NWIL 6-Month GPRA Follow-Up
Which organization administered the GPRA?
Northwest Instituto Latino Addicciones
If RMC Research needs to reach you (the interviewer) with questions about the GPRA, what is your email?
Client ID
Client Type:
Client in recovery
Interview Date
-
Month
-
Day
Year
Date
Contract/Grant ID
Is the client present? If no, skip to I.
Yes
No
B. DRUG AND ALCOHOL USE
1. During the past 30 days, how many days have you used the following?
Number of Days
REFUSED
DON'T KNOW
a. Any Alcohol (IF ZERO, SKIP TO ITEM B1c.)
1
2
b. Alcohol to intoxication (5+ drinks in one sitting)
3
4
b2. Alcohol to intoxication (4 or fewer drinks in one sitting and felt high)
5
6
c. Illegal drugs [IF B1a OR B1c=0, REFUSED (RF), DON'T KNOW (DK), THEN SKIP TO ITEM B2.]
7
8
d. Both alcohol and drugs (on the same day)
9
10
Route of Administration Types: 1. Oral 2. Nasal 3. Smoking 4. Non-intravenous (IV) injection 5. IV *NOTE THE USUAL ROUTE. FOR MORE THAN ONE ROUTE, CHOOSE THE MOST SEVERE. THE ROUTES ARE LISTED FROM LEAST SEVERE (1) TO MOST SEVERE (5).
2. During the past 30 days, how many days have you used any of the following: [IF THE VALUE IN ANY ITEM B2a-B2i>0, THEN THE VALUE IN B1c MUST BE .0.]
Number of Days
RF
DK
Route*
RF
DK
a. Cocaine/Crack
11
12
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
13
14
b. Marijuana/Hashish(Pot, Joints, Blunts, Chronic, Weed, Mary Jane)
15
16
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
17
18
c. Opiates (skip to 1)
19
20
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
21
22
1. Heroin (Smack, H, Junk, Skag)
23
24
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
25
26
2. Morphine
27
28
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
29
30
3. Dilaudid
31
32
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
33
34
4. Demerol
35
36
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
37
38
5. Percocet
39
40
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
41
42
6. Darvon
43
44
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
45
46
7. Codeine
47
48
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
49
50
8. Tylenol 2,3,4
51
52
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
53
54
9. OxyCotin/Oxycodone
55
56
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
57
58
d. Non-prescription methadone
59
60
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
61
62
e. Hallucinogens/psychedelics, PCP (Angel dust, Ozone, Wack, Rocket Fuel), MDMA (Ecstacy, XTC, Adam), LSD (Acid, Boomers, Yellow Sunshine), Mushrooms, or Mescaline
63
64
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
65
66
f. Methamphetamine or other amphetamines (Meth, Uppers, Speed, Ice, Chalk, Crystal, Glass, Fire, Crank)
67
68
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
69
70
Route of Administration Types: 1. Oral 2. Nasal 3. Smoking 4. Non-intravenous (IV) injection 5. IV *NOTE THE USUAL ROUTE. FOR MORE THAN ONE ROUTE, CHOOSE THE MOST SEVERE. THE ROUTES ARE LISTED FROM LEAST SEVERE (1) TO MOST SEVERE (5).
2. During the past 30 days, how many days have you used any of the following: [IF THE VALUE IN ANY ITEM B2a-B2i>0, THEN THE VALUE IN B1c MUST BE .0.]
Number of Days
RF
DK
Route
RF
DK
g 1. Benzodiazepines: Diazepam (Valium); Alprazolam (Xanax); Triazolam (Halcion); and Estasolam (Prosom and Rohypnol, also known as roofies, roche, and cope
71
72
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
73
74
2. Barbiturates: Mephobarbital (Mebacut) and pentobarbital sodium (Nembutal)
75
76
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
77
78
3. Non-prescription GHB (known as Grievous Bodily Harm, Liquid Ecstasy, and Georgia Home Boy
79
80
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
81
82
4. Ketamine (known as Special K or Vitamin K
83
84
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
85
86
5. Other tranquilizers, downers, sedatives, or hypnotics
87
88
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
89
90
h. Inhalants (poppers, snappers, rush whippets)
91
92
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
93
94
i. other illegal drugs (specify below)
95
96
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
97
98
Please specify the other drug they used in the last 30 days (if any)
In the past 30 days, have you injected drugs? [IF ANY ROUTE OF ADMINISTRATION IN B2a–B2i = 4 or 5, THEN B3 MUST = YES.
