Instr.1_R3_Baseline_Survey

[Survey programming instructions will be inserted here and throughout the survey. In addition, notes to the interviewer will be inserted here and appear throughout the survey. Information for programming or the interviewer are in blue italics. Section sub-headers that indicate specific scales (e.g., “Current Housing Situation” or “Depressive Symptoms”) should not be read or displayed on the survey visible to parents/caregivers.]

Welcome

[The survey will begin with a welcome to the participant that includes: brief reminders related to the voluntary nature of survey, the expected 45 minute length of the survey, and the gift card. This section will end with broad instructional information about the survey. The Privacy Act and PRA statements will be included, as below]

According to the Paperwork Reduction Act (PRA), 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 and expiration date for this collection are OMB #: XXXX-XXXX, Exp: XX/XX/XXXX.

This project is subject to the Privacy Act. Your participation is voluntary. Your data will be used solely for statistical research and evaluation. Your data may be shared with researchers involved in similar work and with federal agencies that may have additional data that can inform this study. The legal authority for this project is 42 U.S.C. § 1310a and Public Law 115-271. For System of Records Notice (SORN) information, please see the SORN number 09-80-0361, “OPRE Research and Evaluation Project Records.”

Verification

Before we begin, we would like to make sure we have your legal name and date of birth right in our records.

A1. What is your legal name?

First: _______________

Middle: _______________

Last: _______________

Interviewer: Does legal name match records?

1 Yes – ASK A2

2 No [SKIP TO TERMINATION SCRIPT]

A2. What is your date of birth?

Month (MM): ____

Day (DD): ____

Year (YYYY): ____

Interviewer: Does date of birth match records?

1 Yes - CONTINUE

2 No [SKIP TO TERMINATION SCRIPT]

TERMINATION SCRIPT

Thank you for taking the time to answer these questions. The information you provided does not match our records. I will investigate further to determine how to resolve this issue. If we are able to do so, we will contact you again. Have a nice a day – and thank you.

Thank you very much. Let’s begin the survey.

HOUSING/HOUSEHOLD COMPOSITION

[Section preamble:] People live in many kinds of housing. Sometimes for a short time (temporary) and sometimes for longer. We want to start the survey by asking a few questions about where you live now, where you’ve stayed in the past year, and who lives with you.

Current housing situation

HOUS-1. Which of the following best describes your current living situation? By “current living situation” we mean where you slept the majority of nights in the past week. [Interviewer: READ ALL CATEGORIES]]

**[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will only be able to select one option.]**	1= Yes
House or apartment you own or rent. This does not include your parent’s home or apartment
A friend, relative, or partner’s house or apartment and paying part or all of the rent. By partner, we mean a boyfriend, girlfriend, fiancé, or significant other.
A friend, relative, or partner’s house or apartment but not paying rent. By partner, we mean a boyfriend, girlfriend, fiancé, or significant other.
Permanent housing program, transitional housing program, or sober housing program
Emergency shelter or domestic violence shelter
Hotel or motel
Car or another vehicle, abandoned building, or anywhere outside
Somewhere else (Please specify: _____________________)
[Display only for interviewer, not to be read aloud] 99 = Prefer not to answer [refused]

Housing stability - housing mobility

HOUS-2. Now I’d like to ask you to think about the past year, that is since [DISPLAY MONTH, YEAR for ONE YEAR PRIOR TO INTERVIEW]. Think about all the different places you have lived or stayed during the past year. How many different places have you lived or stayed? Please include the place where you currently live or stay.

# of places: _________ [1-49]

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Housing stability – eviction

HOUS-3. During the past year have you been evicted or forced to move when you didn’t want to? Answer yes if you are in the middle of an eviction.

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will only be able to select one option.]

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Household composition

HOUS-4. How many adults, aged 18 and older, currently live with you?

Include everyone aged 18 and older who usually stays with you at least two nights a week, even if they are away from home right now.

# adults _________ [0-20]

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

ASK IF HOUS-4 =1-20

HOUS-4a. Does the count of [INSERT HOUS-4 VALUE] adults include you?

PROGRAMMING NOTE: If HOUS-4a=1 (YES), the response for HOUS-4 will be reduced by 1.

HOUS-5. How many children, under the age of 18, live with you? Please include your biological, adoptive, foster, step, or other children that spends at least two nights a week with you.

# children _________ [0-20]

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

ASK IF HOUS-5 = 1-20

HOUS-5a. How many children that live with you are you responsible for?

# children responsible for_________ [0-20]

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Marital and cohabitation status

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will only be able to select one option.]

HOUS-6. What is your current marital status? Are you… [select one]

1 Married

2 Divorced

3 Separated

4 Widowed

5 Never married

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

HOUS-7a. [IF MARRIED HOUS-6 = 1] Does your spouse currently live with you?

1 Yes

2 No

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

HOUS-7b. [ELSE HOUS-6 = 2,3,4,5,99] Do you have a partner who currently lives with you? By partner, we mean a boyfriend, girlfriend, fiancé, or significant other.

