Which award is this client's services funded by?
* must provide value
SOR I NCE SOR II 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
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
Methadone
Buprenorphine
Naltrexone
Extended-release naltrexone
Client did not receive an FDA-approved medication for an opioid use disorder
Don't know
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
Naltrexone
Extended-release naltrexone
Disulfiram
Acamprosate
Client did not receive an FDA-approved medication for an alcohol use disorder
Don't know
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)
Case Management
Day Treatment
Inpatient/ Hospital (Other Than Detox)
Outpatient
Outreach
Intensive Outpatient
Methadone
Residential/ Rehabilitation
Detoxification (Specify below)
After Care
Recovery Support
Other (Specify below)
Hospital Inpatient Free-Standing Residential Ambulatory Support
Treatment Setting (Other)
Treatment Services (Select at least one service)
Screening
Brief Intervention
Brief Treatment
Referral to Treatment
Assessment
Treatment/Recovery Planning
Individual Counseling
Group Counseling
Family/Marriage Counseling
Co-Occurring Treatment/ Recovery Services
Pharmacological Interventions
HIV/AIDS Counseling
Other Clinical Services (Specify Below)
Treatment Services (Other)
Family Services (including Marriage Education, Parenting, Child Development Services)
Child Care
Employment Service (Specify)
Individual Services Coordination
Transportation
HIV/ AIDS Services
Supportive Transitional Drug-Free Housing Services
Other Case Management Services (Specify below)
Pre-Employment
Employment Coaching
Case Management Services (Other)
Medical Care
Alcohol/Drug Testing
HIV/AIDS Medical Support & Testing
Other Medical Services (Specify)
Continuing Care
Relapse Prevention
Recovery Coaching
Self-Help and Support Groups
Spiritual Support
Other After Care Services (Specify)
After Care Services (Other)
Substance Abuse Education
HIV/AIDS Education
Other Education Services (Specify)
Education Services (Other)
Peer-to-Peer Recovery Support Services
Peer Coaching or Mentoring
Housing Support
Alcohol- and Drug-Free Social Activities
Information and Referral
Other Peer-to-Peer Recovery Support Services (Specify below)
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
Central American
Cuban
Dominican
Mexican
Puerto Rican
South American
Other (Specify)
Other Ethnic Group (Specify)
3. What is your race? You may say yes to more than one.
* must provide value
Black or African American
Asian
Native Hawaiian or other Pacific Islander
Alaska Native
White
American Indian
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
Never Deployed
Iraq or Afghanistan (E.G., Operation Enduring Freedom [OEF]/ Operation Iraqi Freedom [OIF]/ Operation New Dawn [OND])
Persian Gulf (Operation Desert Shield/Desert Storm)
Vietnam/Southeast Asia
Korea
WWII
Deployed to a combat zone not listed above (E.G., Bosnia/Somalia)
Refused
Don't Know
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
Mother
Father
Brother
Sister
Spouse
Partner
Child
Other (Specify)
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?
Mother
Father
Brother
Sister
Spouse
Partner
Child
Other (Specify)
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?
Mother
Father
Brother
Sister
Spouse
Partner
Child
Other (Specify)
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?
Mother
Father
Brother
Sister
Spouse
Partner
Child
Other (Specify)
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?
Mother
Father
Brother
Sister
Spouse
Partner
Child
Other (Specify)
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?
Mother
Father
Brother
Sister
Spouse
Partner
Child
Other (Specify)
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
Oral
Nasal
Smoking
Non-IV injection
IV
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
Oral
Nasal
Smoking
Non-IV injection
IV
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
Oral
Nasal
Smoking
Non-IV injection
IV
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
Oral
Nasal
Smoking
Non-IV injection
IV
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
Oral
Nasal
Smoking
Non-IV injection
IV
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
Oral
Nasal
Smoking
Non-IV injection
IV
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
Oral
Nasal
Smoking
Non-IV injection
IV
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
Oral
Nasal
Smoking
Non-IV injection
IV
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
Oral
Nasal
Smoking
Non-IV injection
IV
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
Oral
Nasal
Smoking
Non-IV injection
IV
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
Oral
Nasal
Smoking
Non-IV injection
IV
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
Oral
Nasal
Smoking
Non-IV injection
IV
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
Oral
Nasal
Smoking
Non-IV injection
IV
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
Oral
Nasal
Smoking
Non-IV injection
IV
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
Oral
Nasal
Smoking
Non-IV injection
IV
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
Oral
Nasal
Smoking
Non-IV injection
IV
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
Oral
Nasal
Smoking
Non-IV injection
IV
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
Oral
Nasal
Smoking
Non-IV injection
IV
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
Oral
Nasal
Smoking
Non-IV injection
IV
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
Oral
Nasal
Smoking
Non-IV injection
IV
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
Oral
Nasal
Smoking
Non-IV injection
IV
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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