Form 2011 OTP Questionn 2011 OTP Questionn 2011 OTP Questionnaire

U.S. Department of Health and Human Services

OMB No. xxx-xxxx
Approval Expires: xx/xx/xxxx

2011 Opioid Treatment Program (OTP)
Questionnaire
March 31, 2011
Sponsored by the Substance Abuse and Mental Health Services Administration
(SAMHSA)

PLEASE REVIEW THE INFORMATION BELOW.
CROSS OUT ANY ERRORS AND ENTER THE CORRECT INFORMATION.

PLEDGE TO RESPONDENTS
The information you provide will be protected to the fullest extent allowable under the Public Health Service Act, 42 USC Sec 501(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. Responses to questions will be published only in statistical summaries so
that individual treatment facilities cannot be identified.

PREPARED BY MATHEMATICA POLICY RESEARCH

PLEASE READ THIS ENTIRE PAGE
BEFORE COMPLETING THE QUESTIONNAIRE

Would you prefer to complete this questionnaire online?
See the neon green flyer enclosed in your questionnaire
packet for the Internet address and your unique user ID and
password. As with the N-SSATS survey, 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 OTP Survey helpline at 1-xxx-xxx-xxxx.

INSTRUCTIONS
Many of the questions in this survey ask about “this Opioid Treatment Program (OTP).” By “this OTP”
we mean the specific opioid treatment program whose name and location are printed on the front
cover. If this OTP is part of a larger facility, report only about the services and activities at this OTP.
If you have any questions about how “this OTP” applies to your facility, please call 1-xxx-xxx-xxxx.
Return the completed questionnaire in the envelope provided. Please keep a copy for your records.
For additional information about this survey, please visit http://info.nssats.com/otp.
If you have any questions please contact:

MATHEMATICA POLICY RESEARCH
1-xxx-xxx-xxxx

PREPARED BY MATHEMATICA POLICY RESEARCH

SECTION A
OPIOID TREATMENT PROGRAM
SERVICES AND
CHARACTERISTICS

A4.

Section A asks about services and characteristics of this
Opioid Treatment Program (OTP), that is, the OTP at the
location listed on the cover of this survey. If this OTP is
part of a larger facility, report only about the services and
activities at this OTP.
A1.

A2.

A5.

 Yes

0

 No

1

 Yes

0

 No

For each day of the week, record this OTP’s
number of scheduled daily hours…
Column A – For dispensing methadone,
buprenorphine (Subutex® or generic) or
buprenorphine/naloxone (Suboxone®).

Is this OTP, at this location, normally scheduled to
be open 365 days a year?
1

Does this OTP have a written agreement (as
provided in 42 CFR Part 2) that permits other
health service providers to receive, process,
store, or otherwise manage patient records?

Column B – For counseling.
If not scheduled on a given day, record “0” hours
for that activity on that day.

Does this OTP have a plan or an agreement with
another provider to provide continuity of care for
patients during service disruptions, whether due
to a major disaster or more routine event, such as
a snowstorm?
1

 Yes

0

 No

Column A

Column B

Total Number
of Scheduled
Hours for
Dispensing
Medication

Total Number
of Scheduled
Hours for
Counseling

Monday

__________

__________

Tuesday

__________

__________

Wednesday

__________

__________

Thursday

__________

__________

Friday

__________

__________

Saturday

__________

__________

Sunday

__________

__________

SKIP TO A3 (BELOW)

A2a. With which of the following providers does this
OTP have such a plan or agreement?
MARK “YES” OR “NO” FOR EACH

YES

NO

1.

A hospital ............................................ 1 

0



2.

Another OTP ....................................... 1 

0



3.

A pharmacy ......................................... 1 

0



4.

Other (Specify below: ......................... 1 

0


)

A3.

Does this OTP have a formal agreement for
medical referral purposes with…
MARK “YES” OR “NO” FOR EACH

YES

NO

A Federally Qualified Health
Center (FQHC) .................................... 1 

0



2.

A hospital ............................................ 1 

0



3.

A medical clinic ................................... 1 

0



4.

Other (Specify below: ......................... 1 

0



1.

)

A6.

Does the OTP, at this location, provide
vaccinations for…
MARK “YES” OR “NO” FOR EACH

YES

NO

1.

Hepatitis B........................................... 1 

0



2.

Influenza ............................................. 1 

0



1

A7.

This question asks about screening and
diagnostic tests provided at this OTP.

A8.

MARK “YES” OR “NO” FOR EACH

Column A – For which of these conditions does this
OTP routinely screen? Consider all
screening performed at intake,
assessment or admission.

YES

Column B – For which of these conditions does this
OTP perform diagnostic tests? Consider
all testing performed as medically
appropriate.

Yes
1. Diabetes

1



No
0



Yes
1



Does this OTP routinely test for any of the
following drugs at admission?

NO

1.

Marijuana ............................................ 1 

0



2.

Cocaine ............................................... 1 

0



3.

Benzodiazepines ................................ 1 

0



4.