1 Yes

2 No

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

CASE ENGAGEMENT

[Section preamble:] The next set of questions are about your experiences and interactions with child welfare. When answering these questions, please think about your current or most recent experience with child welfare. In these questions, case means your most recent child welfare case, and caseworker means your child welfare caseworker. Remember that the information you share will be kept private and your name will never appear in reports.

Please tell me how much you agree or disagree with each of the following. [INSERT ATTRIBUTE]. Would you say you Strongly disagree, Disagree, Neither disagree nor agree, Agree or Strongly agree?

INTERVIEWER: Repeat the scale for the first three attributes and then as needed if the participant seems unsure

[Note: This scale will be programmed and presented in tabular format for survey administration. Each item will appear in a column on the left side of the table and the response options along the top row of the table. PROGRAMMING: Randomize the presentation of these questions.]

Item	1 = Strongly disagree	2 = Disagree	3 = Neither disagree nor agree	4 = Agree	5 = Strongly agree	[Display only for interviewer, not to be read aloud] 99 = Prefer not to answer [refused]
Engagement Subscale
CEE-1. My caseworker and I communicate well with one another.
CEE-2. I feel heard at the meetings about my case.
CEE-3. I feel confident advocating for myself and my children.
CEE-4. I feel hopeful about how my case will turn out.
Disaffection Subscale
CED-5. I don’t trust my caseworker.
CED-6. I am frustrated about my case.
CED-7. I feel excluded from deciding what is on my case plan.
CED-8. I am confused about what my caseworker expects from me.
CED-9. I am worried about how things will turn out for my family.
Motivation Subscale
CEM-10. I understand what I need to do to make progress on my case.
CEM-11. I feel like I can do what I need to do to make progress on my case.
CEM-12. I feel like the services I’m offered will help me.
CEM-13. Completing the things on my case plan will help me resolve my case.

ADULT WELL-BEING: MENTAL/EMOTIONAL HEALTH

[Section preamble:] Next, we ask about your health, life, and relationships. People have different thoughts, experiences, connections, and approaches to life.

Depressive symptoms

I’ll begin with some of the ways you may have felt or behaved. Please tell me how often you have felt this way during the past week. [INSERT ATTRIBUTE]. Would you say Rarely or none of the time (less than 1 day, Some or a little of the time (1-2 days), Occasionally or a moderate amount (3-4 days) or Most of the time (5-7 days)?

INTERVIEWER: Repeat the scale for the first three attributes and then as needed if the participant seems unsure

Item	1 = Rarely or none of the time, less than 1 day	2 = Some or a little of the time, 1-2 days	3 = Occasionally or a moderate amount of time, 3-4 days	4 = Most of the time, 5-7 days	[Display only for interviewer, not to be read aloud] 99 = Prefer not to answer [refused]
DEP-1. I was bothered by things that usually don’t bother me.
DEP-2. I had trouble keeping my mind on what I was doing.
DEP-3. I felt depressed.
DEP-4. I felt that everything I did was an effort.
DEP-5. I felt hopeful about the future.
DEP-6. I felt fearful.
DEP-7. My sleep was restless.
DEP-8. I was happy.
DEP-9. I felt lonely.
DEP-10. I could not ‘get going.’

Social support (PAPF – Social Connections subscale)

Next, I want to learn more about the people you have in your life. For each statement, tell me the answer that best describes you during the last couple of months. In responding, please keep 3 points in mind:

1. Please respond truthfully to each statement. There are no right or wrong answers – only your opinions.

2. Some statements may seem like others, but no two statements are exactly the same.

3. You are encouraged to respond to every statement.

[INSERT ATTRIBUTE]. Would you say NOT AT ALL LIKE me or what I believe, NOT MUCH LIKE me or what I believe, A LITTLE LIKE me or what I believe, LIKE me or what I believe or VERY MUCH LIKE me or what I believe?

INTERVIEWER: Repeat the scale for the first three attributes and then as needed if the participant seems unsure

Item	1 = NOT AT ALL LIKE me or what I believe	2 = NOT MUCH LIKE me or what I believe	3 = A LITTLE LIKE me or what I believe	4 = LIKE me or what I believe	5 = VERY MUCH LIKE me or what I believe	[Display only for interviewer, not to be read aloud:] 99 = Prefer not to answer [refused]
SS – 1. I have someone who will help me get through tough times.
SS -2. I have someone who helps me reset when I get upset.
SS – 3. I have someone who can help me reset if I get frustrated with my child(ren).
SS – 4. I have someone who will encourage me when I need it.
SS – 5. I have someone I can ask for help when I need it.
SS – 6. I have someone I trust who will give me feedback on my parenting.
SS – 7. I have someone who helps me feel good about myself.
SS – 8. I am comfortable asking for help from my family or people who are like family to me. [Interviewer: if state they do not have family or people who are like family, code as 1 = not at all like me]
SS – 9. I have someone to talk to about important things.