YES
NO
REFUSED
DON'T KNOW
In the past 30 days, how often did you use a syringe/needle, cooker, cotton, or water that someone else used?
Always
More than half the time
Half the time
Less than half the time
Never
REFUSED
DON'T KNOW
C. FAMILY AND LIVING CONDITIONS
1. In the past 30 days, where have you been living most of the time? [DO NOT READ RESPONSE OPTIONS TO CLIENT.]
SHELTER (SAFE HAVENS, TRANSITIONAL LIVING CENTER [TLC], LOW-DEMAND FACILITIES, RECEPTION CENTERS, OTHER TEMPORARY DAY OR EVENING FACILITY)
STREET/OUTDOORS (SIDEWALK, DOORWAY, PARK, PUBLIC OR ABANDONED BUILDING
INSTITUTION (HOSPITAL, NURSING HOME, JAIL/PRISON
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
REFUSED
DON'T KNOW
Other
2. How satisfied are you with the conditions of your living space?
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? [IF B1a OR B1c > 0, THEN C3 CANNOT = “NOT APPLICABLE.”
Not at all
Somewhat
Considerably
Extremely
NOT APPLICABLE [USE ONLY IF B1A AND B1C = 0.] 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? [IF B1a OR B1c>0, THEN C4 CANNOT = "NOT APPLICABLE."
Not at all
Somewhat
Considerably
Extremely
NOT APPLICABLE [USE ONLY IF B1A AND B1C = 0.]
REFUSED
DON'T KNOW
5. During the past 30 days, has your use of alcohol or other drugs caused you to have emotional problems? [IF B1a OR B1c > 0, THEN C5 CANNOT = “NOT APPLICABLE.”.”
Not at all
Somewhat
Considerably
Extremely
NOT APPLICABLE [USE ONLY IF B1A AND B1C = 0.] REFUSED
DON’T KNOW
6. [IF NOT MALE] Are you currently pregnant?
YES
NO
REFUSED
DON'T KNOW
7. Do you have children?
YES
NO
REFUSED
DON'T KNOW
a. How many children do you have? [If C7=YES, THEN THE VALUE IN C7a MUST BE .0.]
Number of children below
REFUSED
DON'T KNOW
How many children do you have
99
100
b. Are any of your children living with someone else due to a child protection court order?
YES
NO
REFUSED
DON'T KNOW
c. [IF YES] How many of your children are living with someone else due to a child protection court order? [THE VALUE IN C7c CANNOT EXCEED THE VALUE IN C7a.]
Number of children below
REFUSED
DON'T KNOW
c. [IF YES] How many of your children are living with someone else due to a child protection court order? [THE VALUE IN C7c CANNOT EXCEED THE VALUE IN C7a.]
101
102
For how many of your children have you lost parental rights? [THE CLIENT’S PARENTAL RIGHTS WERE TERMINATED.] [THE VALUE IN ITEM C7d CANNOT EXCEED THE VALUE IN C7a.]
Number of children below
REFUSED
DON'T KNOW
d. For how many of your children have you lost parental rights? [THE CLIENT’S PARENTAL RIGHTS WERE TERMINATED.] [THE VALUE IN ITEM C7d CANNOT EXCEED THE VALUE IN C7a.]
103
104
D. EDUCATION, EMPLOYMENT, AND INCOME
Are you currently enrolled in school or a job training program? [IF ENROLLED] Is that full time or part time? [IF CLIENT IS INCARCERATED, CODE D1 AS “NOT ENROLLED.”]
NOT ENROLLED
ENROLLED, FULL TIME
ENROLLED, PART TIME
REFUSED
DON'T KNOW
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/ASSOCIATES'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 SCHOO
REFUSED
DON'T KNOW
Are you currently employed? [CLARIFY BY FOCUSING ON STATUS DURING MOST OF THE PREVIOUS WEEK, DETERMINING WHETHER CLIENT WORKED AT ALL OR HAD A REGULAR JOB BUT WAS OFF WORK. IF CLIENT IS “ENROLLED, FULL TIME” IN D1 AND INDICATES “EMPLOYED, FULL TIME” IN D3, ASK FOR CLARIFICATION. IF CLIENT IS INCARCERATED AND HAS NO WORK OUTSIDE OF JAIL, CODE D3 AS “UNEMPLOYED, NOT LOOKING FOR WORK.”]