Heroin ................................................. 1 

0



5.

Prescription opioids ............................ 1 

0



6.

Methamphetamines ............................ 1 

0



7.

Other stimulants (Please specify: ....... 1 

0


)

No
0


A9.

2. Hepatitis C

1



0



1



0



3. HIV/AIDS

1



0



1



0



For each of the listed psychiatric conditions,
please indicate if this OTP…
Column A – Routinely screens for the condition.
Column B – Provides treatment involving medication.

4. Hypertension (high blood
1



0



1



0



5. Pregnancy

1



0



1



0



6. Heartbeat abnormalities

1



0



1



0



pressure)

Column C – Provides treatment involving counseling
therapy.

7. Sexually transmitted

infections (STIs, including
gonorrhea, syphilis)

1



0



1



0



ROUTINELY
SCREENS

TREATMENT
INVOLVING
MEDICATION

Yes

Yes

No

No

TREATMENT
INVOLVING
COUNSELING

Yes

No

1. Anxiety/Panic
1



0



1



0



1



0



2. Bipolar disorder

1



0



1



0



1



0



1



0



1



0



1



0



1



0



1



0



1



0



1



0



1



0



1



0



1



0



1



0



1



0



disorder

8. Sleep apnea

1



0



1



0



9. Alcohol use

1



0



1



0



3. Depression

10. Tobacco use

1



0



1



0



4. Post traumatic

stress disorder
5. Schizophrenia
6. Other (Specify

below:

)

2

A10. This question concerns the clinical staff providing
patient services at this OTP in a typical week.
Please count a staff member in one category only.

A12. For each of the following activities, please
indicate if staff members routinely use computer
or electronic resources, paper only, or a
combination of both to accomplish their work…

Column A – Please record total number employed
at this OTP.

MARK ONE METHOD FOR EACH ACTIVITY

Column B – Please record the sum total hours
worked for all staff listed in Column A
in a typical week.
COLUMN A

COLUMN B

TOTAL
NUMBER
EMPLOYED AT
THIS OTP

SUM TOTAL
NUMBER OF
HOURS
WORKED IN
TYPICAL
WEEK

CLINICAL STAFF

Physician (MD, DO,
Psychiatrist, etc.)

______

______

2.

Registered Nurse (RN)

______

______

3.

Licensed Practical
Nurse (LPN)

1.

______

______

Mid-level medical
personnel (Nurse
Practitioner, PA,
APRN, etc.)

______

______

5.

Pharmacist

______

______

6.

Doctoral level
counselor
(Psychologist, etc.)

______

______

Masters level counselor
(MSW, etc.)

______

______

4.

7.

8.

9.

Other degreed
counselor (BA, BS)

______

______

Associate degree or
non degreed counselor

______

______

1.

Intake

1



2



3



2.

Assessment

1



2



3



3.

Treatment
plan

1



2



3



4.

Discharge

1



2



3



5.

Referrals

1



2



3



6.

Issue/Receive
lab results

1



2



3



7.

Billing

1



2



3



8.

Outcomes
management

1



2



3



Medication
dispensing

1



2



3



9.

A13.

Do computers at this OTP have the capability to
access the Internet?
1

 Yes

0

 No

A13a. Does this OTP primarily access the Internet
using…
1

A11. For clinical management, does this OTP…

2

MARK “YES” OR “NO” FOR EACH

YES

SKIP TO A14

NO

3

 A regular “dial-up” telephone line
 DSL, cable modem, fiber optics, satellite,
wireless (such as Wi-Fi) or some other
broadband Internet connection?
 Something else? (Specify below:

1. Use in-house or proprietary software

(software that was created for, or
modified specifically for, this OTP
or facility)? .......................................... 1 

)
0



0



2 . Use commercially-available software

that has not been modified specifically
for this OTP or facility? ...................... 1 
3. Use a paper system only (no computer/

electronic clinical management)? ....... 1 

0



A14.

Do any outpatients travel an hour or more,
each way, to be treated at this OTP?
1

 Yes

0

 No

n

 Not applicable, no outpatient OTP patients
3

B3.

SECTION B: OTP PATIENT
CHARACTERISTICS
For this survey, an OTP patient is a person who has
been admitted to this OTP and who receives
methadone or buprenorphine.

On March 31, 2011, how many of these OTP
patients were…
Each category total should equal the number
reported in the TOTAL BOX in B2.
ENTER THE NUMBER OF PATIENTS IN EACH CATEGORY
(IF NONE, ENTER “0”)

GENDER
Male ..................................................................
Female..............................................................
Other, unknown or not collected ........................
GENDER TOTAL: (Should=B2)

QUESTION B1 REFERS ONLY TO NEW
PATIENTS ADMITTED TO THIS OTP IN 2010.
AGE

B1.

During the 2010 calendar year, how many new
patients were admitted to this OTP?
ENTER A NUMBER
(IF NONE, ENTER “0”)

Under 18 ...........................................................
18-34 ................................................................
35-54 ................................................................
55 and over.......................................................