Parenting stress

For the following items please think about how your relationship with your [IF HOUSE-5 = 1 “child”, IF HOUSE-5 = 2+ OR PREFER NOT TO ANSWER“ children” typically is. Please tell me how much you agree or disagree with the following items.

INSERT ATTRIBUTE]. Would you say you Strongly disagree, Disagree, Neither disagree nor agree, Agree or Strongly agree?

INTERVIEWER: Repeat the scale for the first three attributes and then as needed if the participant seems unsure

[Note: This scale will be programmed and presented in tabular format for survey administration. Each item will appear in a column on the left side of the table and the response options along the top row of the table.] PROGRAMMER: IF HOUSE-5 = 1 READ IN “child”. IF HOUSE-5 = 2+ OR PREFER NOT TO ANSWER READ IN “children” for items with “child(ren)”,

Item	1 = Strongly Disagree	2 = Disagree	3 = Neither disagree nor agree	4 = Agree	5 = Strongly Agree	[Display only for interviewer, not to be read aloud] 99 = Prefer not to answer [Refused]
PS – 1. I am happy in my role as a parent.
PS – 2. There is little or nothing I wouldn’t do for my child(ren) if it was necessary.
PS – 3. Caring for my child(ren) sometimes takes more energy than I have to give.
PS – 4. I sometimes worry whether I am doing enough for my child(ren).
PS – 5. I feel close to my child(ren).
PS – 6. I enjoy spending time with my child(ren).
PS – 7. My child(ren) is an important source of affection for me.
PS – 8. Having child(ren) gives me a more certain and optimistic view of the future.
PS – 9. The major source of stress in my life is my child(ren).
PS – 10. Having child(ren) leaves little time and flexibility in my life.
PS – 11. Having child(ren) has been a financial burden.
PS – 12. It is difficult to balance different responsibilities because of my child(ren).
PS – 13. The behavior of my child(ren) is often embarrassing or stressful to me.
PS – 14. If I had to do it over again, I might decide not to have child(ren).
PS – 15. I feel overwhelmed by the responsibility of being a parent.
PS – 16. Having child(ren) has meant having too few choices and too little control over my life.
PS – 17. I am satisfied as a parent.
PS – 18. I find my child(ren) enjoyable.

Overall quality of life (QOL) and general health

Next, please rate your feelings based on your life in the last two weeks. I will read a rating scale for each question and you can let me know the best answer for you.

QoL – 1. How would you rate your quality of life?

1 Very poor

2 Poor

3 Neither poor nor good

4 Good

5 Very good

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

QoL – 2. How satisfied are you with your health?

1 Very dissatisfied

2 Dissatisfied

3 Neither dissatisfied nor satisfied

4 Satisfied

5 Very satisfied

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Resilience

Now I’d to ask you about how you deal with different types of situations. Please tell me how much you agree or disagree with the following.

[INSERT ATTRIBUTE]. Would you say you Strongly disagree, Disagree, Neither disagree nor agree, Agree or Strongly agree?

INTERVIEWER: Repeat the scale for the first three attributes and then as needed if the participant seems unsure.

Item	1 = Strongly Disagree	2 = Disagree	3 = Neither disagree nor agree	4 = Agree	5 = Strongly Agree	[Display only for interviewer, not to be read aloud] 99 = Prefer not to answer [Refused]
RESIL - 1. I tend to bounce back quickly after hard times.
RESIL – 2. I have a hard time making it through stressful events. [reverse coded, strongly disagree = 5]
RESIL – 3. It does not take me long to recover from a stressful event.
RESIL – 4. It is hard for me to snap back when something bad happens. [reverse coded, strongly disagree = 5]
RESIL – 5. I usually come through difficult times with little trouble.
RESIL – 6. I tend to take a long time to get over set-backs in my life. [reverse coded, strongly disagree = 5]

Protective factors-family functioning- concrete support

In responding to the following statements, please keep 3 points in mind:

1. Please respond truthfully to each statement. There are no right or wrong answers – only

your opinions.

2. Some statements may seem like others, but no two statements are exactly the same.

3. You are encouraged to respond to every statement.

For each statement please select the answer that best describes you during the last couple of months. [INSERT ATTRIBUTE]. Would you say NOT AT ALL LIKE me or what I believe, NOT MUCH LIKE me or what I believe, A LITTLE LIKE me or what I believe, LIKE me or what I believe or VERY MUCH LIKE me or what I believe?

INTERVIEWER: Repeat the scale for the first three attributes and then as needed if the participant seems unsure

	1 = NOT AT ALL LIKE me or what I believe	2 = NOT MUCH LIKE me or what I believe	3 = A LITTLE LIKE me or what I believe	4 = LIKE me or what I believe	5 = VERY MUCH LIKE me or what I believe	[Display only for interviewer, not to be read aloud] 99 = Prefer not to answer [Refused]
PF – 1. I don’t give up when I run into problems trying to get the services I need.
PF – 2. I make an effort to learn about the resources in my community that might be helpful for me.
PF – 3. When I cannot get help right away, I don’t give up until I get the help I need.
PF – 4. I know where to go if my child needs help.
PF – 5. I am willing to ask for help from community programs or agencies.
PF – 6. I know where I can get helpful information about parenting and taking care of children.
PF – 7. Asking for help for my child is easy for me to do.
PF – 8. I know where to get help if I have trouble taking care of emergencies.
PF – 9. I try to get help for myself when I need it.

Agency/ goals (“Hope”)

For the following statements please tell me the response that best describes how you think about yourself right now. Please take a few moments to focus on yourself and what is going on in your life at this moment. [INSERT ATTRIBUTE]. Would you say Definitely false, Mostly false, Some-what false, Slightly false, Slightly true, Some-what true, Mostly true or Definitely true?

INTERVIEWER: Repeat the scale for the first three attributes and then as needed if the participant seems unsure

	1 = Definitely false	2 = Mostly false	3 = Some-what false	4 = Slightly false	5 = Slightly true	6 = Some-what true	7 = Mostly true	8 = Definitely true	[Display only for interviewer, not to be read aloud] 99 = Prefer not to answer [Refused]
HOPE -1. If I should find myself in a jam, I could think of many ways to get out of it.
HOPE – 2. At the present time, I am energetically pursuing my goals.
HOPE – 3. There are lots of ways around any problem that I am facing now.
HOPE – 4. Right now, I see myself as being pretty successful.
HOPE – 5. I can think of many ways to reach my current goals.
HOPE – 6. At this time, I am meeting the goals that I have set for myself.

ADULT WELL-BEING: SUBSTANCE USE

The next questions are about substance use and recovery. There are many unique challenges when it comes to substance use, and people take many paths during their recovery journey. Remember that the information you share will be kept private and your name will never appear in reports.

Readiness for recovery “ladder”

[[For in-person or web administration the statements below will be shown alongside an image of a ladder, with the rungs corresponding to a statement].

SUDRR -1-ALC. I would like you to think of a ladder. Each rung of this ladder shows] where various people are in thinking about changing their ALCOHOL use. Select the number that best matches where you are now. [Select one.]

1 I do not have a problem with drinking, and I do not intend to change the way I use alcohol.

2 I might have a problem with drinking, but I have no plans to change the way I use alcohol.

3 I am thinking about changing the way I use alcohol, but I have not made any definite plans.

4 I have decided to change the way I use alcohol and am ready to make some plans.

5 I have taken steps to change the way I use alcohol and will never go back to the way I used before.

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

SUDRR-2-DRU. Once again, I would like you to think of a ladder. Each rung of this ladder shows where various people are in thinking about changing their DRUG use. Select the number that best matches where you are now. [Select one.]

1 I do not have a problem with drugs, and I do not intend to change the way I use drugs.

2 I might have a problem with drugs, but I have no plans to change the way I use drugs.

3 I am thinking about changing the way I use drugs, but I have not made any definite plans.

4 I have decided to change the way I use drugs and am ready to make some plans.

5 I have taken steps to change the way I use drugs and will never go back to the way I used before.

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Substance use- type/ frequency [alcohol]

The next questions ask about alcohol and drugs. These are questions about different experiences some people may have if they use drugs or alcohol. We are asking these questions of everyone in the study. Remember that the information you provide will be kept private and your name will never appear in reports.

SUDAL – 1. Have you ever used alcohol – Any use at all?

1 Yes

2 No [skip to next section on drugs – skip to SUDOTDA-A1]

99 Prefer not to answer [Refused] – skip to SUDOTDA-A1]

[if yes, SUDAL-1 = 1] SUDAL – 1.b. How many days in the past 30 days have you used alcohol – Any use at all?

# days ____ [ 0-30]

[Interviewer: If respondent says, “I don’t know”, please indicate that an estimate is fine. Please do your best to get an estimated number, if respondent truly doesn’t know can select “don’t know”]

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[if yes, SUDAL-1=1] SUDAL – 1.c. How many years in your life have you used alcohol – Any

use at all?

# years ____ [ 0 to 97]

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[if yes, SUDAL-1=1] SUDAL – 2. Have you ever used alcohol – To Intoxication?

1 Yes

2 No

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[if yes, SUDAL – 2 =1 ] SUDAL – 2.b. How many days in the past 30 days have you used alcohol – To Intoxication?

# days ____ [number 0-30]

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[if yes, SUDAL-2=1] SUDAL – 2.c. How many years in your life have you regularly used alcohol – To Intoxication?

# years ____ [0to 97]

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Substance use- alcohol[if yes, SUDAL-1 = 1] SUDALRA – 1. Do you sometimes take a drink in the morning when you first get up?

1 Yes

2 No

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[if yes, SUDAL-1 = 1] SUDALRA – 2. During the past 6 months, has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?

1 Yes

2 No

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[if yes, SUDAL-1 = 1] SUDALRA – 3. During the past 6 months, have you had a feeling of guilt or remorse after drinking?

1 Yes

2 No

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[if yes, SUDAL-1 = 1] SUDALRA – 4. During the past 6 months, have you failed to do what was normally expected of you because of drinking?

1 Yes

2 No

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Substance use- other drugs

In the next questions, we will ask you about drug use in the past 12 months. "Drug use" refers to (1) the use of prescribed or over‐the‐counter drugs in excess of the directions, or (2) any nonmedical use of drugs. This could include using various classes of drugs like cannabis such as marijuana, weed, pot, grass or hash, methamphetamines such as crystal meth or ice, inhalants such as nitrous oxide, glue, gas or paint thinner, sedatives or tranquilizers such as Valium, Serax, Ativan, Xanax, Librium, Rohypnol, or GHB, barbiturates, cocaine such as coke or crack, stimulants such as speed, Ritalin, Concerta, Dexedrine, Adderall, hallucinogens such as LSD, Psilocybin or mushrooms, PCP, Ketamine or Special K, ecstasy or X or opioids such as heroin.

Again, these questions ask about drug use. They do not ask about alcoholic beverages. Please answer No or Yes to every question. If you have difficulty with a statement, then choose the response that is mostly right.

SUDOTDA-A1. Have you ever used drugs other than those required for medical reasons?

1 Yes

2 No [skip to treatment Qs – SUDOT-6]

99 Prefer not to answer [Refused] [skip to treatment Qs – SUDOT-6]

[if SUDOTDA-A1=1] SUDOTDA-1. In the past 12 months, have you used drugs other than those required for medical reasons?

1 Yes

2 No [skip to treatment Qs – SUDOT-6]

Prefer not to answer [Refused] [skip to treatment Qs – SUDOT-6]

[if yes, SUDOTDA-1=1]SUDOTDA-2. In the past 12 months, have you used more than one drug at a time?

1 Yes

2 No

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[if yes, SUDOTDA-1=1]

SUDOTDA – 3. In the past 12 months, have you been able to stop using drugs when you want to?

1 Yes

2 No

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[if yes, SUDOTDA-1=1]

SUDOTDA– 4. In the past 12 months, have you had “blackouts” or “flashbacks” as a result of drug use?

1 Yes

2 No

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[if yes, SUDOTDA-1=1]

SUDOTDA – 5. Have you ever in the past 12 months felt bad or guilty about your drug use?

1 Yes

2 No

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[if yes, SUDOTDA-1=1]SUDOTDA – 6. Have your friends or relatives ever in the past 12 months complained about your involvement with drugs?

1 Yes

2 No

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[if yes, SUDOTDA-1=1]

SUDOTDA – 7. Have you ever in the past 12 months not spent time with your family or missed work because of drug use?

1 Yes

2 No

99 Prefer not to answer [Refused]

[if yes, SUDOTDA-1=1]

SUDOTDA – 8. In the past 12 months, have you engaged in illegal activities in order to obtain drugs?

1 Yes

2 No

99 Prefer not to answer [Refused]

[if yes, SUDOTDA-1=1]

SUDOTDA – 9. Have you ever in the past 12 months experienced withdrawal symptoms when you stopped taking drugs?

1 Yes

2 No

99 Prefer not to answer [Refused]

[if yes, SUDOTDA-1=1]

SUDOTDA – 10. In the past 12 months, have you had medical problems as a result of your drug use such as memory loss, hepatitis, convulsions, bleeding, overdose, etc.?

1 Yes

2 No

99 Prefer not to answer [Refused]

[if ever used drugs SUDOTDA-A1=1]

Substance use- type/ frequency [other drugs]

The next questions ask if you have used certain substances and how often. If you are not sure about the number of days or years, your best guess is fine.

	SUDOT – 1. Have you ever used…? 1 Yes 2 No 99 Prefer not to answer [Refused]	[if yes to ever used, ask after each substance before asking next substance] SUDOT – 2. How many days in the past 30 days have you used….? # days ____ [0 to 30] 98 Don’t Know 99 Prefer not to answer [Refused]	[if yes to ever used, ask after each substance before asking next substance] SUDOT – 3. How many years in your life have you regularly used....? # years ____ [0 to 97] 98 Don’t Know 99 Prefer not to answer [Refused]
a. Cannabis such as Marijuana, Weed, Pot, Grass or Hash
b. Fentanyl
c. Methadone, outside of methadone maintenance treatment
d. Other opioids/opiates/ painkillers not as prescribed for you by a doctor
e. Hallucinogens such as LSD, Psilocybin or mushrooms, PCP, Ketamine or Special K, X or ecstasy, MDMA or Molly
f. Barbiturates
g. Sedatives, hypnotics, or tranquilizers (Valium, Serax, Ativan, Xanax, Librium, Rohypnol or GHB)
h. Cocaine such as coke orcrack
i. Methamphetamines such as crystal meth or ice)
j. Stimulants such as speed, Ritalin or Adderall
k. Heroin
l. Inhalants such as nitrous oxide, glue, gas or paint thinner
m. More than one substance per day (including alcohol)
n. any other substance not already mentioned (specify) _________________

