensive outpatient treatment, which is similar to
ASAM Level II.1. (9 or more hours per week)
Regular outpatient treatment, which is similar to ASAM
Level I. (Outpatient treatment, non-intensive)

<2>
<3>
<4>
<5>

Va21a1_a2

[if A19a1 & A20a1 & A21a1 = <0>]
INTERVIEWER: YOU WILL BE TAKEN BACK TO ANSWER QUESTIONS A2A AND
A2B
<1>

RETURN TO A2A AND A2B

[ask if A21a2 = <1> and A10e_51 = <0>]

Va10e_22

Two responses appear to be inconsistent. I recorded that
methadone is not provided by this facility. However, I just
recorded that this facility offers an Outpatient methadone
maintenance program.
Have I recorded something incorrectly?
<1>
<4>

Va21_1

Two responses appear to be inconsistent. I recorded that this
facility offers Outpatient substance abuse services. However, I
just recorded that this facility does not offer Outpatient
detoxification, Outpatient methadone/buprenorphine/vivitrol
maintenance, Outpatient day treatment or partial
hospitalization, Intensive outpatient treatment or Regular
outpatient treatment. Have I recorded something incorrectly?
<1>
<2>
<3>
<4>
<5>
<6>
<7>

Va21_2

TO RECORD VERBATIM
DOES NOT OFFER SUBSTANCE ABUSE TREATMENT SERVICES

[ask A19 & A20 & A21 = <0>]
So, this facility does not offer Hospital Inpatient,
Residential, or Outpatient substance abuse services. Is that
correct?
<1>
<2>

Va19_a21_2

ALL a21, a21a_1, a21a_2, a21a_3, a21a_4 AND a21a_5 ARE
CORRECT AS REPORTED [goto Va22_2]
DOES NOT OFFER OUTPATIENT TREATMENT SERVICES
RETURN TO a21a_1 TO CORRECT OUTPATIENT DETOXIFICATION
RETURN TO a21a_2 TO CORRECT OUTPATIENT METHADONE
MAINTENANCE
RETURN TO a21a_3 TO CORRECT OUTPATIENT DAY TREATMENT
OR PARTIAL HOSPITALIZATION
RETURN TO a21a_4 TO CORRECT INTENSIVE OUTPATIENT
TREATMENT
RETURN TO a21a_5 TO CORRECT REGULAR OUTPATIENT
TREATMENT

What kind of Outpatient services are offered by this facility?
<1>
<2>

Va19_a21_1

RETURN TO a10e_51 TO CORRECT METHADONE PROVIDED BY
THIS FACILITY
RETURN TO a21a_2 TO CORRECT OUTPATIENT METHADONE
MAINTENANCE

YES, THAT IS CORRECT
NO, CHANGE a19, a20, or a21

What type of substance abuse treatment does this facility
offer?
<1> TO RECORD VERBATIM
<2> DOES NOT OFFER SUBSTANCE ABUSE TREATMENT SERVICES

Va20a3

I have a question about something I've coded and need to talk
to my supervisor. I will call you back as soon as possible.
<1> continue

Va21_a11

Two responses appear to be inconsistent. I recorded that this
facility offers Outpatient methadone maintenance. However, I
also recorded that this facility does not operate an Opioid
Treatment Program (OTP). Have I recorded something incorrectly?
<1>
<2>

A22

RETURN TO a11a, FACILITY DOES HAVE AN OTP PROGRAM
RETURN TO a21a_2, FACILITY DOES NOT HAVE A MAINTENANCE
PROGRAM

Does this facility use a sliding fee scale?
READ IF NECESSARY: A sliding fee scale adjusts the fee for
service based on income and other factors.

A22a

<1>
<0>

YES
NO [goto A23]

DON’T KNOW
REFUSED

Do you want the availability of a sliding fee scale published
in SAMHSA's Directory and Locator?
READ IF NECESSARY: The Directory and Locator will explain that
sliding fee scales are based on income and other factors.

A23

A23a

<1>
<0>

YES
NO

DON’T KNOW
REFUSED

Does this facility offer treatment at no charge to clients who
cannot afford to pay?
<1>
<0>

YES
NO [goto A24]

DON’T KNOW
REFUSED

Do you want the availability of free care for eligible clients
published in SAMHSA's Directory and Locator?
READ IF NECESSARY: The Directory and Locator will explain that
potential clients should call the facility for information on
eligibility.
<1>
<0>

YES
NO

DON’T KNOW
REFUSED

A24

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 will be included in
the next question.

A25

<1>
<0>

YES
NO

DON’T KNOW
REFUSED

Which of the following types of client payments or insurance
are accepted by this facility for substance abuse treatment?
<1>
<0>

YES
NO

DON’T KNOW
REFUSED

<2>
<3>

Cash or self-payment
Medicare

READ IF NECESSARY: Medicare is the federal health insurance
program for people age 65 and older and people with
disabilities.
<4>

Medicaid

READ IF NECESSARY: Medicaid is a joint federal and state
program that helps with medical costs for some people with low
incomes and limited resources. Medicaid programs vary from
state to state.
<5>
<6>
<7>
<8>

A state-financed health insurance plan other than
Medicaid
Federal military insurance (e.g., TRICARE)
Private health insurance
Access To Recovery (ATR) vouchers

READ IF NECESSARY: Access To Recovery (ATR) is a competitive,
discretionary, grant program funded by the Substance Abuse and
Mental Health Services Administration, Center for Substance
Abuse Treatment, which provides vouchers to clients for the
purchase of substance abuse clinical treatment and recovery
support services.
<9>
<10>

A25_1

IHS/638 contract care funds
Other (SPECIFY)

[ask if A25_2 to A25_9 ALL = <0>]
Does this facility offer free treatment to all clients, that
is, no payment is accepted?
<1>
<0>

Yes
No

A25-9

A25_9

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
<1>
<2>
<3>
<4>

Computer/Electronic only
Paper only
Both electronic and paper
N/A
don’t know
refused

<1>
<2>
<3>
<4>
<5>
<6>
<7>
<8>
<9>
<10>
<11>

Intake
Assessment
Treatment plan
Discharge
Referrals
Issue/receive lab results
Billing
Outcomes management
Medication prescribing/dispensing
Health records
Interoperability with other providers (such as primary
care, mental health providers, etc)

DO NOT READ. IF OTHER TYPES OF PAYMENTS ARE VOLUNTEERED, RECORD
HERE, OTHERWISE, PRESS "0" TO PROCEED.
<1>
<0>

A27

The next questions ask about the number of clients in treatment
at this facility at specified times. Which of the following
options best describes how you will report client counts for
this facility?
<1>
<2>
<3>

ta27a1_2

TO RECORD OTHER TYPES OF PAYMENTS ACCEPTED
NO OTHER PAYMENTS VOLUNTEERED

You will report client counts for this facility alone,
[goto A28]
You will report client counts for this facility
combined with other facilities, or
You will not report any client counts. Another
facility will report this facility's client counts)
[goto A34]
DON’T KNOW
REFUSED