2010 CALENDAR YEAR
TOTAL BOX

Unknown or not collected ..................................
AGE TOTAL: (Should=B2)

Questions B2 – B6 ask about ALL patients
in treatment at this OTP on March 31, 2011.

RACE & ETHNICITY
White, Non-Hispanic ..........................................
Black, Non-Hispanic ..........................................

B2.

On March 31, 2011, how many patients were
in treatment at this OTP?

Hispanic .............................................................
Asian..................................................................

ENTER A NUMBER
(IF NONE, ENTER “0”)

MARCH 31, 2011
TOTAL BOX

American Indian or Alaska Native ......................
Native Hawaiian or Other Pacific Islander .........
Two or more races .............................................
Unknown or not collected ..................................
RACE & ETHNICITY TOTAL: (Should=B2)

VETERAN STATUS
Veteran .............................................................
Non Veteran ......................................................
Unknown or not collected ..................................
VETERAN TOTAL: (Should=B2)

4

B4.

Of the patients in treatment on March 31, 2011,
how many had been in treatment continuously
at this OTP for…

B5c.

How many of the patients in B5 had been
receiving methadone for 2 years or more?
ENTER A NUMBER
(IF NONE, ENTER “0”)

ENTER THE NUMBER OF PATIENTS
(IF NONE, ENTER “0”)

0-90 days

_______

91-180 days

_______

181-365 days

_______

More than 1 year to less than
2 years

_______

2 years or longer

_______

TOTAL (Should = B2)

B5.

NUMBER RECEIVING
METHADONE FOR
2 YEARS OR MORE

B5d.

Of the patients in B5c, how many were receiving
take-home doses for the following number of
days…
ENTER THE NUMBER OF PATIENTS
(IF NONE, ENTER “0”)

NUMBER
OF DAYS

0 days (did not receive take-home doses)

_______

How many of the patients in treatment on
March 31, 2011 were dispensed methadone?

1-7 days

_______

8-14 days

_______



15-30 days

_______

NONE, DO NOT DISPENSE METHADONE
SKIP TO B6
ENTER A NUMBER
(IF NONE, ENTER “0”)

Total Receiving Methadone for 2 years or more
(Should = B5c)

NUMBER DISPENSED
METHADONE

B6.
B5a.

Of these patients, how many were receiving
methadone for…
ENTER THE NUMBER OF PATIENTS
(IF NONE, ENTER “0”)

Maintenance

_______

Detoxification

_______



NONE, DO NOT DISPENSE BUPRENORPHINE
SKIP TO B7
ENTER A NUMBER
(IF NONE, ENTER “0”)

Total Receiving Methadone

NUMBER DISPENSED
BUPRENORPHINE OR
BUPRENORPHINE/NALOXONE

(Should = B5)

B5b.

How many of the patients in treatment on
March 31, 2011 were receiving buprenorphine
(Subutex® or generic) or buprenorphine/
naloxone (Suboxone®)?

How many methadone maintenance patients in
B5a were receiving methadone doses of…

B6a.

Of these patients, how many were receiving
buprenorphine for…

ENTER THE NUMBER OF PATIENTS
(IF NONE, ENTER “0”)

Less than 40 mg.

_______

40 to 79 mg.

_______

80 to 119 mg.

_______

120 mg. or above

_______

Total Receiving Methadone

ENTER THE NUMBER OF PATIENTS
(IF NONE, ENTER “0”)

Maintenance

_______

Detoxification

_______

Total Receiving Buprenorphine
(Should = B6)

(Should = B5)

5

B6b.

How many buprenorphine maintenance patients in B6a were receiving buprenorphine doses of…
ENTER THE NUMBER OF PATIENTS
(IF NONE, ENTER “0”)

BUPRENORPHINE (SUBUTEX® OR GENERIC)

BUPRENORPHINE/NALOXONE
(SUBOXONE®)

Less than 8 mg.

__________

__________

8 to 16 mg.

__________

__________

17 to 24 mg.

__________

__________

25 to 32 mg.

__________

__________

More than 32 mg.

__________

__________

DOSAGE

TOTAL RECEIVING BUPRENORPHINE
(Should = B6)

B7.

Who was primarily responsible for completing this form?
Name:
Title:
Phone Number:

(_____) – ______ -

Fax Number:

(_____) – ______ -

Email Address:

B8.

PLEASE INDICATE ANY COMMENTS

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-OTP
P.O. Box 2393
Princeton, NJ 08543-2393
Public burden for this collection of information is estimated to average 50 minutes per response 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, Room 8-1099, 1 Choke Cherry Road, Rockville, MD 20857. 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
number for this project is xxxx-xxxx.

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MPR DOCUMENTATION:
N:\Shared-NJ1\Secretaries\Questionnaires (for Survey)\OTP\OTP Supplement Survey (12-10-10 lmb)-12.docx
(12-10-10)

12/10/2010 2:58 PM

Lynne revised for Matthew Anderson
Shading is Custom 198, 217, 241
OTP – 06667.825

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