[If answered yes to ever used (SUDOT-1) for more than one above] SUDOT-4. What substance is the main issue? [select one] [display only substances said yes to ever used]

a. Cannabis such as Marijuana, Weed, Pot, Grass or Hash

b. Fentanyl

c. Methadone, outside of methadone maintenance treatment

d. Other opioids/opiates/ painkillers(not as prescribed for you by a doctor

e. Hallucinogens such as LSD, Psilocybin or mushrooms, PCP, Special K, ecstasy, MDMA or Molly

f. Barbiturates

g. Sedatives, hypnotics, or tranquilizers such as Valium, Serax, Ativan, Xanax, Librium, Rohypnol, or GHB)

h. Cocaine such as coke or crack

i. Methamphetamine such as crystal meth or ice

j. Stimulants such as speed, Ritalin or Adderall

k. Heroin

l. Inhalants such as nitrous oxide, glue, gas or paint thinner

m. More than one substance per day including alcohol

m. Other (specify) [display other specify from SUDOT-1]

98 Don’t know –

99 Prefer not to answer [Refused]

[If answered yes to ANY ever used (SUDOT-1) above]

SUDOT – 5. How long was your last period of voluntary abstinence from [display substance from SUDOT-4 IF ASKED, ELSE DISPLAY SINGLE SUBSTANCE FROM SUDOT-1], IF SUDOT-4 = 98 OR 99 INSERT “ANY DRUG”?

______Years (0-60)_______ months (1-12)

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Ask all

SUDOT – 6. Are you currently taking opioid medications for pain such as fentanyl, oxycodone including OxyContin and Percocet, hydrocodone including Vicodin, methadone and buprenorphine that have been prescribed for you by a doctor or dentist?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Ask all

Substance use – treatment engagement

The next questions are about treatment you may or may not have received for substance use. These questions are being asked of everyone, regardless of how you answered previous questions about substance use.

How many times in your life have you been treated for….

SUDTR – 1. Alcohol use?

# times ___________[0-97]?

98 Don’t Know

99 Prefer not to answer [Refused]

SUDTR – 2. Other substance use?

# times ___________ [0-97]?

98 Don’t Know

99 Prefer not to answer [Refused]

SUDTR – 3. Which of the following categories best describes how you define yourself now with respect to treatment services for alcohol and/or other substance use? Would you say that… [Select one]

1 You have not had an assessment for treatment and are not currently in treatment.

2 You had an assessment for treatment with recommendations to attend treatment and are not currently in treatment.

3 You currently are in treatment for use of alcohol or other substances.

4 You have completed treatment and are currently in recovery.

99 Prefer not to answer [Refused]

SUDTR – 4. Which of the following professionally assisted formal treatment services have you ever participated in? [Select all that apply]

1 Outpatient addiction treatment

2 Alcohol / drug detoxification services

3 Inpatient or residential treatment for alcohol and/or other substance use

4 None of the above [do not allow other items to be selected]99 Prefer not to answer [Refused]

SUDTR– 5. Which of the following recovery support services have you ever participated in? [Select all that apply]

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will be able to select multiple options.]

1 Mutual-help support groups such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Women for Sobriety, etc.)

2 Sober living environment such as a halfway house, Oxford house, sober dorm

3 Recovery high schools or college recovery programs/communities

4 Recovery community organization or center (RCO / RCC)

5 Faith-based recovery services such as an addiction recovery support group provided by a church, synagogue, mosque)

6 Online recovery communities such as Facebook groups, In The Rooms, etc.

7 Phone applications such as SoberGrid, CHESS, etc.

8 Peer recovery support (one-on-one peer recovery coach/specialist/navigator)

9 Wellbriety

10 Other (please specify) _____________

98 None of the above

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

SUDTR– 6. Have you been taking any of the following while in the care of a medical professional during the past 30 days? [Select all that apply.]

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will be able to select multiple options.]

1 Methadone

2 Buprenorphine including Subutex ® and Suboxone ®

3 Naltrexone including Vivitrol ®

4 Antabuse

6 Or something else (Please specify:__________)

97 None of the above

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

ECONOMIC CIRCUMSTANCES

People have different financial situations and circumstances. Some may experience challenges with making ends meet and receiving healthcare and some may not. The next questions ask about your experiences making ends meet and your access to healthcare.

Financial Strain

ECFS – 1. In general, how do your family's finances usually work out at the end of the month? Do you find that you usually end up with…?

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will only be able to select one option.]

Some money left over
Just enough money to make ends meet
Not enough money to make ends meet

98 Don’t know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Material hardship

[Food hardship]

ECMH – 1. In the past 12 months, did you receive free food or meals or vouchers to obtain food? This does not include nutritional cash assistance such as food stamps/SNAP or WIC.

