Which award is this client's services funded by?
* must provide value
SOR II SOR II NCE Don't Know
Does the client agree to participate in the SOR GPRA Evaluation?
* must provide value
Yes
No
Please provide a reason for the client declining participation:
* must provide value
Would you like to upload a completed paper copy of a GPRA Baseline Interview?
* must provide value
Yes
No
Completed GPRA Baseline
* must provide value
Client ID
* must provide value
Client Type
* must provide value
Treatment client Client in recovery
Jurisdiction
* must provide value
Allegany Anne Arundel Baltimore City Baltimore County Calvert Caroline Cecil Dorchester/Mid-Shore Frederick Harford Howard Kent/Mid-Shore Montgomery Prince George's Queen Anne's St. Mary's Talbot Worcester Wicomico Other, not listed
If other jurisdiction, please provide:
* must provide value
Date of Enrollment into SOR-funded services
* must provide value
Program Type
* must provide value
Detention Center (MAT) Oxford House Adult Recovery House Healthy Beginnings Intensive Care Coordination (ICC) Community/Faith-Based Organizations, MOTA OUD MEETS Hub & Spoke EMOCHA
Date of Interview
* must provide value
Name of Person Completing Survey
* must provide value
Title of Person Completing Survey
Telephone Number of Person Completing Survey
* must provide value
Email Address of Person Completing Form
Expected Release Date
* must provide value
F10.10 - Alcohol use disorder, uncomplicated, mild
F10.11 - Alcohol use disorder, mild, in remission
F10.20 - Alcohol use disorder, uncomplicated, moderate/severe
F10.21 - Alcohol use disorder, moderate/severe, in remission
F10.9 - Alcohol use, unspecified
F11.10 - Opioid use disorder, uncomplicated, mild
F11.11 - Opioid use disorder, mild, in remission
F11.20 - Opioid use disorder, uncomplicated, moderate/severe
F11.21 - Opioid use disorder, moderate/severe, in remission
F11.9 - Opioid use, unspecified
F12.10 - Cannabis use disorder, uncomplicated, mild
F12.11 - Cannabis use disorder, mild, in remission
F12.20 - Cannabis use disorder, uncomplicated, moderate/severe
F12.21 - Cannabis use disorder, moderate/severe, in remission
F12.9 - Cannabis use, unspecified
F13.10 - Sedative, hypnotic, or anxiolytic-related use disorder, uncomplicated, mild
F13.11 - Sedative, hypnotic, or anxiolytic-related use disorder, mild, in remission
F13.20 - Sedative, hypnotic, or anxiolytic-related use disorder, uncomplicated, moderate/severe
F13.21 - Sedative, hypnotic, or anxiolytic-related use disorder, moderate/severe, in remission
F13.9 - Sedative, hypnotic, or anxiolytic-related use, unspecified
F14.10 - Cocaine use disorder, uncomplicated, mild
F14.11 - Cocaine use disorder, mild, in remission
F14.20 - Cocaine use disorder, uncomplicated, moderate/severe
F14.21 - Cocaine use disorder, moderate/severe, in remission
F14.9 - Cocaine use, unspecified
F15.10 - Other stimulant use disorder, uncomplicated, mild
F15.11 - Other stimulant use disorder, mild, in remission
F15.20 - Other stimulant use disorder, uncomplicated, moderate/severe
F15.21 - Other stimulant use disorder, moderate/severe, in remission
F15.9 - Other stimulant use, unspecified
F16.10 - Hallucinogen use disorder, uncomplicated, mild
F16.11 - Hallucinogen use disorder, mild, in remission
F16.20 - Hallucinogen use disorder, uncomplicated, moderate/severe
F16.21 - Hallucinogen use disorder moderate/severe, in remission
F16.9 - Hallucinogen use, unspecified
F18.10 - Inhalant use disorder, uncomplicated, mild
F18.11 - Inhalant use disorder, mild, in remission
F18.20 - Inhalant use disorder, uncomplicated, moderate/severe
F18.21 - Inhalant use disorder, moderate/severe, in remission
F18.9 - Inhalant use, unspecified
F19.10 - Other psychoactive substance use disorder, uncomplicated, mild
F19.11 - Other psychoactive substance use disorder, in remission
F19.20 - Other psychoactive substance use disorder, uncomplicated, moderate/severe
F19.21 - Other psychoactive substance use disorder, moderate/severe, in remission
F19.9 - Other psychoactive substance use, unspecified
F17.20 - Tobacco use disorder, mild/moderate/severe
F17.21 - Tobacco use disorder, mild/moderate/severe, in remission
F21 - Schizotypal disorder
F22 - Delusional disorder
F23 - Brief psychotic disorder
F24 - Shared psychotic disorder
F25 - Schizoaffective disorders
F28 - Other psychotic disorder not due to a substance or known physiological condition
F29 - Unspecified psychosis not due to a substance or known physiological condition
F32 - Major depressive disorder, single episode
F33 - Major depressive disorder, recurrent
F34 - Persistent mood [affective] disorders
F39 - Unspecified mood [affective] disorder
F40-F48 - Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders
F51 - Sleep disorders not due to a substance or known physiological condition
F60.2 - Antisocial personality disorder
F60.3 - Borderline personality disorder
F60.0, F60.1, F60.4-F69 - Other personality disorders
F70-F79 - Intellectual disabilities
F80-F89 - Pervasive and specific developmental disorders
F90 - Attention-deficit hyperactivity disorders
F93 - Emotional disorders with onset specific to childhood
F94 - Disorders of social functioning with onset specific to childhood or adolescence
F98 - Other behavioral and emotional disorders with onset usually occurring in childhood and adolescence