EMPLOYED, FULL TIME (35+ HOURS PER WEEK, OR WOULD HAVE BEEN)
EMPLOYED, PART TIME
UNEMPLOYED, LOOKING FOR WORK
UNEMPLOYED, DISABLED
UNEMPLOYED, VOLUNTEER WORK
UNEMPLOYED, RETIRED
UNEMPLOYED, NOT LOOKING FOR WORK
REFUSED
DON’T KNOW
Other
4. Approximately, how much money did YOU receive (pre-tax individual income) in the past 30 days from … [IF D3 DOES NOT = “EMPLOYED” AND THE VALUE IN D4a IS GREATER THAN ZERO, PROBE. IF D3 = “UNEMPLOYED, LOOKING FOR WORK” AND THE VALUE IN D4b = 0, PROBE. IF D3 = “UNEMPLOYED, RETIRED” AND THE VALUE IN D4c = 0, PROBE. IF D3 = “UNEMPLOYED, DISABLED” AND THE VALUE IN D4d = 0, PROBE.
Number $
RF
DK
a. Wages
105
106
b. Public assistance
107
108
c. Retirement
109
110
d. Disability
111
112
e. Non-legal income
113
114
f. Family and/or Friends
115
116
g. Other (Specify Below)
117
118
Other income (from above)
5. Have you enough money to meet your needs?
Not at all
A little
Moderately
Mostly
Completely
REFUSED
DON'T KNOW
Back
Next
E. CRIME AND CRIMINAL JUSTICE STATUS
119
TIMES
RUFUSED
DON'T KNOW
1. In the past 30 days, how many times have you been arrested? [IF NO ARRESTS, SKIP TO ITEM E3.]
120
121
2. In the past 30 days, how many times have you been arrested from drug-related offenses? [THE VALUE IN E2 CANNOT BE GREATER THAN THE VALUE IN E1.]
122
123
124
NIGHTS
RUFUSED
DON'T KNOW
3. In the past 30 days, how many nights have you spent in jail/prison? [IF THE VALUE IN E3 IS GREATER THAN 15, THEN C1 MUST = INSTITUTION (JAIL/PRISON). IF C1 = INSTITUTION (JAIL/PRISON), THEN THE VALUE IN E3 MUST BE GREATER THAN OR EQUAL TO 15.]
125
126
127
TIMES
RUFUSED
DON'T KNOW
4. In the past 30 days, how many times have you committed a crime? [CHECK NUMBER OF DAYS USED ILLEGAL DRUGS IN ITEM B1c. ANSWER HERE IN E4 SHOULD BE EQUAL TO OR GREATER THAN NUMBER IN B1c BECAUSE USING ILLEGAL DRUGS IS A CRIME.]
128
129
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
Back
Next
F. MENTAL AND PHYSICAL HEALTH PROBLEMS AND TREATMENT AND RECOVERY
1. How would you rate your overall health right now?
Excellent
Very good
Good
Poor
REFUSED
DON'T KNOW
2. During the past 30 days, did you receive:
YES
[IF YES] Altogether for how many nights
NO
RF
DK
a. Impatient treatment for: i. Physical complaint
130
131
132
133
a. Impatient treatment for: ii. mental or emotional difficulties
134
135
136
137
a. Impatient treatment for iii. Alcohol or substance abuse
138
139
140
141
2. During the past 30 days, did you receive:
YES
[IF YES] Altogether for how many nights
NO
RF
DK
b. Outpatient treatment for i. Physical complaint
142
143
144
145
b. Outpatient treatment for ii. Mental or emotional difficulties
146
147
148
149
b. Outpatient treatment for iii. Alcohol or substance abuse
150
151
152
153
2. During the past 30 days, did you receive:
YES
[IF YES] Altogether for how many nights
NO
RF
DK
c. Emergency room treatment for i. Physical complaint
154
155
156
157
c. Emergency room treatment for ii. Mental or emotional difficulties
158
159
160
161
c. Emergency room treatment for iii. Alcohol or substance abuse
162
163
164
165
During the past 30 days, did you engage in sexual activity?
Yes
No
NOT PERMITTED TO ASK
DON'T KNOW
Altogether, how many:
Contacts
RF
DK
a. Sexual contacts (vaginal, oral, or anal) did you have?