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[Medical hardship]

ECMH – 2 . In the past 12 months, was there anyone in your household who needed to see a doctor or go to the hospital but couldn’t go because of the cost?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[Utility hardship]

ECMH – 3. In the past 12 months, were one or more of your utility services such as electric, water, gas or oil turned off?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

ECMH – 4. In the past 12 months, was service disconnected by the telephone, cell phone, or internet/cable company because payments were not made?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[Bill-paying hardship]

ECMH – 5. In the past 12 months, did you not pay the full amount of rent or mortgage payments because there was not enough money?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

ECMH – 6. In the past 12 months, did you not pay the full amount of a gas, oil or electricity bill because there was not enough money?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Public Assistance

ECPA – 1. During the past year, did you or anyone in your household receive income or assistance from any of the following sources? [Check all that apply]

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will be able to select more than one option. Checked = 1, Not Checked = 2]

Disability benefits from SSA (SSI or SSDI)
TANF or [state specific TANF name]
Unemployment insurance (UI)
Worker’s compensation
Short-term disability
Food stamps/SNAP/[state specific program]
WIC
HCV/Section 8/public housing
Veterans benefits
Medicaid or CHIP
None of the above 99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Health insurance

ECHI – 1. What type of health insurance do you currently have? (IF MORE THAN ONE ASK: What is the main type of health insurance?)

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will only be able to select one option.]

Medicaid [specify local names]
Private health insurance, including from the (Affordable Care Act) Exchange or Marketplace
Or some other kind (Please specify) ___________
None/uninsured

98. Don’t Know

99. Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Usual health care provider

ECHCP – 1. Is there a place you usually go when you are sick and need health care?

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will only be able to select one option.]

Yes
There is no place

98 Don’t know

99 Prefer not to answer [refused]

ECHP – 2. [IF YES]: What kind of place(s)? [select all that apply]

A doctor’s office or health center
Urgent care or clinic in a drug store or grocery store
Hospital emergency room
A VA Medical Center or VA outpatient clinic
Some other place
Does not go to one place most often

98 Don’t know

Prefer not to answer [Refused]

PERSONAL HISTORY/CIRCUMSTANCES

Many people face unique circumstances throughout life. Some may have had personal experiences or circumstances that can be painful. The next set of questions ask about some personal experiences that may be sensitive. Remember that the information you share will be kept private and your name will never appear in reports.

Intimate Partner Violence

PHDV – 1. Within the last year, have you been hit, slapped, kicked or otherwise physically hurt by your partner?

1 Yes

2 No

99 Prefer not to answer [Refused]

PHDV-2. Within the last year, have you hit, slapped, kicked or otherwise physically hurt your partner?

1 Yes

2 No

99 Prefer not to answer [Refused]

Experience as a child in child welfare system

PHCW - 1. During your first 18 years of life, were you ever in foster care?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused]

Experience as a child with substance use in the home

PHSU- 1. During your first 18 years of life did you live with anyone who was a problem drinker or alcoholic?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused]

PHSU- 2. During your first 18 years of life did you live with anyone who used illegal street drugs or who misused prescription medications?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused]

Justice System Involvement

PHJS-1. During your first 18 years of life was your parent or guardian ever incarcerated?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused]

PHJS-2. There are different ways of being involved in the criminal justice system. Have you ever had any of the following types of justice system involvement?

[Note: These response options will be programmed and presented in check box format for survey administration.]

	1= Yes	2 = No	[Display only for interviewer, not to be read aloud] 99 = Prefer not to answer [refused]
a. Arrested for a crime
b. Charged with a crime
c. Convicted of a crime
d. Been incarcerated (served time in a jail, prison, or correctional facility)
e. Been on parole or probation

Discrimination

[Note: These following questions and their two follow-up questions will be programmed and presented in a matrix for survey administration.]

In the following questions, we are interested in the way other people have treated you. Can you tell me if any of the following has ever happened to you:

PHDS - 1. At any time in your life, have you ever been unfairly fired?

1 Yes

2 No

99 Prefer not to answer [Refused]

[IF YES, ask the three follow-up questions below, PHDS-FU – 1 through PHDSFU -3, before proceeding]

PHDS - 2. For unfair reasons, have you ever not been hired for a job?

1 Yes

2 No

99 Prefer not to answer [Refused]

[IF YES, ask the three follow-up questions below, PHDS-FU – 1 through PHDSFU -3, before proceeding]

PHDS - 3. Have you ever been unfairly stopped, searched, questioned, physically threatened or abused by the police?

1 Yes

2 No99 Prefer not to answer [Refused]

[IF YES, ask the three follow-up questions below, PHDS-FU – 1 through PHDSFU -3, before proceeding]

PHDS - 4. Have you ever been unfairly discouraged by a teacher or advisor from continuing your education?

1 Yes

2 No

99 Prefer not to answer [Refused]

[IF YES, ask the three follow-up questions below, PHDS-FU – 1 through PHDSFU -3, before proceeding]

PHDS - 5. Have you ever been unfairly prevented from moving into a neighborhood because the landlord or a realtor refused to sell or rent you a house or apartment?