INTERVIEWER: THE DATABASE HAS NO FACILITIES LINKED WITH THIS
ORGANIZATION.
Which facilities will be included in the client counts that you
will report? Please give me the name, address, and phone number
of each facility.
PLEASE RECORD THE FACILITY NAME, ADDRESS, AND PHONE NUMBER FOR
EACH FACILITY INCLUDED IN THE CLIENT COUNTS USING THE
AddFacility TAB ABOVE.

ta27a1_3

I am looking at a screen that shows the other facilities
currently linked to this facility in our database.
INTERVIEWER: IF FACILITIES BEING INCLUDED IN CLIENT COUNTS ARE
NOT DISPLAYED, RECORD INFORMATION ON THE MISSING FACILITIES
USING THE AddFacility TAB ABOVE.
ENTER 1 TO DISPLAY LIST OF FACILITIES

A27a1

Please tell me which facilities will be included in the client
counts you will report and I will record them here.
PROBE:

Any other facilities?

INTERVIEWER: CODE ALL THAT APPLY ON THIS SCREEN
A27a2

Which facilities will be included in the client counts you will
report and I will record them here.
PROBE:

Any other facilities?

INTERVIEWER: CODE ALL THAT APPLY ON THIS SCREEN
A27a3

Which facilities will be included in the client counts you will
report and I will record them here.
PROBE:

Any other facilities?

INTERVIEWER: CODE ALL THAT APPLY ON THIS SCREEN
A27a4

Which facilities will be included in the client counts you will
report and I will record them here.
PROBE:

Any other facilities?

INTERVIEWER: CODE ALL THAT APPLY ON THIS SCREEN
A27a5

Which facilities will be included in the client counts you will
report and I will record them here.
PROBE:

Any other facilities?

INTERVIEWER: CODE ALL THAT APPLY ON THIS SCREEN
A27a6

Which facilities will be included in the client counts you will
report and I will record them here.
PROBE:

Any other facilities?

INTERVIEWER: CODE ALL THAT APPLY ON THIS SCREEN
A27_del

INTERVIEWER: WERE THERE FACILITIES THAT NEED TO BE REMOVED
FROM THIS NETWORK? IF YES THEN INDICATE WHICH ONES USING THE
DelFacility TAB ABOVE.
<1>
<0>

YES
NO

A27_1

INTERVIEWER: YOU HAVE RECORDED NO ADDITIONAL FACILITIES THAT
WILL BE INCLUDED IN THE CLIENT COUNT. PLEASE RESOLVE: TO RECORD
FACILITIES, GO BACK TO a30a1 OR ta30a1
TO CHANGE Q30 TO REPORTING FOR SELF ONLY, RETURN TO Q30
Continue

A28

The next questions ask about the number of clients receiving
Hospital Inpatient, Residential, non-hospital, and Outpatient
substance abuse treatment services on March 29, 2013. First,
I'll ask about Hospital Inpatients.
On March 29, 2013, did any patients receive Hospital Inpatient
substance abuse services at this facility?

A28a

<1>
<0>

YES
NO [goto A29]

DON’T KNOW
REFUSED

This question asks about the number of Hospital Inpatients who
received services on March 29, 2013. Count a patient in one
service only, even if the patient received multiple services.
Do not count family members, friends, or other non-treatment
patients.
On March 29, 2013, how many patients received the following
Hospital Inpatient substance abuse services at this location...
INTERVIEWER:
<1>

A28b

<2>

Hospital Inpatient detoxification, similar to ASAM
Levels IV-D and III.7-D (medically managed or
monitored inpatient detoxification)
Hospital Inpatient treatment, similar to ASAM Levels
IV and III.7 (medically managed or monitored intensive
inpatient treatment)

DON’T KNOW
REFUSED

How many of the [fill a28a_total] Hospital Inpatients you just
reported were under the age of 18?
INTERVIEWER:

A28c1

ENTER A NUMBER. IF NONE, ENTER "0"

ENTER A NUMBER. IF NONE, ENTER "0"

DON’T KNOW
REFUSED

How many of the [fill a28a_total] Hospital Inpatients you just
reported received methadone dispensed at this facility?
Include patients who received this drug for detoxification or
maintenance purposes.
INTERVIEWER:

ENTER A NUMBER. IF NONE, ENTER "0"

DON’T KNOW
REFUSED

A28c_2

How many of the [fill a28a_total] Hospital Inpatients you just
reported received buprenorphine dispensed or prescribed at this
facility?
Include patients who received this drug for detoxification or
maintenance purposes.
INTERVIEWER:

A28c_3

ENTER A NUMBER. IF NONE, ENTER "0"

DON’T KNOW
REFUSED

How many of the [fill a28a_total] Hospital Inpatients you just
reported received Vivitrol® (injectible Naltrexone) dispensed
or prescribed at this facility?
Include patients who received this drug for detoxification or
maintenance purposes
INTERVIEWER: ENTER A NUMBER. IF NONE, ENTER “0”

A28d

DON’T KNOW
REFUSED

On March 29, 2013, how many of the Hospital Inpatient beds at
this facility were specifically designated for substance abuse
treatment?
INTERVIEWER:

Va28

ENTER A NUMBER. IF NONE, ENTER "0"

DON’T KNOW
REFUSED

Two responses I recorded appear to be inconsistent. I recorded
that this facility offers Hospital Inpatient substance abuse
services but did not have any clients receiving these services
on March 29, 2013. Is that correct?
NO, FACILITY DOES NOT OFFER INPATIENT SERVICES (CHANGE a20 AND
THEN CHECK FORWARD)
NO, FACILITY DID HAVE INPATIENTS ON March 29 (CHANGE a28 AND
THEN CHECK FORWARD)
<1>
<2>
<3>

Va28q

YES, THAT IS CORRECT
CHANGE a20
CHANGE a28

Two responses I recorded appear to be inconsistent. I recorded
that this facility does not offer Hospital Inpatient substance
abuse services but did have patients receiving these services
on March 29, 2013. Is that correct?
NO, FACILITY DOES OFFER INPATIENT SERVICES (CHANGE a20 AND THEN
CHECK FORWARD)
NO, FACILITY DID NOT HAVE INPATIENTS ON March 29 (CHANGE a28)
<1>
<2>
<3>

