Form Augmentation Scree Augmentation Scree Augmentation Screener Questionnaire

Attachment A3- Augmentation screener questionnaire
U.S. Department of Health and Human Services

OMB No: xxxx-xxxx
APPROVAL EXPIRES: xx/xx/xxxx
See OMB burden statement on last page

2019 BEHAVIORAL HEALTH SCREENER
Hello, I am calling on behalf of SAMHSA, the Substance Abuse and Mental Health Services Administration. SAMHSA is
currently updating their database of behavioral health treatment facilities. I would like to ask you a few questions about
your facility to assist us with this update.
A1.

First, I’d like to confirm that this is [FACILITY NAME], located at [LOCATION ADDRESS] and [PHONE
NUMBER]. Is that correct?
IF RESPONDENT IS CLEARLY NOT AT A FACILITY OFFERING MENTAL HEALTH OR
SUBSTANCE ABUSE SERVICES (e.g., Joe’s Pizza or Collision Insurance),
CHECK THIS BOX
1
0

A2.

□
□

□ SKIP TO LOCATING (PAGE 6)

YES, NAME ADDRESS AND PHONE CORRECT

SKIP TO A3 (NEXT PAGE)

NO, NAME ADDRESS AND/OR PHONE INCORRECT

RECORD CORRECT INFORMATION BELOW:
NAME:
STREET :
CITY/TOWN: __________________________________

STATE : __________ ZIP: ________________

PHONE:
A2a.

INTERVIEWER: DID THE ADDRESS CHANGE?
1
0
2

A2b.

□
□
□

YES
NO
THE LOCATION ADDRESS HAS BEEN
EDITED BUT IT IS THE SAME ADDRESS

SKIP TO A2d (NEXT PAGE)

Is there another mental health treatment or substance abuse treatment facility in your organization that is
currently located at [LOCATION ADDRESS]?
1
0
2
d
r

□
□
□
□
□

YES

SKIP TO A2b.1 (NEXT PAGE)

NO

SKIP TO A2d (NEXT PAGE)

NO MH/SA
DON’T KNOW
REFUSED

SKIP TO END (PAGE 6)
SKIP TO A2b.1 (NEXT PAGE)

Page 1 of 7

Attachment A3- Augmentation screener questionnaire
A2b.1. INTERVIEWER: COLLECT NEW FACILITY INFORMATION WHILE RESPONDENT IS ON THE PHONE.
IF A2b = 1 CONTINUE TO A2c. IF A2b = d OR r SKIP TO END.
A2c.

We need to collect information about [LOCATION ADDRESS]. Could you give me the TELEPHONE
number for that location?
INTERVIEWER: IF A NEW NUMBER IS RECORDED SAY:
(_______) - ___________ - ___________
“Thank you for your time.”
Area Code
DIAL NEW PHONE NUMBER AND BEGIN WITH A1.
d

A2d.

0
2
3

0

□
□
□
□

YES
NO
MISSPELLED

SKIP TO A3 (BELOW)

ABBREVIATION IN NAME

□
□

YES
NO

SKIP TO LOCATING (PAGE 6)

Did this name change result in a new license number for this facility?
1
0

A3.

SKIP TO LOCATING (PAGE 6)

Was this facility ever called [FACILITY NAME]?
1

A2f.

DON’T KNOW

INTERVIEWER: DID THE FACILITY NAME CHANGE?
1

A2e.

□

□
□

YES
NO

INTERVIEWER:

COLLECT NEW FACILITY INFORMATION WHILE RESPONDENT
IS ON THE PHONE, THEN CONTINUE TO A3.

Does this facility, at this location, provide mental health treatment, that is, interventions that treat a
person’s mental health problem or condition, reduce symptoms, and improve functioning?
INTERVIEWER: PROBE IF NECESSARY: “Please include treatments such as therapy and psychotropic
medication as providing mental health treatment.”
1
0
2

A3a.

□
□
□

YES

SKIP TO A4 (NEXT PAGE)

NO
RESPONDENT INDICATES THAT THEY ALREADY
COMPLETED THIS PAST YEAR’S MENTAL HEALTH SURVEY

SKIP TO A6 (PAGE 4)

Does this facility provide only administrative services for a mental health treatment facility?
INTERVIEWER: PROBE IF NECESSARY: “Administrative services include services related to the
provision of administrative and operational functions (e.g., workforce/staff management, financial/billing
management) of a mental health treatment facility or facilities. Administrative services do not include the
direct provision of mental health treatment.”
1
0

□
□

YES
NO

SKIP TO A5b (PAGE 4)

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Attachment A3- Augmentation screener questionnaire
A4.

Does this facility, at this location, provide any of the following services:
MARK ALL THAT APPLY
1
2
3
4
5
6

□
□
□
□
□
□

Assisted living or nursing home care
Supported housing
Group homes
Clubhouse services
Emergency shelter such as homeless, domestic violence, etc.
Care for only individuals with a developmental disability

INTERVIEWER: PROBE IF NECESSARY: “That is, significant limitations in intellectual functioning.”

A4a.

7

□

8

□

Care at only a jail, prison, or detention center that
provides treatment exclusively for incarcerated persons
or juvenile detainees
None of these services

SKIP TO A5 (NEXT PAGE)

For this facility at this location, that is, [FILL LOCATION ADDRESS], what is the main focus? Is it…
INTERVIEWER: OF THE CATEGORIES BELOW, FOR A4a.1 THROUGH A4a.7, ONLY LIST THE
CATEGORIES THE RESPONDENT SELECTED IN A4; AND, END WITH A4a.8 AND A4a.9.
MARK ONE ONLY

1. Assisted living or nursing home care ..............................................

1

2. Supported housing ......................................................................

2

3. Group homes ..............................................................................

3

4. Clubhouse services .....................................................................

4

5. Emergency shelter such as homeless, domestic violence, etc. ...........

5

6. Care for only individuals with a developmental disability ....................

6

7. Care at only a jail, prison, or detention center that provides treatment
exclusively for incarcerated persons or juvenile detainees .................

7

8. Mental health treatment................................................................

8

9. Or, some other focus ...................................................................
INTERVIEWER: If selected, ask: “What is this facility’s main focus?”
______________________________________________________
A4b.

9

□
□
□
□
□
□
□
□
□

INTERVIEWER: DID THIS FACILITY ANSWER ANY CATEGORY IN A4a BETWEEN A4a.1 THROUGH
A4a.7?
1
0

□
□

YES

SKIP TO A5b (NEXT PAGE)

NO

SKIP TO A5 (NEXT PAGE)

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Attachment A3- Augmentation screener questionnaire
A5.

Is this facility an office with only one independent practitioner or a small group of practitioners?
1
0

A5a.

□
□

YES
NO

SKIP TO A5b (BELOW)

Is this facility licensed or accredited as a mental health clinic or mental health center?
 Do not count the licenses or credentials of individual practitioners.
1
0

A5b.

0

NO

□
□

YES (THIS FACILITY IS ELIGIBLE FOR THE MH SURVEY)
NO (THIS FACILITY IS NOT ELIGIBLE FOR THE MH SURVEY)

Does this facility, that is, the facility located at [LOCATION ADDRESS], have a licensed, certified or
accredited substance abuse treatment program or unit at this address?
1
0
2

A7.

YES

INTERVIEWER: DID THIS FACILITY ANSWER [A3a AS “YES;”] OR [(ANSWER A4 AS “8” OR A4b AS
“NO;”) AND (ANSWER A5 AS “NO” OR A5a AS “YES?”)] PLEASE USE SHADED BOXES
FOR REFERENCE.
1

A6.

□
□

□
□
□

YES
NO

SKIP TO A9 (BELOW)

RESPONDENT INDICATES THAT THEY ALREADY COMPLETED THIS PAST YEAR’S
SUBSTANCE ABUSE SURVEY
SKIP TO A16 (NEXT PAGE)

Which of the following substance abuse services are offered by this facility, at this location?
PROBE IF NECESSARY: Please report for only this location.
MARK “YES” OR
“NO” FOR EACH
YES

A8.

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

1

2. Detoxification..............................................................................

1

□
□

3. Substance abuse treatment, that is, services that focus on initiating
and maintaining an individual’s recovery from substance abuse and on
averting relapse...........................................................................

1

□

0

□
□

0

□

0

Is this facility a solo practice, meaning, an office with only one independent practitioner or counselor?
1
0

A9.

NO

□
□

YES
NO

Does this facility operate transitional housing or a halfway house for substance abuse clients at this
location?
1
0

□
□

YES
NO

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Attachment A3- Augmentation screener questionnaire
A10.