F99 - Unspecified mental disorder
1. In the past 30 days, was this client diagnosed with an opioid use disorder?
* must provide value
Yes No Don't know
1a. In the past 30 days, which U.S. Food and Drug Administration (FDA)-approved medication did the client receive for the treatment of this opioid use disorder?
* must provide value
Specify how many days received
2 In the past 30 days, was the client diagnosed with an alcohol use disorder?
* must provide value
Yes No Don't know
2a. In the past 30 days, which U.S. Food and Drug Administration (FDA)-approved medication did the client receive for the treatment of this alcohol use disorder?
* must provide value
Specify how many days received
3. Was the client screened by your program for co-occurring mental health and substance use disorders?
* must provide value
Yes
No
3a. Did the client screen positive for co-occurring mental health and substance use disorders?
* must provide value
Yes
No
Treatment Setting (choose at least one modality)
Hospital Inpatient Free-Standing Residential Ambulatory Support
Treatment Setting (Other)
Treatment Services (Select at least one service)
Treatment Services (Other)
Case Management Services (Other)
After Care Services (Other)
Education Services (Other)
Peer-to-Peer Recovery Support Services
Peer-to-Peer Recover Support Services (other)
1. What is your gender?
* must provide value
Male
Female
Transgender
Other (specify below)
Refused
Gender (if other)
* must provide value
2. Are you Hispanic or Latino?
* must provide value
Yes
No
Refused
2a. Ethnic Group
* must provide value
Other Ethnic Group (Specify)
3. What is your race? You may say yes to more than one.
* must provide value
4. What is your date of birth? If Refused, enter 0.
* must provide value
5. Have you ever served in the Armed Forces, in the Reserves, or National Guard?
* must provide value
No Yes- In the Armed Forces Yes- In the Reserves Yes- In the National Guard Refused Don't Know
5a. Are you currently on active duty in the Armed Forces, In the Reserves, or in the National Guard?
* must provide value
No-separated or retired from the Armed Forces, Reserves, or National Guard Yes-In the Armed Forces Yes- In the Reserves Yes- In the National Guard Refused Don't Know
5b. Have you ever been deployed to a combat zone?
* must provide value
6. Is anyone in your family or someone close to you on active duty in the Armed Forces, In the Reserves, or in the National Guard or separated or retired from the Armed Forces, In the Reserves, or in the National Guard?
* must provide value
No Yes- Only one Yes- More than one Refused Don't Know
What is the relationship of that person (Service Member) to you? (can provide information for up to 6)
* must provide value
Other (Specify)
* must provide value
6a. 1. Deployed in support of combat operations (e.g., Iraq or Afghanistan)?
* must provide value
Yes
No
Refused
Don't Know
6b. 1. Was physically injured during combat operations?
* must provide value
Yes
No
Refused
Don't Know
6c. 1. Developed combat stress symptoms/ difficulties adjusting following deployment, including post-traumatic stress disorder (PTSD), depression, or suicidal thoughts?
* must provide value
Yes
No
Refused
Don't Know
6d. 1. Died or was killed?
* must provide value
Yes
No
Refused
Don't Know
What is the relationship of that person (Service Member) to you?
Other (Specify)
* must provide value
6a. 2. Deployed in support of combat operations (e.g., Iraq or Afghanistan)?
* must provide value
Yes
No
Refused
Don't Know
6b. 2. Was physically injured during combat operations?
* must provide value
Yes
No
Refused
Don't Know
6c. 2. Developed combat stress symptoms/ difficulties adjusting following deployment, including post-traumatic stress disorder (PTSD), depression, or suicidal thoughts?
* must provide value
Yes
No
Refused
Don't Know
6d. 2. Died or was killed?
* must provide value
Yes
No
Refused
Don't Know
Do you have another service member to enter?
Yes
No
What is the relationship of that person (Service Member) to you?
Other (Specify)
* must provide value
6a. 3. Deployed in support of combat operations (e.g., Iraq or Afghanistan)?
* must provide value
Yes
No
Refused
Don't Know
6b. 3. Was physically injured during combat operations?
* must provide value
Yes
No
Refused
Don't Know
6c. 3. Developed combat stress symptoms/ difficulties adjusting following deployment, including post-traumatic stress disorder (PTSD), depression, or suicidal thoughts?
* must provide value
Yes
No
Refused
Don't Know
6d. 3. Died or was killed?
* must provide value
Yes
No
Refused
Don't Know
Do you have another service member to enter?
Yes
No
What is the relationship of that person (Service Member) to you?
Other (Specify)
* must provide value
6a. 4. Deployed in support of combat operations (e.g., Iraq or Afghanistan)?
* must provide value
Yes
No
Refused
Don't Know
6b. 4. Was physically injured during combat operations?
* must provide value
Yes
No
Refused
Don't Know
6c. 4. Developed combat stress symptoms/ difficulties adjusting following deployment, including post-traumatic stress disorder (PTSD), depression, or suicidal thoughts?
* must provide value
Yes
No
Refused
Don't Know
6d. 4. Died or was killed?
* must provide value
Yes
No
Refused
Don't Know
Do you have another service member to enter?
Yes
No
What is the relationship of that person (Service Member) to you?
Other (Specify)
* must provide value
6a. 5. Deployed in support of combat operations (e.g., Iraq or Afghanistan)?
* must provide value
Yes
No
Refused
Don't Know
6b. 5. Was physically injured during combat operations?
* must provide value
Yes
No
Refused
Don't Know
6c. 5. Developed combat stress symptoms/ difficulties adjusting following deployment, including post-traumatic stress disorder (PTSD), depression, or suicidal thoughts?
* must provide value
Yes
No
Refused
Don't Know
6d. 5. Died or was killed?
* must provide value
Yes
No
Refused
Don't Know
Do you have another service member to enter?
Yes
No
What is the relationship of that person (Service Member) to you?
Other (Specify)
* must provide value
6a. 6. Deployed in support of combat operations (e.g., Iraq or Afghanistan)?
* must provide value
Yes
No
Refused
Don't Know
6b. 6. Was physically injured during combat operations?
* must provide value
Yes
No
Refused
Don't Know
6c. 6. Developed combat stress symptoms/ difficulties adjusting following deployment, including post-traumatic stress disorder (PTSD), depression, or suicidal thoughts?
* must provide value
Yes
No
Refused
Don't Know
6d. 6. Died or was killed?
* must provide value
Yes
No
Refused
Don't Know
1a. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
1b. During the past 30 days, how many days have you used:
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
1b. 2 During the past 30 days, how many days have you used:
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
1c. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
1d. During the past 30 days, how many days have you used:
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
a. During the past 30 days, how many days have you used: Cocaine/Crack
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
b. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
c1. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
c2. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
c3. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
c4. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
c5. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
c6. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
c7. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
c8. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
c9. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
d. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
e. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
f. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
g1. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
g2. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
g3. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
g4. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
g5. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
h. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
i. During the past 30 days, how many days have you used:
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
Route of Administration
* must provide value
3. In the past 30 days, have you injected drugs?
* must provide value
Yes No Refused Don't Know
4. In the past 30 days, how often did you use a syringe/needle, cooker, cotton, or water that someone else used?
* must provide value
Always More than half the time Half the time Less than half the time Never Refused Don't Know
1. In the past 30 days, where have you been living most of the time?
* must provide value
Shelter (safe havens, transitional living center, low demand facilities, reception centers, other temporary day or evening facility) Street/outdoors (Sidewalk, doorway, park, public or abandoned building) Housed- own/rent apartment, room or house Housed- someone else's apartment, room or house Housed- Dormitory/College residence Housed- Halfway House Housed- residential treatment Housed- other housed (*Specify below*) Refused Don't Know
Housed- Other Housed, Specify
* must provide value
2. How satisfied are you with the conditions of your living space?
* must provide value
Very dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very Satisfied
Refused
Don't Know
3. During the past 30 days, how stressful have things been for you because of your use of alcohol or other drugs?
* must provide value
Not at all
Somewhat
Considerably
Extremely
Not Applicable
Refused
Don't Know
4. During the past 30 days, has your use of alcohol or other drugs caused you to reduce or give up important activities?
* must provide value
Not at all
Somewhat
Considerably
Extremely
Not Applicable
Refused
Don't Know
5. During the past 30 days, has your use of alcohol or other drugs caused you to have emotional problems?
* must provide value
Not at all
Somewhat
Considerably
Extremely
Not Applicable
Refused
Dont Know
6. Are you currently pregnant ?
* must provide value
Yes
No
Refused
Don't Know
7. Do you have children?
* must provide value
Yes
No
Refused
Don't Know
7a. How many children do you have?