YES, THAT IS CORRECT
CHANGE a20
CHANGE a28

Va28a_1

Two responses I recorded appear to be inconsistent. I recorded
that this facility does not offer Hospital Inpatient
detoxification but did have [fill a28a_1] Hospital Inpatients
receiving these services on March 29, 2013. Is that correct?
NO, FACILITY DOES OFFER SERVICES (CHANGE a19a_1 THEN CHECK
FORWARD)
NO, FACILITY DID NOT HAVE CLIENTS ON March 29 (CHANGE a28 THEN
CHECK FORWARD)
<1>
<2>
<3>

Va28a1

Your response to this question is unusually large compared to
most other facilities. I have recorded that this location had
[fill a28a_tot] Hospital Inpatients receiving substance abuse
treatment on March 29, 2013. Is that correct?
<1>
<2>

Va28a2

YES, THAT IS CORRECT
CHANGE a28A

Two responses I recorded are inconsistent. A moment ago, I
recorded that on March 29, 2013, some clients were receiving
Hospital Inpatient substance abuse services at this location.
However, I've just recorded that zero clients were receiving
substance abuse treatment or detoxification. Have I recorded
something incorrectly?
<1>
<2>
<3>

Va28a_sum

YES, THAT IS CORRECT
CHANGE a19a_1
CHANGE a28

YES (CHANGE a28 or a28a)
YES (CHANGE a28 or a28a)
NO

Two responses I recorded are inconsistent. A moment ago, I
recorded that on March 29, 2013, some clients were receiving
Hospital Inpatient substance abuse services at this location.
However, I've just recorded that zero clients were receiving
substance abuse treatment or detoxification. Have I recorded
something incorrectly?
(CHANGE a28, a28a_1 or a28a_2)
<1>
<2>
<3>

Va28a3

CHANGE a28
CHANGE a28a_1 or a28a_2
NO

What type of Hospital Inpatient substance abuse services were
clients receiving at this location on March 29, 2013?
BACKCODE TO a28a (1 AND 2) WHEN APPROPRIATE
<1>

Va28b

RECORD SERVICE

Two responses I recorded are inconsistent. I just recorded that
[fill a28b] Hospital Inpatients were under the age of 18.
However, earlier I recorded that this location had a total of
[fill a28a_tot] Hospital Inpatients on March 29. Have I
recorded something incorrectly?
CHANGE THE NUMBER OF INPATIENTS IN a28a
CHANGE THE NUMBER UNDER AGE 18 IN a28b
<1>

Continue

Va28c

Two responses I recorded are inconsistent. I just recorded that
[fill a28c_tot] Hospital Inpatients received either methadone,
buprenorphine, or vivitrol on March 29. However, earlier I
recorded that this location had a total of [fill a28a_tot]
Hospital Inpatients on March 29. Have I recorded something
incorrectly?
CHANGE THE NUMBER OF INPATIENTS IN a28a
CHANGE THE NUMBER RECEIVING METHADONE IN a28c_1 (CURRENTLY
RECORDED AS [a28c_1])
CHANGE THE NUMBER RECEIVING BUPRENORPHINE IN a28c_2 (CURRENTLY
RECORDED AS [a28c_2])
CHANGE THE NUMBER OF INPATIENTS RECEIVING VIVITROL IN a28c_3
(CURRENTLY RECORDED AS [a28c_2]
<1>

Va28az2

Continue

Your response to this question is unusually large compared to
the [fill a28a_tot] patients who received Hospital Inpatient
services on March 29. I recorded this location had [fill a28d]
beds designated for Hospital Inpatient substance abuse
treatment clients on March 29, 2013. Is that correct?
NO, CHANGE THE NUMBER OF BEDS IN a28d
NO, CHANGE THE NUMBER OF INPATIENTS IN a28a (CURRENTLY LISTED
AS [a28a_tot])
<1>
<2>
<3>

A29

YES, THAT IS CORRECT
CHANGE a28d
CHANGE a28A_1 or a28a_2

Now I'll be asking about Residential, non-hospital, clients. On
March 29, 2013, did any clients receive Residential, nonhospital, substance abuse services at [fill facility name]
[fill LOCATION ADDRESS]?
<1>
<0>

YES
NO [goto A30]

DON’T KNOW
REFUSED

A29a

This question asks about the number of Residential clients
receiving services on March 29, 2013. Count a client in one
service only, even if the client received multiple services.
Do not count family members, friends, or other non-treatment
clients.
On March 29, 2013, how many clients received the following
Residential substance abuse services at this facility...
INTERVIEWER:
<1>
<2>
<3>

A29b

Residential detoxification, Similar to ASAM Level
III.2-D (clinically managed residential detoxification
or social detoxification)
Residential short-term treatment, Similar to ASAM
Level III.5 (clinically managed high-intensity
residential treatment, typically 30 days or less)
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)
DON’T KNOW
REFUSED

How many of the [fill a29a_total] Residential clients you just
reported were under the age of 18?
INTERVIEWER:

A29c_1

ENTER A NUMBER. IF NONE, ENTER "0"

ENTER A NUMBER. IF NONE, ENTER "0"

DON’T KNOW
REFUSED

How many of the [fill a29a_total] Residential clients you just
reported received methadone dispensed at this facility?
Include clients who received this drug for detoxification or
maintenance purposes.
INTERVIEWER:

A29c_2

ENTER A NUMBER. IF NONE, ENTER "0"

DON’T KNOW
REFUSED

How many of the [fill a29a_total] Residential clients you just
reported received buprenorphine dispensed or prescribed at this
facility?
Include clients who received this drug for detoxification or
maintenance purposes.
INTERVIEWER:

ENTER A NUMBER. IF NONE, ENTER "0"

DON’T KNOW
REFUSED

A29c_3

How many of the [fill a29a_total] Residential clients you just
reported received Vivitrol® (injectible Naltrexone) dispensed
or prescribed at this facility?
Include patients who received this drug for detoxification or
maintenance purposes
INTERVIEWER: ENTER A NUMBER. IF NONE, ENTER “0”

A29d

On March 29, 2013, how many of the Residential beds at this
facility were specifically designated for substance abuse
treatment?