166
167
b. Unprotected sexual contacts did you have? [THE VALUE IN F3b. SHOULD NOT BE GREATER THAN THE VALUE IN F3a.] [IF ZERO, SKIP TO F4.]
168
169
c. Unprotected sexual contacts were with an individual who is or was [NONE OF THE VALUES IN F3c1–F3c3 CAN BE GREATER THAN THE VALUE IN F3b.] 1. HIV positive or has AIDS
170
171
c. Unprotected sexual contacts were with an individual who is or was [NONE OF THE VALUES IN F3c1–F3c3 CAN BE GREATER THAN THE VALUE IN F3b.] 2. An injection drug user
172
173
c. Unprotected sexual contacts were with an individual who is or was [NONE OF THE VALUES IN F3c1–F3c3 CAN BE GREATER THAN THE VALUE IN F3b.] 3. High on some substance
174
175
Have you ever been tested for HIV?
Yes
No
REFUSED
DON'T KNOW
Do you know the results of your HIV testing?
Yes
No
5. How would you rate your quality of life?
Very poor
Poor
Neither poor nor good
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 activites?
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
10. In the past 30 days, not due to your use of alcohol or drugs, how many days have you:
Days
RF
DK
a. Experienced serious depression
176
Yes
No
b. Experienced serious anxiety or tension
177
Yes
No
c. Experienced hallucinations
178
Yes
No
d. Experienced trouble understanding, concentrating, or remembering
179
Yes
No
e. Experienced trouble controlling violent behavior
180
Yes
No
f. Attempted suicide
181
Yes
No
g. Been prescribed medication for psychological/emotional problem
182
Yes
No
[IF CLIENT REPORTS ZERO DAYS, RF, OR DK, TO ALL ITEMS IN QUESTION F10, SKIP TO ITEM F12
11. How much have you been bothered by these psychological or emotional problems in the past 30 days?
Not at all
Slightly
Moderately
Considerable
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
Did any of these experiences feel so frightening, horrible, or upsetting that, in the past and/or the present, you:
12a. Have had nightmares about it or thought about it when you did not want to?
YES
NO
REFUSED
DON'T KNOW
12b. 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. Were constantly on guard, watchful, or easily startled?
YES
NO
REFUSED
DON'T KNOW
12d. 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
More than a few times
REFUSED
DON'T KNOW
Back
Next
G. SOCIAL CONNECTEDNESS
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 nonprofessional, peeroperated 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
NO
REFUSED
DON'T KNOW
[IF YES] SPECIFY HOW MANY TIME
NUMBER
REFUSED
DON'T KNOW
SPECIFY HOW MANY TIMES
183
184
2. In the past 30 days, did you attend any religious/faith-based-affiliated recovery self-help groups?
YES
NO
REFUSED
DON'T KNOW
[IF YES] SPECIFY HOW MANY TIMES
NUMBER
REFUSED
DON'T KNOW
SPECIFY HOW MANY TIMES
185
186
3. In the past 30 days, did you attend any meetings of organizations that support recovery other than the organizations described above?
YES
NO
REFUSED
DON'T KNOW
[IF YES] SPECIFY HOW MANY TIMES
NUMBER
REFUSED
DON'T KNOW
SPECIFY HOW MANY TIMES
187
188
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 when you are having trouble? [SELECT ONLY ONE.]
NO ONE
CLERGY MEMBER
FAMILY MEMBER
FRIENDS
REFUSED
DON'T KNOW
Other
6. How satisfied are you with your personal relationships?
Very dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisified
REFUSED
DON'T KNOW
I. FOLLOW-UP STATUS
[REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT FOLLOW-UP.]
What is the follow-up status of the client? [THIS IS A REQUIRED FIELD: NA, REFUSE, DON'T KNOW, AND MISSING WILL NOT BE ACCEPTED.]
01 = Deceased at time of due date
11 = Completed interview within specified window
12 = Completed interview outside specified window
21 = Located, but refused, unspecified
22 = Located, but unable to gain instiutional access
23 = Located, but otherwise unable to gain access
24 = Located, but withdrawn from project
31 = Unable to locate, moved
32 = Unable to locate, other (Specify below)
Specify from 32 (above)
Is the client still receiving services from your organization?
Yes
No
The interview is complete
Submit
Should be Empty: