Between Cycle N-SS Between Cycle N-SSATS (N-SSATS BC)

National Survey of Substance Abuse Treatment Services (N-SSATS)

Attachment B3 - Between Cycle N-SSATS (N-SSATS BC)

N-SSATS BC

OMB: 0930-0106

Document [pdf]
Download: pdf | pdf
U.S. Department of Health and Human Services

OMB No. 0930-0106
APPROVAL EXPIRES: 12/31/2018
See OMB burden statement on last page

National Survey of
Substance Abuse Treatment Services
(N-SSATS)
March 31, 2016
Substance Abuse and Mental Health Services Administration (SAMHSA)

PLEASE REVIEW THE FACILITY INFORMATION PRINTED ABOVE.
CROSS OUT ERRORS AND ENTER CORRECT OR MISSING INFORMATION.
CHECK ONE

Information is complete and correct, no changes needed
All missing or incorrect information has been corrected

Would you prefer to complete this questionnaire online? See the pink flyer enclosed in
your survey packet for the Internet address and your unique user ID and password. You can
log on and off the website as often as needed to complete the questionnaire. When you log on
again, the program will take you to the next unanswered question. If you need more information,
call the N-SSATS helpline at 1-888-324-8337.

INSTRUCTIONS
•
•
•
•
•

Most of the questions in this survey ask about “this facility.” By “this facility” we mean the specific
treatment facility or program whose name and location are printed on the front cover. 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 the specific facility or program whose name and location are printed on the
front cover, unless otherwise specified in the questionnaire.
If the questionnaire has not been completed online, return the completed questionnaire in the
envelope provided. Please keep a copy for your records.
For additional information about this survey and definitions of some of the terms used, please visit
our website at https://info.nssats.com.
If you have any questions or need additional blank forms, contact:

MATHEMATICA POLICY RESEARCH
1-888-324-8337
NSSATSWeb@mathematica-mpr.com

IMPORTANT INFORMATION
*

Asterisked questions. Information from asterisked (*) questions may be published in SAMHSA’s online
Behavioral Health Treatment Services Locator (found at https://findtreatment.samhsa.gov), in
SAMHSA’s National Directory of Drug and Alcohol Abuse Treatment Programs, and other publically
available listings, unless you designate otherwise in question 29, page 10, of this questionnaire.
Mapping feature in online Locator. Complete and accurate name and address information is needed for
the online Locator so it can correctly map the facility location.
Eligibility for online Locator and Directory. Only facilities designated as eligible by their state substance
abuse office will be listed in the online Locator and Directory. Your state N-SSATS representative can tell
you if your facility is eligible to be listed in the online Locator and Directory. For the name and telephone
number of your state representative, call the N-SSATS helpline at 1-888-324-8337.

*1.

Which of the following substance abuse
services are offered by this facility at this
location, that is, the location listed on the front
cover?

4.

Is this facility a jail, prison, or other organization
that provides treatment exclusively for
incarcerated persons or juvenile detainees?
1
Yes
SKIP TO Q.32 (PAGE 11)
0
No

5.

Is this facility a solo practice, meaning, an office
with only one independent practitioner or
counselor?
1
Yes
0
No

*6.

What is the primary focus of this facility at this
location, that is, the location listed on the front
cover?

MARK “YES” OR “NO” FOR EACH

YES

NO

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

0



2. Detoxification ................................... 1 

0



0



0



3. Substance abuse treatment

(services that focus on initiating and
maintaining an individual’s recovery
from substance abuse and on
averting relapse) ................................ 1 
4. Any other substance abuse

services ............................................ 1 
1a.

MARK ONE ONLY

 Substance abuse treatment services
 Mental health services
3
Mix of mental health and substance abuse
treatment services (neither is primary)
4
General health care
5
Other (Specify: ______________________ )

To which of the following clients does this
facility, at this location, offer mental health
treatment services (interventions such as
therapy or psychotropic medication that treat
a person’s mental health problem or condition,
reduce symptoms, and improve behavioral
functioning and outcomes)?

1
2

*7.

MARK ALL THAT APPLY

 Substance abuse clients
 Clients other than substance abuse clients
3
No clients are offered mental health treatment
services

MARK ONE ONLY

1


2
3
4

A private for-profit organization
A private non-profit organization
State government
Local, county, or community
government
5
Tribal government
6
Federal Government
1

2

2.

Did you answer “yes” to detoxification in
option 2 of question 1 above?
1
0

*2a.

 Yes
 No

SKIP TO Q.3 (BELOW)

*7a.

Does this facility detoxify clients from . . .

Which Federal Government agency?


3
4
1

NO

2

1. Alcohol ............................................... 1 

0



2. Benzodiazepines ............................... 1 

0



3. Cocaine ............................................. 1 

0



4. Methamphetamines ........................... 1 

0



5. Opioids .............................................. 1 

0





0



6. Other (Specify:_______________) ..

*2b.

1

Does this facility routinely use medications
during detoxification?
 Yes
0
No

SKIP TO Q.4 (NEXT COLUMN)

Did you answer “yes” to substance abuse
treatment in option 3 of question 1?
 Yes
0
No
1

Department of Veterans Affairs
Department of Defense
Indian Health Service
Other (Specify: ______________________ )

*8.

Is this facility a hospital or located in or operated
by a hospital?
1
Yes
0
No
SKIP TO Q.9 (NEXT PAGE)

*8a.

What type of hospital?
MARK ONE ONLY

 General hospital (including VA hospital)
2
Psychiatric hospital
3
Other specialty hospital, for example,
alcoholism, maternity, etc.
1

1

3.

SKIP TO
Q.8
(BELOW)

MARK ONE ONLY

MARK “YES” OR “NO” FOR EACH

YES

Is this facility operated by . . .

GO TO Q.4 (NEXT COLUMN)

(Specify: ___________________________ )

SKIP TO Q.25 (PAGE 9)
1

*9.

What telephone number(s) should a potential
client call to schedule an intake appointment?

24

25

1. (______) ________ - ____________ ext._____
2. (______) ________ - ____________ ext._____

26
27

*10. Which of the following services are provided by
this facility at this location, that is, the location
listed on the front cover?
MARK ALL THAT APPLY
1

 Screening for substance abuse

2

 Screening for mental health disorders

3

 Comprehensive substance abuse assessment or
diagnosis

4

 Comprehensive mental health assessment or
diagnosis (for example, psychological or
psychiatric evaluation and testing)

29

30

31

32
33

5

 Screening for tobacco use

34

6

 Outreach to persons in the community who may
need treatment

35
36

7

 Interim services for clients when immediate
admission is not possible

37

8

 We do not offer any of these assessment
and pre-treatment services

38

Testing (Include tests performed at this location, even if
specimen is sent to an outside source for chemical
analysis.)
9

 Breathalyzer or other blood alcohol testing

10

 Drug or alcohol urine screening

11

 Screening for Hepatitis B

12

 Screening for Hepatitis C

13

 HIV testing

14

 STD testing

15

 TB screening

16

 We do not offer any of these testing services

Transitional Services
17

 Discharge planning

18

 Aftercare/continuing care

19

 We do not offer any of these transitional services

Ancillary Services

2

28

20

 Case management services

21

 Social skills development

22

 Mentoring/peer support

23

 Child care for clients’ children

39

 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—family or partner
violence services (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/tobacco cessation counseling
 We do not offer any of these ancillary
services

Other Services
40  Treatment for gambling disorder
41  Treatment for Internet use disorder
42  Treatment for other addiction disorder
(non-substance abuse)
43  We do not offer any of these other services
Pharmacotherapies
44  Disulfiram (Antabuse®)
45  Naltrexone (oral)
46  Naltrexone (extended-release,
injectable, for example, Vivitrol®)
®
47  Acamprosate (Campral )
48  Nicotine replacement
49  Non-nicotine smoking/tobacco
cessation medications (for example,
bupropion, varenicline)
50  Medications for psychiatric disorders
51  Methadone
52  Buprenorphine with naloxone (Suboxone®)
53  Buprenorphine without naloxone
54  We do not offer any of these
pharmacotherapy services

*11.

How does this facility treat opioid (narcotic) addiction?
MARK ALL THAT APPLY

*11a.

1

 This facility does not treat opioid addiction.

2

 This facility uses methadone or buprenorphine for pain management, emergency
cases, or research purposes. It is NOT a federally-certified OTP.

3

 This facility treats opioid addiction, but it does not use methadone, buprenorphine,
and/or naltrexone to treat opioid addiction, nor does it accept clients using those
medications to treat opioid addiction.

4

 This facility accepts clients who are on methadone, buprenorphine and/or naltrexone
(Vivitrol®) maintenance or treatment, but these medications originate from or are
prescribed by another entity. (The medications may or may not be
stored/delivered/monitored onsite.)

5

 This facility prescribes and/or administers buprenorphine and/or naltrexone (Vivitrol®). This
facility is NOT a federally-certified OTP. Buprenorphine use is authorized through a Data 2000
waivered physician.

6

 This facility administers and/or dispenses methadone, buprenorphine and/or naltrexone (Vivitrol®)
as a federally-certified Opioid Treatment Program (OTP). A Data 2000 waivered physician may or
may not also be onsite. (While most OTPs use methadone, some only use buprenorphine.)

Are ALL of the substance abuse clients at this facility currently receiving methadone, buprenorphine, or
extended-release, injectable naltrexone (Vivitrol®)?
1
0

*11b.

SKIP TO
Q.12 (BELOW)

 Yes
 No

Which of the following medication services does this program provide?
MARK ALL THAT APPLY


2
3
4
1

*12.

Maintenance services with methadone or buprenorphine
Maintenance services with medically-supervised withdrawal after a pre-determined time
Detoxification services with methadone or buprenorphine
Relapse prevention with extended-release, injectable naltrexone (Vivitrol®)

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.
MARK ONE BOX 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

1. Individual counseling

1



2



3



4



5



2. Group counseling

1



2



3



4



5



3. Family counseling

1



2



3



4



5



4. Marital/couples counseling

1



2



3



4



5



3

*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.
• For definitions of these approaches, go to: https://info.nssats.com
MARK ONE FREQUENCY FOR EACH APPROACH

CLINICAL/THERAPEUTIC APPROACHES

NEVER

RARELY

SOMETIMES

ALWAYS
OR OFTEN

NOT FAMILIAR
WITH THIS
APPROACH

1. Substance abuse counseling

1



2



3



4



5



2. 12-step facilitation

1



2



3



4



5



3. Brief intervention

1



2



3



4



5



4. Cognitive behavioral therapy

1



2



3



4



5



5. Dialectical behavior therapy

1



2



3



4



5



6. Contingency management/motivational incentives

1



2



3



4



5



7. Motivational interviewing

1



2



3



4



5



8. Trauma-related counseling

1



2



3



4



5



9. Anger management

1



2



3



4



5



10. Matrix Model

1



2



3



4



5



11. Community reinforcement plus vouchers

1



2



3



4



5



12. Rational emotive behavioral therapy (REBT)

1



2



3



4



5



13. Relapse prevention

1



2



3



4



5



14. Computerized substance abuse
treatment/telemedicine (including Internet, Web,
mobile, and desktop programs)

1



2



3



4



5



15. Other treatment approach (specify:

1



2



3



4



________________________________________________________ )

*14.

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

*14a.

 Yes
 No

Does this facility serve only DUI/DWI clients?
 Yes
0
No
1

4

SKIP TO Q.15 (NEXT PAGE)

*15.

Does this facility provide substance abuse
treatment services in sign language at this
location for the deaf and hard of hearing (for
example, American Sign Language, Signed
English, or Cued Speech)?
• Mark “yes” if either a staff counselor or an on-call

interpreter provides this service.
1
Yes
0
No
*16.

0

16a.

 Yes
 No

In what other languages do staff counselors
provide substance abuse treatment at this
facility?
• Do not count languages provided only by on-call

interpreters.
MARK ALL THAT APPLY

American Indian or Alaska Native:

Does this facility provide substance abuse
treatment services in a language other than
English at this location?
1

*16b.

SKIP TO Q.17 (NEXT PAGE)

At this facility, who provides substance
abuse treatment services in a language other
than English?
MARK ONE ONLY

 Staff counselor who speaks a language other
than English
2
On-call interpreter (in person or by phone)
brought in when needed
SKIP TO Q.17

1

 Hopi

2

 Lakota

3

 Navajo

4

 Ojibwa

5

 Yupik

6

 Other American Indian or Alaska Native
language
(Specify: __________________________ )

Other Languages:
7

 Arabic

8

 Any Chinese language

9

 Creole

1

(NEXT PAGE)
3

 BOTH staff counselor and on-call interpreter

*16a1. Do staff counselors provide substance
abuse treatment in Spanish at this facility?
 Yes
0
No
1

16a2.

SKIP TO Q.16b (NEXT COLUMN)

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

 Yes

GO TO Q.16b (NEXT COLUMN)

0

 No

SKIP TO Q.17 (NEXT PAGE)

10

 Farsi

11

 French

12

 German

13

 Greek

14

 Hebrew

15

 Hindi

16

 Hmong

17

 Italian

18

 Japanese

19

 Korean

20

 Polish

21

 Portuguese

22

 Russian

23

 Tagalog

24

 Vietnamese

25

 Any other language
(Specify: __________________________ )

5

*17.

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?
•

Indicate only the highest or lowest age the facility would accept. Do not indicate the highest or lowest age
currently receiving services in the facility.
MARK “YES” OR “NO” FOR
EACH CATEGORY

TYPE OF CLIENT

1. Female

2. Male

*17a.

IF SERVED, WHAT IS
THE LOWEST AGE SERVED

SERVED BY THIS FACILITY

1

1

Yes

Yes

0

0

No

| | |
YEARS

No

| | |
YEARS

0

0

No minimum age

| | |
YEARS

0

No maximum age

No minimum age

| | |
YEARS

0

No maximum age

Many facilities have clients in one or more of the following categories. For which client categories does
this facility at this location offer a substance abuse treatment program or group specifically tailored for
clients in that category? If this facility treats clients in any of these categories but does not have a
specifically tailored program or group for them, do not mark the box for that category.
MARK ALL THAT APPLY
1

 Adolescents

2

 Young adults

3

 Adult women

4

 Pregnant/postpartum women

5

 Adult men

6

 Seniors or older adults

7

 Lesbian, gay, bisexual, transgender (LGBT) clients

8

 Veterans

9

 Active duty military

10

 Members of military families

11

 Criminal justice clients (other than DUI/DWI)

12

 Clients with co-occurring mental and substance abuse disorders

13

 Clients with HIV or AIDS

14

 Clients who have experienced sexual abuse

15

 Clients who have experienced intimate partner violence, domestic violence

16

 Clients who have experienced trauma

17

 Specifically tailored programs or groups for any other types of clients
(Specify: ______________________________________________)

18

6

IF SERVED, WHAT IS
THE HIGHEST AGE SERVED

 No specifically tailored programs or groups are offered

*18.

*18a.

Does this facility offer HOSPITAL INPATIENT
substance abuse services at this location,
that is, the location listed on the front cover?
1

 Yes

0

 No

*19.

SKIP TO Q.19 (NEXT COLUMN)

Which of the following HOSPITAL INPATIENT
services are offered at this facility?
MARK “YES” OR “NO” FOR EACH

*19a.

Does this facility offer RESIDENTIAL
(non-hospital) substance abuse services at
this location, that is, the location listed on
the front cover?
1

 Yes

0

 No

SKIP TO Q.20 (NEXT PAGE)

Which of the following RESIDENTIAL
services are offered at this facility?
MARK “YES” OR “NO” FOR EACH

YES
1.

2.

NO

Hospital inpatient detoxification ........ 1 
(Similar to ASAM Levels IV-D and
III.7-D, medically managed or
monitored inpatient detoxification)

0

Hospital inpatient treatment .............. 1 
(Similar to ASAM Levels IV and III.7,
medically managed or monitored
intensive inpatient treatment)

0

YES



1. Residential detoxification .................. 1 

NO
0



0



0



(Similar to ASAM Level III.2-D,
clinically managed residential
detoxification or social detoxification)


NOTE: ASAM is the American Society of Addiction Medicine.
For more information on ASAM please go to
https://info.nssats.com.

2. Residential short-term treatment ...... 1 

(Similar to ASAM Level III.5, clinically
managed high-intensity residential
treatment, typically 30 days or less)
3. Residential long-term treatment........ 1 

(Similar to ASAM Levels III.3 and
III.1, clinically managed medium- or
low-intensity residential treatment,
typically more than 30 days)

7

*20.

*20a.

Does this facility offer OUTPATIENT substance abuse services at this location, that is, the location listed
on the front cover?
1

 Yes

0

 No

SKIP TO Q.21 (NEXT PAGE)

Which of the following OUTPATIENT services are offered at this facility?
MARK “YES” OR “NO” FOR EACH

YES

810

1.

Outpatient detoxification ............................................................................................................ 1 
(Similar to ASAM Levels I-D and II-D, ambulatory detoxification)

2.

Outpatient methadone/ buprenorphine maintenance or Vivitrol® treatment ............................. 1 

3.

NO
0



0



Outpatient day treatment or partial hospitalization.................................................................... 1 
(Similar to ASAM Level II.5, 20 or more hours per week)

0



4.

Intensive outpatient treatment ................................................................................................... 1 
(Similar to ASAM Level II.1, 9 or more hours per week)

0



5.

Regular outpatient treatment..................................................................................................... 1 
(Similar to ASAM Level I, outpatient treatment, non-intensive)

0



*21.

Does this facility use a sliding fee scale?
1

 Yes

0

 No

*24.

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

SKIP TO Q.22 (BELOW)

MARK “YES,” “NO,” OR “DON’T KNOW” FOR EACH
YES

21a.

*22.

22a.

DON’T
KNOW

Do you want the availability of a sliding fee
scale published in SAMHSA’s online Locator
and Directory?

1. No payment accepted (free

treatment for ALL clients) ............. 1 

0



d



• The online Locator and Directory will explain that
sliding fee scales are based on income and other
factors.

2. Cash or self-payment ................... 1 

0



d



3. Medicare ....................................... 1 

0



d



4. Medicaid ....................................... 1 

0



d



0



d



(e.g., TRICARE) ........................... 1 

0



d



7. Private health insurance ............... 1 

0



d



(ATR vouchers) ............................ 1 

0



d



9. IHS/Tribal/Urban (ITU funds) ........ 1 

0



d



10. Other ............................................. 1 

0



d



1

 Yes

0

 No

5. State-financed health insurance

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

 Yes

0

 No

plan other than Medicaid .............. 1 
6. Federal military insurance

SKIP TO Q.23 (BELOW)

Do you want the availability of free care for
eligible clients published in SAMHSA’s
online Locator and Directory?

8. Access To Recovery

• The online Locator and Directory will explain that

potential clients should call the facility for
information on eligibility.

*23.

NO

1

 Yes

0

 No

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?

(Specify:
*25.

• Do not include Medicare, Medicaid, or federal
military insurance. These forms of client payments
are included in Q.24.
*26.

)

Does this facility operate transitional
housing or a halfway house for substance
abuse clients at this location, that is, the
location listed on the front cover?
1

 Yes

0

 No

1

 Yes

0

 No

Which of the following statements BEST
describes this facility’s smoking policy for
clients?

d

 Don’t Know

MARK ONE ONLY
1

 Not permitted to smoke anywhere outside or
within any building

2

 Permitted in designated outdoor area(s)

3

 Permitted anywhere outside

4

 Permitted in designated indoor area(s)

5

 Permitted anywhere inside

6

 Permitted anywhere without restriction

9

*27.

Is this facility or program licensed, certified,
or accredited to provide substance abuse
services by any of the following
organizations?

29.

• The Directory will be available at
http://www.samhsa.gov/data/substance-abusefacilities-data-nssats

• Do not include personal-level credentials or
general business licenses such as a food service
license.

• The Locator can be found at:
https://findtreatment.samhsa.gov

MARK “YES,” “NO,” OR “DON’T KNOW” FOR EACH
YES

NO

DON’T
KNOW

0

 No

SKIP TO Q.30 (BELOW)



d



2. State mental health department ... 1 

0



d



3. State department of health ........... 1 

0



d



4. Hospital licensing authority ........... 1 

0



d



5. The Joint Commission .................. 1 

0



d



To increase public awareness of behavioral
health services, SAMHSA may be sharing
facility contact information with large
commercially available Internet search
engines, such as Google, Bing, Yahoo!, etc.
Do you want your facility information shared
on these Internet search engines?



• Information to be shared would be: facility
name, location address, telephone number,
and website address.

29a.

0



d

7. National Committee for

Quality Assurance (NCQA) .......... 1 

0



d



8. Council on Accreditation (COA) ... 1 

0



d


30.

9. Healthcare Facilities

Accreditation Program (HFAP) ..... 1 

0



d



0



d



10. Other national organization

or federal, state, or local agency .. 1 
(Specify:

)

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

 Yes

0

 No

SKIP TO Q.29 (NEXT COLUMN)

If eligible, the website address for this facility
will appear in the Directory and online
Locator. Please provide the address exactly
as it should be entered in order to reach your
site.
Web Address:

10

 Yes

0

Rehabilitation Facilities (CARF) ... 1 

*28a.

1

1. State substance abuse agency .... 1 

6. Commission on Accreditation of

*28.

If eligible, does this facility want to be listed in the
Directory and the online Locator? (See inside front
cover for eligibility information)

1

 Yes

0

 No

Is this facility part of an organization with
multiple facilities or sites that provide
substance abuse treatment?
1

 Yes

GO TO Q.31 (TOP OF NEXT PAGE)

0

 No

SKIP TO Q.32 (NEXT PAGE)

31.

What is the name, address, and phone number of the facility that is the parent, or master site, of the
organization?
Name:
Address:

Phone Number: (_____) ______________ - ____________
32.

Who was primarily responsible for completing this form? This information will only be used if we need
to contact you about your responses. It will not be published.
MARK ONE ONLY
1

 Ms.

5

 Other (Specify:

2

 Mrs.

3

 Mr.

4

 Dr.
)

Name:
Title:
Phone Number: (_____) ______________ - ____________
Fax Number:

Ext. _____________

(_____) ______________ - ____________

Email Address:
Facility Email Address:

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 may be published in SAMHSA’s online Behavioral Health Treatment
Services Locator, the National Directory of Drug and Alcohol Abuse Treatment Programs, and other publically available listings. Responses to nonasterisked questions will be published with no direct link to individual treatment facilities.

Thank you for your participation. Please return this questionnaire in the envelope provided.
If you no longer have the envelope, please mail this questionnaire to:
MATHEMATICA POLICY RESEARCH
ATTN: RECEIPT CONTROL - Project 06667
P.O. Box 2393
Princeton, NJ 08543-2393
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 0930-0106. 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, 5600
Fishers Lane, Room 15E57-B, Rockville, Maryland 20857.

11


File Typeapplication/pdf
File TitleN-SSATS 2016 Questionnaire Non_Variable MINI ( 5-2-16 dab) (003)
AuthorRMcInerney
File Modified2016-05-03
File Created2016-05-02

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