Va29q

DON’T KNOW
REFUSED

DON’T KNOW
REFUSED

Two responses I recorded appear to be inconsistent. I recorded
that this facility does not offer Residential, non-hospital,
substance abuse services but did have clients receiving these
services on March 29, 2013. Is that correct?
NO, FACILITY DOES OFFER RESIDENTIAL SERVICES (CHANGE a21 THEN
CHECK FORWARD)
NO, FACILITY DID NOT HAVE RESIDENTIAL CLIENTS ON March 29
(CHANGE a29 THEN CHECK FORWARD)
<1>
<2>
<3>

Va29q2

YES, THAT IS CORRECT
CHANGE a20
CHANGE a29

Two responses I recorded appear to be inconsistent. I recorded
that this facility offers Residential, non-hospital, substance
abuse services but did not have clients receiving these
services on March 29, 2013. Is that correct?
NO, FACILITY DOES NOT OFFER RESIDENTIAL SERVICES (CHANGE a20
THEN CHECK FORWARD)
NO, FACILITY DID HAVE RESIDENTIAL CLIENTS ON March 29 (CHANGE
a29 THEN CHECK FORWARD)
<1>
<2>
<3>

Va29_a24

YES, THAT IS CORRECT
CHANGE a20
CHANGE a29

Two responses I recorded appear to be inconsistent. I recorded
that this facility offers Residential substance abuse services
but did not have clients receiving these services on March 29,
2013. Is that correct?
NO, FACILITY DOES NOT OFFER RESIDENTIAL SERVICES (CHANGE a20
THEN CHECK FORWARD)
NO, FACILITY DID HAVE RESIDENTIAL CLIENTS ON March 29 (CHANGE
a29 THEN CHECK FORWARD)
<1>
<2>
<3>
<4>

YES, THAT IS CORRECT
CHANGE a20
CHANGE a29
CHANGE BOTH a20 and a29

Va29_a24b

Two responses I recorded appear to be inconsistent. I recorded
that this facility does not offer Residential substance abuse
services but did have clients receiving these services on March
29, 2013. Is that correct?
NO, [fill q29a] OFFER RESIDENTIAL SERVICES (CHANGE a20 THEN
CHECK FORWARD)
NO, [fill q29b] HAVE RESIDENTIAL CLIENTS ON March 29 (CHANGE
a29 THEN CHECK FORWARD)
<1>
<2>
<3>
<4>

Va29a_1

YES, THAT IS CORRECT
CHANGE a20
CHANGE a29
CHANGE BOTH a20 and a29

Two responses I recorded appear to be inconsistent. I recorded
that this facility does not offer Residential detoxification
but did have [fill a29a_1] clients receiving these services on
March 29, 2013. Is that correct?
NO, FACILITY DOES OFFER SERVICES (CHANGE a20a_1 THEN CHECK
FORWARD)
NO, FACILITY DID NOT HAVE CLIENTS ON March 29 (CHANGE a29 THEN
CHECK FORWARD)
<1>
<2>
<3>

Va29a_2

YES, THAT IS CORRECT
CHANGE a20a_1
CHANGE a29

Two responses I recorded appear to be inconsistent. I recorded
that this facility does not offer Residential short-term
treatment, but did have [fill a29a_2] clients receiving these
services on March 29, 2013. Is that correct?
NO, FACILITY DOES OFFER SERVICES (CHANGE a20a_2 THEN CHECK
FORWARD)
NO, FACILITY DID NOT HAVE CLIENTS ON March 29 (CHANGE a29 THEN
CHECK FORWARD)
<1>
<2>
<3>

Va29a_3

YES, THAT IS CORRECT
CHANGE a20a_2
CHANGE a29

Two responses I recorded appear to be inconsistent. I recorded
that this facility does not offer Residential long-term
treatment, but did have [fill a29a_3] clients receiving these
services on March 29, 2013. Is that correct?
NO, FACILITY DOES OFFER SERVICES (CHANGE a20a_3 THEN CHECK
FORWARD)
NO, FACILITY DID NOT HAVE CLIENTS ON March 29 (CHANGE a29 THEN
CHECK FORWARD)
<1>
<2>
<3>

YES, THAT IS CORRECT
CHANGE a20a_3
CHANGE a29

Va29a_sum

Two responses I recorded are inconsistent. A moment ago, I
recorded that on March 29, 2013 some clients were receiving
Residential substance abuse services at this facility. However,
I've just recorded that zero clients were receiving substance
abuse treatment or detoxification. Have I recorded something
incorrectly?
(CHANGE a29, a29a_1, a29a_2 or a29a_3)
<1>
<2>
<3>

Va29act

CHANGE a29
CHANGE a29a_1, a29a_2 or a29a_3
NO

The number of clients receiving Residential services is the
same number I recorded earlier for Hospital Inpatients. Are you
counting the same clients in both categories?
YES - CHANGE HOSPITAL INPATIENTS IN a28a
YES - CHANGE RESIDENTIAL CLIENTS IN a29a
<1>
<2>
<3>

Va29ax

NO - NOT COUNTED TWICE
YES CHANGE a28A
YES CHANGE a29A

Two responses I recorded may be inconsistent. I just recorded
that [fill a29a_1] clients were receiving residential
detoxification on March 29, 2013. However, earlier I recorded
that this facility does not offer residential detoxification.
Have I recorded something incorrectly?
DID NOT HAVE RESIDENTIAL DETOXIFICATION CLIENTS ON 3/29/13
CHANGE a29a
DOES OFFER RESIDENTIAL DETOXIFICATION - CHANGE a20
<1>
<2>
<3>

Va29a4

CORRECT AS RECORDED
CHANGE a29A
CHANGE a20

Two responses I recorded may be inconsistent. I just recorded
that [fill a29a_2] clients were receiving residential shortterm treatment. However, earlier I recorded that this facility
does not offer residential short-term treatment. Have I
recorded something incorrectly?
DID NOT HAVE RESIDENTIAL SHORT-TERM CLIENTS ON 3/29/13 CHANGE
a29a
DOES OFFER RESIDENTIAL SHORT-TERM TREATMENT - CHANGE a20
<1>
<2>
<3>

CORRECT AS RECORDED
CHANGE a29A
CHANGE a20

Va29a29

Two responses I recorded may be inconsistent. I just recorded
that zero clients were receiving residential short-term
treatment on March 29. However, earlier I recorded that this
facility offers residential short-term treatment. Have I
recorded something incorrectly?
DID HAVE RESIDENTIAL SHORT-TERM TREATMENT CLIENTS ON 3/29/13
CHANGE a29a
DOES NOT OFFER RESIDENTIAL SHORT-TERM TREATMENT - CHANGE a20a_2
<1>
<2>
<3>

Va29az

CORRECT AS RECORDED
CHANGE a29A
CHANGE a20a_2

Two responses I recorded may be inconsistent. I just recorded
that [fill a29a_3] patients were receiving residential longterm treatment. However, earlier I recorded that this facility
does not offer residential long-term treatment. Have I recorded
something incorrectly?
DID NOT HAVE RESIDENTIAL LONG-TERM CLIENTS ON 3/29/13 CHANGE
a29a_3
DOES OFFER RESIDENTIAL LONG-TERM TREATMENT - CHANGE a20
<1>
<2>
<3>

Va29az3

CORRECT AS RECORDED
CHANGE a29A_3
CHANGE a20

Two responses I recorded may be inconsistent. I just recorded
that zero clients were receiving residential long-term
treatment on March 29. However, earlier I recorded that this
facility offers residential long-term treatment. Have I
recorded something incorrectly?
DID HAVE RESIDENTIAL LONG-TERM TREATMENT CLIENTS ON 3/29/13
CHANGE a29a_3
DOES NOT OFFER RESIDENTIAL LONG-TERM TREATMENT - CHANGE a20a_3
<1>
<2>
<3>