Type in RF for Refused or DK for Don't Know
7b. Are any of your children living with someone else due to a child protection court order?
Yes
No
Refused
Don't Know
7c. How many of your children are living with someone else due to a child protection court order?
Type in RF for Refused or DK for Don't Know
7d. For how many children have you lost parental rights?
Type in RF for Refused or DK for Don't Know
1. Are you currently enrolled in school or a job training program?
Not Enrolled
Enrolled, Full Time
Enrolled, Part Time
Other (specify below)
Refused
Don't Know
School or Job Program, Other
2. What is the highest level of education you have finished, whether or not you received a degree?
Never Attended 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade 7th grade 8th grade 9th grade 10th grade 11th grade 12th grade/high school diploma/equivalent College or university/1st year completed College or university/2nd year completed/associate's degree (AA, AS) College or university/3rd year completed Bachelor's degree (BA, BS) or higher Vocational/technical (VOC/TECH) program after high school but no VOC/TECH diploma VOC/TECH diploma after high school Refused Don't Know
3. Are you currently employed?
Employed, Full Time (35+ hours per week)
Employed, Part Time
Unemployed, looking for work
Unemployed, disabled
Unemployed, volunteer work
Unemployed, retired
Unemployed, not looking for work
Other (Specify Below)
Refused
Don't Know
4a. Approximately how much money did you receive (pre-tax individual income) in the past 30 days from:
* must provide value
Type in RF for Refused or DK for Don't Know
4b. Approximately how much money did you receive (pre-tax individual income) in the past 30 days from:
* must provide value
Type in RF for Refused or DK for Don't Know
4c. Approximately how much money did you receive (pre-tax individual income) in the past 30 days from:
* must provide value
Type in RF for Refused or DK for Don't Know
4d. Approximately how much money did you receive (pre-tax individual income) in the past 30 days from:
* must provide value
Type in RF for Refused or DK for Don't Know
4e. Approximately how much money did you receive (pre-tax individual income) in the past 30 days from:
* must provide value
Type in RF for Refused or DK for Don't Know
4f. Approximately how much money did you receive (pre-tax individual income) in the past 30 days from:
* must provide value
Type in RF for Refused or DK for Don't Know
4g. Approximately how much money did you receive (pre-tax individual income) in the past 30 days from:
* must provide value
Type in RF for Refused or DK for Don't Know
Other Income
* must provide value
5. Have you enough money to meet your needs?
* must provide value
Not at all
A little
Moderately
Mostly
Completely
Refused
Don't Know
1. In the past 30 days, how many times have you been arrested?
Type in RF for Refused or DK for Don't Know
2. In the past 30 days, how many times have you been arrested for drug-related offenses?
Type in RF for Refused or DK for Don't Know
3. In the past 30 days, how many nights have you spent in jail/prison?
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
4. In the past 30 days, how many times have you committed a crime? (VALUE MUST BE GREATER THAN OR EQUAL TO AMOUNT OF DAYS IN WHICH ILLEGAL DRUGS WERE USED)
Type in RF for Refused or DK for Don't Know
5. Are you currently awaiting charges, trial, or sentencing?
Yes
No
Refused
Don't Know
6. Are you currently on parole or probation?
Yes No Refused Don't Know
1. How would you rate your overall health right now?
Excellent
Very good
Good
Fair
Poor
Refused
Don't Know
Altogether for how many nights
* must provide value
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Altogether for how many nights
* must provide value
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Altogether for how many nights
* must provide value
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Altogether for how many times
* must provide value
Altogether for how many times
* must provide value
Altogether for how many times
* must provide value
Altogether for how many times
* must provide value
Altogether for how many times
* must provide value
Altogether for how many times
* must provide value
3. During the past 30 days, did you engage in sexual activity?
* must provide value
Yes
No
Not permitted to ask
Refused
Don't Know
3a. Altogether how many sexual contacts (vaginal, oral, anal) did you have?
Type in RF for Refused or DK for Don't Know
3b. Altogether how many unprotected sexual contacts did you have?
Type in RF for Refused or DK for Don't Know
c1. Altogether how many unprotected sexual contacts were with an individual who is or was HIV positive or has AIDS?
Type in RF for Refused or DK for Don't Know
c2. Altogether how many unprotected sexual contacts were with an individual who is or was an injection drug user?
Type in RF for Refused or DK for Don't Know
c3. Altogether how many unprotected sexual contacts were with an individual who is or was high on some substance?
Type in RF for Refused or DK for Don't Know
4. Have you ever been tested for HIV?
Yes
No
Refused
Don't Know
4a. Do you know the results of your HIV testing?
Yes
No
5. How would you rate your quality of life?
Very poor
Poor
Neither good nor poor
Good
Very good
Refused
Don't Know
6. How satisfied are you with your health?
Very dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
Refused
Don't Know
7. Do you have enough energy for everyday life?
Not at all
A little
Moderately
Mostly
Completely
Refused
Don't Know
8. How satisfied are you with your ability to perform your daily activities?
Very dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
Refused
Don't Know
9. How satisfied are you with yourself?
Very dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
Refused
Don't Know
10a. In the past 30 days, not due to your use of alcohol or drugs, how many days have you experienced serious depression?
N/A 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
10b. In the past 30 days, not due to your use of alcohol or drugs, how many days have you experienced serious anxiety or tension?
N/A 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
10c. In the past 30 days, not due to your use of alcohol or drugs, how many days have you experienced hallucinations?
N/A 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
10d. In the past 30 days, not due to your use of alcohol or drugs, how many days have you experienced trouble understanding, concentrating, or remembering?
N/A 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
10e. In the past 30 days, not due to your use of alcohol or drugs, how many days have you experienced trouble controlling violent behavior?
N/A 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
10f. In the past 30 days, not due to your use of alcohol or drugs, how many days have you attempted suicide?
N/A 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
10g. In the past 30 days, not due to your use of alcohol or drugs, how many days have you been prescribed medication for a psychological/emotional problem?
N/A 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Type in RF for Refused or DK for Don't Know
11. How much have you been bothered by these psychological or emotional problems in the past 30 days?
Not at all
Slightly
Moderately
Considerably
Extremely
Refused
Don't Know
12. Have you ever experienced violence or trauma in any setting (including community or school violence; domestic violence; physical, psychological, or sexual maltreatment/assault within or outside of the family; natural disaster; terrorism; neglect; or traumatic grief)?
Yes
No
Refused
Don't Know
12a. Did any of these experiences feel so frightening, horrible, or upsetting that, in the past and/or the present, you have had nightmares about it or thought about it when you did not want to?
Yes
No
Refused
Don't Know
12b. Did any of these experiences feel so frightening, horrible, or upsetting that, in the past and/or the present, you tried hard not to think about it or went out of your way to avoid situations that remind you of it?
Yes
No
Refused
Don't Know
12c. Did any of these experiences feel so frightening, horrible, or upsetting that, in the past and/or the present, you were constantly on guard, watchful, or easily startled?
Yes
No
Refused
Don't Know
12d. Did any of these experiences feel so frightening, horrible, or upsetting that, in the past and/or the present, you felt numb and detached from others, activities, or your surroundings?
Yes
No
Refused
Don't Know
13. In the past 30 days, how often have you been hit, kicked, slapped, or otherwise physically hurt?
Never
A few times
Refused
Don't Know
1. In the past 30 days, did you attend any voluntary self-help groups for recovery that were not affiliated with a religious or faith-based organization? In other words, did you participate in a non-professional, peer-operated organization that is devoted to helping individuals who have addiction-related problems, such as Alcoholics Anonymous, Narcotics Anonymous, Oxford House, Secular Organization for Sobriety, or Women for Sobriety, etc.?
Yes (specify how many times below)
No
Refused
Don't Know
2. In the past 30 days, did you attend any religious/faith-affiliated recovery self-help groups?
Yes (specify how many times below)
No
Refused
Don't Know
3. In the past 30 days, did you attend meetings or organizations that support recovery other than organizations described above?
Yes (specify how many times below)
No
Refused
Don't Know
4. In the past 30 days, did you have interaction with family and/or friends that are supportive of your recovery?
Yes
No
Refused
Don't Know
5. To whom do you turn to when you are having trouble?
No one
Clergy member
Family member
Friends
Refused
Don't Know
Other (specify)
6. How satisfied are you with your personal relationships?
Very dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
Refused
Don't Know
Submit
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