INTERVIEWER: DID THIS FACILITY ANSWER YES TO EITHER A7.2, A7.3, OR A9 ABOVE? PLEASE USE
THE SHADED BOXES FOR REFERENCE.
1
0

A11.

□
□

YES
NO

SKIP TO A16 (BELOW)

Is [LOCATION ADDRESS] also the mailing address for this substance abuse treatment facility?
1
0

□
□

YES

SKIP TO A12 (BELOW)

NO

A11a. What is the mailing address for [FACILITY NAME] located at [LOCATION ADDRESS]?
NAME:
STREET :
CITY/TOWN: __________________________________
A12.

STATE : __________ ZIP: ________________

Does [FACILITY NAME] have a FAX number?
1

□

YES

A12a. What is that FAX number? (_______) - ___________ -___________
Area Code

0

□

NO

A13.

ASK IF NEEDED, OTHERWISE, VERIFY AND RECORD WITHOUT ASKING: Who is the director of
substance abuse programs at [FACILITY]? (RECORD BELOW)

A14.

Does [DIRECTOR NAME] or the person in charge of substance abuse programs at this facility have an
EMAIL address?
1
0

A15.

□
□

YES
NO

A14a. What is that EMAIL address?
A14b. Name of Contact Person (if not Director)

Does this facility have a website or web page with information about the facility’s substance abuse
treatment programs?
1
0

□
□

YES
NO

SKIP TO A16 (BELOW)

A15a. What is this facility’s website address?
RECORD:
A16.

INTERVIEWER: DOES THIS FACILITY PROVIDE MENTAL HEALTH TREATMENT SERVICES (A5b = 1)?
1
0

□
□

YES
NO

SKIP TO A17 (NEXT PAGE)
SKIP TO END (NEXT PAGE)

Page 5 of 7

Attachment A3- Augmentation screener questionnaire

A17.

Is [LOCATION ADDRESS] also the mailing address for this mental health treatment facility?
1
0
2

□
□
□

YES

SKIP TO A18 (BELOW)

NO
Same as Substance Abuse Mailing Address

SKIP TO A18 (BELOW)

A17a. What is the mailing address for the mental health facility located at [LOCATION ADDRESS]?
NAME:
STREET :
CITY/TOWN:
A18.

_________________________________

STATE : __________ ZIP: ________________

Does [FACILITY NAME] have a FAX number?
1

0
2

□
□
□

YES

A18a. What is that FAX number? (_______) - ___________ -___________
Area Code

NO
Same as Substance Abuse Fax Number

A19.

ASK IF NEEDED, OTHERWISE, VERIFY AND RECORD WITHOUT ASKING: Who is the director of mental
health programs at [FACILITY]? (RECORD BELOW)

A20.

Does [DIRECTOR NAME] or the person in charge of mental health programs at this facility have an EMAIL
address?
A20a. What is that EMAIL address?
1 □ YES
A20b. Name of Contact Person (if not Director)

0
2

A21.

□
□

NO
Same as Substance Abuse Director’s Email Address

Does this facility have a website or web page with information about the facility’s mental health
treatment program(s)?
1
0
2

□
□
□

YES
NO
Same as Substance Abuse Web Site

SKIP TO END (BELOW)

A21a. What is this facility’s website address?
RECORD:

LOCATING:

Thank you very much for your time.

INTERVIEWER:
END:

IF A2f IS “YES,” OR A4a.9 IS VALUED, SEND THE CASE TO SUPERVISOR REVIEW.

Those are all the questions I have. Thank you very much for your time.

Page 6 of 7

Attachment A3- Augmentation screener questionnaire
Pledge to Respondents
The information you provide will be protected to the fullest extent allowable under Section 501(n) of the Public Health
Service Act (42 USC 290aa(n)). This law permits the public release of identifiable information about an establishment
only with the consent of that establishment and limits the use of the information to the purposes for which it was supplied.
This information will be used to determine eligibility for inclusion in SAMHSA’s online Behavioral Health Treatment
Services Locator and other publically available listings.
NOTES:

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays
a currently valid OMB control number. The OMB control number for this project is xxxx-xxxx. Public reporting burden for this collection of information
is estimated to average 5 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer , 5600 Fishers Lane, Room
15E57-B, Rockville, Maryland 20857.

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