Va29a1

CORRECT AS RECORDED
CHANGE a29A_3
CHANGE a20A_3

Your response to this question is unusually large compared to
most other facilities. I recorded that this facility had [fill
a29a_tot] Residential substance abuse treatment clients on
March 29, 2013. Is that correct?
IF NO, CHANGE THE NUMBER OF CLIENTS IN a29a
<1>
<2>

YES, THAT IS CORRECT
NO, CHANGE a29A

Va29a2

Two responses I recorded are inconsistent. A moment ago, I
recorded that on March 29, 2013, some clients were receiving
Residential non-hospital substance abuse treatment or
detoxification at this location. However, I have just recorded
that zero clients were receiving these types of care. Have I
recorded something incorrectly?
YES (CHANGE a29 or a29a)
<1>
<2>

Va29a3

YES CHANGE a29 OR a29A
NO

What type of Residential, non-hospital, substance abuse
services were clients receiving at this facility on March 29,
2013?
BACKCODE TO a29a (1, 2 AND 3) WHEN APPROPRIATE
<1>

Va29b

RECORD TYPE OF CLIENTS

Two responses I recorded are inconsistent. I just recorded that
[fill a29b] Residential clients were under the age of 18.
However, earlier I recorded that this facility had a total of
[fill a29a_tot] Residential clients on March 29. Have I
recorded something incorrectly?
CHANGE THE NUMBER OF RESIDENTIAL CLIENTS IN a29
CHANGE THE NUMBER UNDER AGE 18 IN a29b
<1>

Va29c

Continue

Two responses I recorded are inconsistent. I just recorded that
[fill a29c_tot] Residential clients received either methadone
or buprenorphine on March 29. However, earlier I recorded that
this facility had a total of [fill a29a_tot] Residential
clients on March 29. Have I recorded something incorrectly?
CHANGE THE NUMBER OF RESIDENTIAL CLIENTS IN a29a
CHANGE THE NUMBER RECEIVING METHADONE IN a29c_1
CURRENTLY RECORDED AS [a29c_1]
CHANGE THE NUMBER RECEIVING BUPRENORPHINE IN a29c_2
CURRENTLY RECORDED AS [a29c_2]
CHANGE THE NUMBER RECEIVING VIVITROL IN a29c_3 (CURRENTLY
RECORDED AS [a29c_3]
<1>

Va29c1

Continue

Two responses I recorded may be inconsistent. I just recorded
that [fill a29c_1] clients were receiving methadone dispensed
at this facility. However, earlier I recorded that this
facility does not operate an Opioid Treatment Program at this
facility. Have I recorded something incorrectly?
DID NOT HAVE METH CLIENTS - CHANGE a29c
DOES OPERATE AN METHADONE TREATMENT PROGRAM - CHANGE a11
<1>
<2>
<3>

CORRECT AS REPORTED, NO CHANGE NEEDED
CHANGE a29C
CHANGE a11

Va29act2

The number of clients receiving Residential services is the
same number I recorded earlier for Hospital Inpatients. Are you
counting the same clients in both categories?
YES - CHANGE HOSPITAL INPATIENTS IN a28a
YES - CHANGE RESIDENTIAL CLIENTS IN a29a
<1>
<2>
<3>

Va29az2

NO - NOT COUNTED TWICE
YES CHANGE a28A
YES CHANGE a29A

Your response to this question is unusually large compared to
the [fill a29a_tot] clients who received Residential services
on March 29. I recorded this location had [fill a29d] beds
designated for Residential substance abuse treatment clients on
March 29, 2013. Is that correct?
NO, CHANGE THE NUMBER OF BEDS IN a29d
NO, CHANGE THE NUMBER OF CLIENTS IN a29A (CURRENTLY LISTED AS
[fill a29a_tot])
<1>
<2>
<3>

A30

A30a_1

YES, THAT IS CORRECT
CHANGE a29D
CHANGE a29A_1 OR a29a_2 OR a29a_3

Now I'll be asking about Outpatient substance abuse clients.
During the month of March 2013, did any clients receive
Outpatient substance abuse services at [fill facility name]
[fill LOCATION ADDRESS]?
<1>
<0>

YES
NO [goto A31]

DON’T KNOW
REFUSED

This question asks about the number of clients who received
Outpatient substance abuse services at this location during
March 2013. Only include clients who received treatment in
March and were still enrolled in treatment on March 29, 2013.
Count a client in one service only, even if the client received
multiple services. Do not count family members, friends, or
other non-treatment clients. Here is the question...
How many clients received each of the following Outpatient
substance abuse services at this facility during March 2013?
INTERVIEWER:
<1>
<2>
<3>
<4>
<5>

ENTER A NUMBER. IF NONE, ENTER "0"

Outpatient detoxification, similar to ASAM Levels I-D
and II-D (ambulatory detoxification)
Outpatient methadone/buprenorphine maintenance, Count
methadone/buprenorphine clients in this category only.
Outpatient day treatment or partial hospitalization,
similar to ASAM Level II.5 (20 or more hours per week)
Intensive outpatient treatment, similar to ASAM Level
II.1 (9 or more hours per week)
Regular outpatient treatment, similar to ASAM Level I
(outpatient treatment, non-intensive)
DON’T KNOW
REFUSED

A30b

How many of the [fill a30a_tot] Outpatient clients you just
reported were under the age of 18?
INTERVIEWER:

Aa30c_1

ENTER A NUMBER. IF NONE, ENTER "0"

DON’T KNOW
REFUSED

How many of the [fill a30a_tot] Outpatient clients you just
reported received methadone dispensed at this location?
Include clients who received this drug for detoxification or
maintenance purposes.
INTERVIEWER:

A30c_2

ENTER A NUMBER. IF NONE, ENTER "0"

DON’T KNOW
REFUSED

How many of the [fill a30a_tot] Outpatient clients you just
reported received buprenorphine dispensed or prescribed at this
location?
Include clients who received this drug for detoxification or
maintenance purposes.
INTERVIEWER:

A30c_3

ENTER A NUMBER. IF NONE, ENTER "0"

DON’T KNOW
REFUSED

How many of the [fill a28a_total] Outpatient clients you just
reported received Vivitrol® (injectible Naltrexone) dispensed
or prescribed at this facility?
Include patients who received this drug for detoxification or
maintenance purposes
INTERVIEWER: ENTER A NUMBER. IF NONE, ENTER “0”

VA3_345

DON’T KNOW
REFUSED

I have recorded that there were no Hospital Inpatient or
Residential, non-hospital, clients receiving services on March
29, and there were no Outpatient clients that received services
during the month of March. Is that correct?
NO, FACILITY DID HAVE HOSPITAL INPATIENT CLIENTS (CHANGE a28)
NO, FACILITY DID HAVE RESIDENTIAL (NON-HOSPITAL) CLIENTS
(CHANGE a29)
NO, FACILITY DID HAVE OUTPATIENT CLIENTS (CHANGE a30)
<1>
<2>
<3>
<4>

YES, THAT IS
NO, DID HAVE
NO, DID HAVE
NO, DID HAVE

CORRECT
HOSPITAL INPATIENT CLIENTS
RESIDENTIAL (NON-HOSPITAL) CLIENTS
OUTPATIENT CLIENTS

Va30

Two responses I recorded appear to be inconsistent. I recorded
that this facility offers Outpatient substance abuse services
but did not have any clients who received Outpatient substance
abuse services during the month of March. Is that correct?
NO, FACILITY DOES NOT OFFER OUTPATIENT SERVICES (CHANGE a21)
NO, FACILITY DID HAVE OUTPATIENT CLIENTS DURING THAT TIME
(CHANGE a30)
<1>
<2>

Va30q

YES, THAT IS CORRECT
NO, DOES NOT OFFER OUTPATIENT SERVICES

Two responses I recorded appear to be inconsistent. I recorded
that this facility does not offer Outpatient substance abuse
services but did have clients who received Outpatient substance
abuse services during the month of March. Is that correct?
NO, FACILITY DOES OFFER OUTPATIENT SERVICES (CHANGE a21)
NO, FACILITY DID NOT HAVE OUTPATIENT CLIENTS DURING THAT TIME
(CHANGE a30)
<1>
<2>
<3>

Va30q2

YES, THAT IS CORRECT
NO, FACILITY DOES OFFER OUTPATIENT SERVICES (CHANGE
a21 THEN CHECK FORWARD)
NO, FACILITY DID NOT HAVE OUTPATIENT CLIENTS DURING
THAT TIME (CHANGE a30 THEN CHECK FORWARD)

Two responses I recorded appear to be inconsistent. I recorded
that this facility does not offer Outpatient substance abuse
services but did have clients enrolled during the month of
March 2013. Is that correct?
NO, FACILITY DOES OFFER OUTPATIENT SERVICES (CHANGE a21a THEN
CHECK FORWARD)
NO, FACILITY DID NOT HAVE OUTPATIENT CLIENTS ON DURING MARCH
(CHANGE a30)
<1>
<2>
<3>

Va30a_1

YES, THAT IS CORRECT
CHANGE a21a
CHANGE a30

Two responses I recorded appear to be inconsistent. I recorded
that this facility does not offer Outpatient detoxification but
did have [fill a30a_1] clients enrolled in these services on
March 29, 2013. Is that correct?
NO, FACILITY DOES OFFER SERVICES (CHANGE a21a_1 THEN CHECK
FORWARD)
NO, FACILITY DID NOT HAVE CLIENTS ON March 29 (CHANGE a30 THEN
CHECK FORWARD)
<1>
<2>
<3>

YES, THAT IS CORRECT
CHANGE a21a_2
CHANGE a30

Va30a_2

Two responses I recorded appear to be inconsistent. I recorded
that this facility does not offer Outpatient methadone
maintenance but did have [fill a30a_2] clients enrolled in
these services as of March 29, 2013. Is that correct?
NO, FACILITY DOES OFFER SERVICES (CHANGE a21a_2 THEN CHECK
FORWARD)
NO, FACILITY DID NOT HAVE CLIENTS ON March 29 (CHANGE a30 THEN
CHECK FORWARD)
<1>
<2>
<3>

Va30a_3

YES, THAT IS CORRECT
CHANGE a21a_2
CHANGE a30

Two responses I recorded appear to be inconsistent. I recorded
that this facility does not offer Outpatient day treatment or
partial hospitalization, but did have [fill a30a_3] clients
enrolled in these services on March 29, 2013. Is that correct?
NO, FACILITY DOES OFFER SERVICES (CHANGE a21a_3 THEN CHECK
FORWARD)
NO, FACILITY DID NOT HAVE CLIENTS ON March 29 (CHANGE a30 THEN
CHECK FORWARD)
<1>
<2>
<3>

Va30a_4

YES, THAT IS CORRECT
CHANGE a21a_3
CHANGE a30

Two responses I recorded appear to be inconsistent. I recorded
that this facility does not offer Intensive outpatient
treatment, but did have [fill a30a_4] clients enrolled in these
services on March 29, 2013. Is that correct?
NO, FACILITY DOES OFFER SERVICES (CHANGE a21a_4 THEN CHECK
FORWARD)
NO, FACILITY DID NOT HAVE CLIENTS ON March 29 (CHANGE a30 THEN
CHECK FORWARD)
<1>
<2>
<3>

Va30b

YES, THAT IS CORRECT
CHANGE a21a_4
CHANGE a30

Two responses I recorded are inconsistent. I just recorded that
[fill a30b] Outpatients were under the age of 18. However,
earlier I recorded that this location had a total enrollment of
[fill a30a_tot] Outpatients on March 29.
Have I recorded something incorrectly?
CHANGE THE NUMBER OF OUTPATIENTS IN a30a
CHANGE THE NUMBER UNDER AGE 18 IN a30b
<1>

Continue

Va30a_5

Two responses I recorded appear to be inconsistent. I recorded
that this facility does not offer Regular outpatient treatment,
but did have [fill a30a_5] clients enrolled in these services
on March 29, 2013. Is that correct?
NO, FACILITY DOES OFFER SERVICES (CHANGE a21 THEN CHECK
FORWARD)
NO, FACILITY DID NOT HAVE CLIENTS ON March 29 (CHANGE a30 THEN
CHECK FORWARD)
<1>
<2>
<3>

Va30a_sum

YES, THAT IS CORRECT
CHANGE a21
CHANGE a30

Two responses I recorded are inconsistent. A moment ago, I
recorded that on March 29, 2013, some clients were enrolled in
Outpatient substance abuse services at this location. However,
I've just recorded a total enrollment of zero clients in
substance abuse treatment or detoxification. Have I recorded
something incorrectly?
(CHANGE a30, a30a_1 or a30a_2)
<1>
<2>
<3>
<4>

Va30a_5b

Two responses I recorded appear to be inconsistent. At question
30 you recorded that some clients received Outpatient
treatment, but did have zero clients receiving these services
on March 29, 2013. Is that correct?
<1>
<2>

Va30z

YES (CHANGE a30)
YES (CHANGE a30a_1 OR a30a_2 OR a30a_3 OR a30a_4 OR
a30a_5)
NO, DISCHARGED ON OR BEFORE March 29
NO

YES, THAT IS CORRECT
CHANGE a30

The number of Outpatient methadone maintenance clients is the
same number as the number of Regular outpatient clients. Are
you counting the same clients in both categories?
YES, CORRECT THE NUMBER OF METHADONE MAINTENANCE CLIENTS IN
Q30a_2
YES, CORRECT THE NUMBER OF REGULAR OUTPATIENT CLIENTS IN Q30a_5
<1>
<2>
<3>

Va30a

NO, CORRECT AS RECORDED
CORRECT THE METHADONE MAINTENANCE CLIENTS IN Q30a_2
CORRECT THE REGULAR OUTPATIENT CLIENTS IN Q30a_5

Your response to this question is unusually large compared to
most other facilities. I have recorded this facility had [fill
a30a_tot] Outpatient substance abuse treatment clients actively
enrolled in Outpatient treatment on March 29, 2013. Is that
correct?
NO, CHANGE THE NUMBER OF CLIENTS IN a30a 1 THROUGH 5
<1>
<2>

YES, THAT IS CORRECT
NO, CHANGE THE NUMBER OF CLIENTS IN a30a 1 THROUGH 5

Va30a1

Two responses I recorded appear to be inconsistent. A moment
ago I recorded that as of March 29, 2013, some clients were
enrolled in an Outpatient substance abuse program at this
location. However, I've just recorded that no clients were
receiving Outpatient detoxification, Outpatient methadone
maintenance, Outpatient day treatment or partial
hospitalization, Intensive outpatient treatment, or Regular
outpatient treatment services on March 29, 2013. Have I
recorded something incorrectly?
YES (CHANGE a30 OR a30a)
<1>
<2>
<3>

Va30a2

YES (CHANGE a30 OR a30a)
NO, ALL CLIENTS WERE DISCHARGED BEFORE March 29
NO

What type of Outpatient substance abuse services were clients
enrolled in at this location on March 29, 2013?
BACKCODE TO a30a_1 THROUGH a30a_5 WHEN APPROPRIATE
<1>

Va30a3

I need to talk with my supervisor regarding the type of
treatment service offered at this location. I may need to call
you again. Thank you very much for your time.
<1>

Va30c1

RECORD TYPE OF SERVICE

Continue

Two responses I recorded may be inconsistent. I just recorded
that [fill a30c_1] patients were receiving methadone dispensed
at this facility. However, earlier I recorded that this
facility does not operate an Opioid Treatment Program at this
facility.
Have I recorded something incorrectly?
DID NOT HAVE METHADONE CLIENTS - CHANGE a30c
DOES OPERATE AN OPIOID TREATMENT PROGRAM - CHANGE a12

Va30c

<1>
CORRECT AS REPORTED; NO CHANGE
<2>
DID NOT HAVE METH CLIENTS - CHANGE a30c
<3>
DOES OPERATE OTP PROGRAM - CHANGE a12
Two responses I recorded are inconsistent. I just recorded that
[fill a30c_tot] of the Outpatients enrolled as of March 29,
2013 received either methadone or buprenorphine. However,
earlier I recorded that this location had a total of [fill
a30a_tot] Outpatients enrolled as of March 29, 2013.
Have I recorded something incorrectly?
CHANGE THE NUMBER OF OUTPATIENTS IN a30a
CHANGE THE NUMBER RECEIVING METHADONE IN a30c_1
CURRENTLY RECORDED AS [a30c_1]
CHANGE THE NUMBER RECEIVING BUPRENORPHINE IN a30c_2
CURRENTLY RECORDED AS [a30c_2]
CHANGE THE NUMBER RECEIVING VIVITROL IN a30c_3 (CURRENTLY
RECORDED AS [a30c_3]
<1>

Continue

Va30c2

Two responses I recorded may be inconsistent. Earlier I
recorded that [fill a30a_2] Outpatients were in a methadone
maintenance program as of March 29, 2013 and I've just recorded
that only [fill a30c_tot] clients were receiving methadone as
of March 29, 2013. Is that correct?
NO, CHANGE THE [a30a_2] METHADONE CLIENTS IN a30a_2
NO, CHANGE THE [a30c_tot] CLIENTS RECEIVING METHADONE IN a30c
<1>
<2>
<3>

Va30c3

Two responses I recorded may be inconsistent. Earlier I
recorded that this facility operates an Opioid Treatment
Program, and I've just recorded that no Hospital Inpatients or
Residential clients were receiving methadone on March 29, 2013,
and there were no Outpatient clients that received methadone
during the month of March. Is that correct?
<1>
<2>
<3>
<4>
<5>

Va30c3_no_a30

YES, THAT IS CORRECT
NO, CHANGE THE [a30a_2] METH CLIENTS IN a30a_2
NO, CHANGE THE [a30c_tot] CLIENTS RECEIVING METH IN
a30c

YES, THAT IS CORRECT
NO, DID NOT OPERATE AN OTP PROGRAM (CHANGE a11)
NO, THAT IS NOT CORRECT. CHANGE INPATIENTS AT a28C_1
NO, THAT IS NOT CORRECT. CHANGE RESIDENTIAL CLIENTS AT
a29C_1
NO, THAT IS NOT CORRECT. CHANGE OUTPATIENTS AT a30C_1

Two responses I recorded may be inconsistent. Earlier I
recorded that this facility operates an Opioid Treatment
Program, and I've just recorded that no clients were receiving
methadone on March 29, 2013. Is that correct?
<1>
<2>
<3>
<4>
<5>

YES, THAT IS CORRECT
NO, DID NOT OPERATE AN OTP (CHANGE a11)
NO, THAT IS NOT CORRECT. CHANGE INPATIENTS AT a28C_1
NO, THAT IS NOT CORRECT. CHANGE RESIDENTIAL CLIENTS AT
a29C_1
NO, THAT IS NOT CORRECT. CHANGE OUTPATIENT CLIENTS AT
a30C_1

A30d

On average, during March 2013, were the outpatient substance
abuse treatment services at this facility operating...
<1>
Well over capacity (over 120%)
<2>
Somewhat over capacity (106 to 120%)
<3>
At or about capacity (95 to 105%)
<4>
Somewhat under capacity (80 to 94%)
<5>
Well under capacity (under 80%)

A31

The next question will ask for the actual number or percent of
substance abuse treatment clients enrolled at this location on
March 29, 2013 who were being treated in the following three
categories; abuse of both alcohol and drugs, alcohol abuse
only, and drug abuse only.
Would you prefer to report the actual number of clients or a
percent?
<1>
<2>

REPORT NUMBERS
REPORT PERCENTS

A31a

This question asks you to categorize the substance abuse
treatment clients at this facility into three groups: clients
in treatment for (1) abuse of both alcohol and drugs other than
alcohol; (2) abuse only of alcohol; (3) abuse only of drugs
other than alcohol.
Here is the question . . .
Thinking about all of your substance abuse clients – including
[fill Hospital Inpatient] [fill Residential], and [fill
Outpatient] - how many of the [fill counts] substance abuse
clients enrolled at this facility on March 29, 2013, were being
treated for . . .

A32

<1>
<2>
<3>

Both alcohol and drugs other than alcohol
Only alcohol
Only drugs other than alcohol

DON’T KNOW
REFUSED

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?
INTERVIEWER:

A33

ENTER A NUMBER. IF NONE, ENTER "0"

DON’T KNOW
REFUSED

Using the most recent 12-month period for which you have data,
approximately how many substance abuse treatment admissions did
this facility have?
For Outpatient clients, count admissions into treatment, not
individual treatment visits. Consider an admission to be the
initiation of a treatment program or course of treatment. Count
any re-admission as an admission.
READ IF NECESSARY: If this is a mental health facility, count
all admissions in which clients received substance abuse
treatment, even if substance abuse was their secondary
diagnosis.

Va33a4

Your response to this question is unusually large compared to
most other facilities. I have recorded [fill a33 total]
substance abuse treatment admissions in the most recent 12month period. Is that correct?
<1>
<2>

A34

DON’T KNOW
REFUSED

YES
NO, CHANGE ADMISSIONS IN a33

Does this facility operate transitional housing or a halfway
house for substance abuse clients at this location, that is,
[fill facility name] located at [fill LOCATION ADDRESS]?
<1>
<0>

YES
NO

DON’T KNOW
REFUSED

A35

Which statement below BEST describes this facilities smoking
policy?
<1>
<2>
<3>
<4>
<5>

A36

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)
Smoking is permitted anywhere without restriction
Other Specify (Specify other smoking policy)

The next question asks if this facility has licensing or
certification from certain organizations. Answer only for
facility-level licensing or certification related to the
provision of substance abuse services.
Do not include general business licenses, fire marshal
approvals, personal-level credentials, food service licenses,
etc.
Here is the question: Does this facility or program have
licensing, certification, or accreditation from any of the
following organizations?
<1>
<0>

YES
NO

DON’T KNOW
REFUSED

<1>
<2>
<3>
<4>
<5>
<6>

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
(SPECIFY THE OTHER AGENCY OR ORGANIZATION)

<7>
<8>
<9>

A37

Does this facility have a National Provider Identifier (NPI)
number?
Do NOT include the NPI numbers of individual practitioners and
groups of practitioners

A37a

<1>
<0>

YES
NO [goto A38]

DON’T KNOW
REFUSED

What is the NPI number for this facility?
If a facility has more than one NPI number, please provide only
the primary number

DON’T KNOW
REFUSED

A38

A38x

A38x_web

Does this facility have a website or web page with information
about the facility's substance abuse treatment programs?
<1>
<0>

YES
NO [goto A39]

DON’T KNOW
REFUSED

Please give me the address exactly as it should be entered in
order to reach your site.
<1>

TO RECORD WEBSITE ADDRESS

DON’T KNOW
REFUSED

INTERVIEWER:

RECORD WEBSITE ADDRESS.

1) DO NOT RECORD "http://" AT THE BEGINNING OF A WEB ADDRESS.
2) IF "WWW" IS NOT REPORTED AT THE BEGINNING OF THE WEB
ADDRESS, ASK IF IT IS NEEDED AND CHANGE IF NECESSARY.
3) IF AN "AT" SIGN IS REPORTED IN THE WEB ADDRESS, ASK IF THIS
IS REALLY AN E-MAIL ADDRESS. IF SO, DO NOT RECORD HERE
A39

Does this facility want to be listed in SAMHSA's Directory and
online Treatment Facility Locator?
READ IF NECESSARY: The Locator is an online directory of
substance abuse treatment facilities in the United States and
the services they offer. It also has a mapping feature so
clients can find facilities easily.

A40

A40a

<1>
<0>

YES
NO

DON’T KNOW
REFUSED

Would you like to receive a free paper copy of the next
National Directory of Drug and Alcohol Abuse Treatment Programs
when it is published?
<1>
<0>

YES
NO

DON’T KNOW
REFUSED

Would you prefer to receive a CD or paper copy of the
Directory?
<1>
<2>

CD
Paper

uloc

I'd like to make a final verification of the name, address, and
phone number that will be listed in the Locator for this
facility:
[fill facility name1]
[fill facility name2]
[fill address 1]
[fill address 2]
[fill City], [fill.State] [fill zip]
<1>
<0>

YES, FACILITY NAME, ADDRESS ARE CORRECT
NO, MAKE CORRECTIONS

[ask if change is made to facility name]
NewLicenseNumA Did this name change result in a new substance abuse license
number for this facility?
<1>
<0>
SupReviewA

YES
NO

I need to talk to my supervisor about this. I may need to call
you again. Thank you very much for your time.
<1> Continue

name_check

Were you ever called [fill original load facility name]?
<1>
<0>
<2>
<3>

VAname

I need to talk to my supervisor so we can compare your name
with our records.
<1>

other2

YES
NO
The location address has been edited but it is the
same address

I need to talk to my supervisor so we can compare your address
with our database.
<1>

Uloca

Continue

Is there another substance abuse treatment facility in your
organization that is currently located at
[fill LOCATION ADDRESS]?
<1>
<0>
<2>

VAother2

YES
NO
MISSPELLED
ABBREVIATION IN NAME

Continue

And the facility’s main telephone number is: ([fill FARE])
[fill FPRF:0] - [fill ESUX:0] EXT: [fill FACN@PXT]
<1> YES, FACILITY PHONE NUMBER IS CORRECT,
<0> NO, (MAKE CORRECTIONS)

uloc2

I would also like to verify this facility's fax number. Our
records show: [fill fax] Is that correct?
<1> YES, FAX NUMBER IS CORRECT,
<0> NO, FAX NUMBER IS NOT CORRECT, MAKE CHANGES,
<2> NO LONGER HAVE FAX MACHINE

uloc3

Does this facility have a fax machine?
<1>
<0>

other_3

YES
NO

I've recorded [fill ac] as the area code for the fax number. Is
that correct?
IF NO, BACK UP TO MAKE THE CHANGE
<1>
YES

uloc5

PRESS ENTER AND THEN ENTER RESPONDENT'S NAME. IF NOT KNOWN,
ASK.
INTERVIEWER: WAS THIS A ...
<1>
<2>
<3>

Exitu

CATI CALLOUT/CALL IN,
WEB INTERVIEW,
HARD COPY INTERVIEW?

INTERVIEWER: ARE THERE ANY REASONS/PROBLEMS WITH THIS CASE THAT
A SUPERVISOR SHOULD REVIEW BEFORE IT IS FINAL STATUSED?
<1>
<0>

IF YES USE THE BREAKOFF TAB
NO PROBLEMS, FINAL STATUS)

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 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.