1 Yes

2 No

99 Prefer not to answer [Refused]

[IF YES, ask the three follow-up questions below, PHDS-FU – 1 through PHDSFU -3, before proceeding]

PHDS - 6. Do you receive poorer service than other people at restaurants or stores?

1 Yes

2 No

99 Prefer not to answer [Refused]

[IF YES, ask the three follow-up questions below, PHDS-FU – 1 through PHDSFU -3, before proceeding]

PHDS-FU-1. What do you think was the main reason for this experience? [Select one]

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will only be able to select one option.]

1 Your ancestry or National Origins

2 Your gender

3 Your race

4 Some other aspect of your physical appearance

5 Your sexual orientation

6 Your education or income level

7 Your justice system record

97 Other (please specify)_________

99 Prefer not to answer [Refused]

PHDS-FU-2. When was the last time this happened? [Select one]

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will only be able to select one option.]

1 Past week

2 Past month

3 Past year

4 More than a year ago

98 Don’t Know

99 Prefer not to answer [Refused]

PHDS-FU-3. How many times has this happened in your lifetime?

# ____ [1-89]

97 Too many times to count [presented as check box]

98 Don’t Know

99 Prefer not to answer [Refused]

DEMOGRAPHIC & BACKGROUND INFORMATION

Before we finish the survey, we’d like to ask you about how you identify yourself, your household composition, and your education. We all have many identifies that we walk through the world with that impact how we experience systems, institutions and life. We would like for you to share some information with us on a few of these.

Race and ethnicity

BKRE – 1. Are you Hispanic or Latino?

1 Yes, Hispanic or Latino

2 No, not Hispanic or Latino

99 Prefer not to answer [Refused]

BKRE -2. What is your race? Select all that apply.

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will be able to select many options.]

1 American Indian or Alaska Native

2 Asian

3 Black or African American

4 Native Hawaiian or Other Pacific Islander

5 White

99 Prefer not to answer [Refused]

Place of birth and language

BKL – 1. Do you speak a language other than English at home?

1 Yes

2 No

99 Prefer not to answer [Refused]

BKL – 2. Where were you born: [select one]

1 Inside the United States

2 Outside the United States (including US territories)

99 Prefer not to answer [Refused]

BKL – 3. [If born outside the US, BKL-2 = 2] When did you come to live in the United States?

Year: _________ 1925-CURRENT YEAR

9999 Prefer not to answer [Refused]

Sex and gender

BKSG - 1. What sex were you assigned at birth, on your original birth certificate? [select one]

1 Male

2 Female

99 Prefer not to answer [Refused]

BKSG – 2. What is your current gender? [Select all that apply]

1 Man

2 Woman

3 Two-Spirit [if respondent is American Indian or Alaska Native]

4 I use a different term _______

98 I don’t know

99 Prefer not to answer

BKSG – 3. Which of the following best represents how you think of yourself? [Select all that apply]

1 Straight, that is, not gay or lesbian

2 Gay or lesbian

3 Bisexual

4 Two-Spirit [if respondent is American Indian or Alaska Native]

5 I use a different term _________

98 I don’t know

99 Prefer not to answer

Education level

BKED - B.1 What is the highest degree or year of school that you have attained? [select one]

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will only be able to select one option.]

1 Less than a high school diploma

2 High school diploma or equivalent

3 Some college or technical training

4 Associate degree or other two-year degree

5 Bachelor degree or higher

99 Prefer not to answer [Refused]

Employment status

BKEM - C.1 Are you currently working for pay?

1 Yes

2 No

99 Prefer not to answer [Refused]

[If Yes to C.1] BKEM - C.2 Are you working 35 or more hours per week?

1 Yes

2 No

99 Prefer not to answer [Refused]

[If Yes to C.1] BKEM - C.3 How many jobs did you work last week?

# ________

99 Prefer not to answer [Refused]

BKEM - C.4 In total, how many months did you work for pay during the past year (including your current job)?

#___________ 0-12

99 Prefer not to answer [Refused]

BKEM - C.5 Are you currently looking for work?

1 Yes

2 No

99 Prefer not to answer [Refused]

CONTACT INFORMATION & IDENTIFIERS

Lastly, we’d like for you to share with us some contact information so that we know how to reach you for future surveys, and so we know where to send your [gift card/incentive] for your participation in today’s survey/interview.

Main phone number [cell] ___________ [required]

Permission to text Y/N

Home phone number ___________

Work phone number ___________

*Email address ____________ [required]

*Address [required]

Street		Apartment #
City	State	Zip Code

Alternative address (e.g., PO Box, or for sending gift card)

Street		Apartment #
City	State	Zip Code

Preferred contact method

Phone
Email
Text
Mail

We would also like for you to share the last four digits of your social security number. This will be used to confirm your identity for the follow-up survey and to match your information in administrative records.

Last 4 digits of SSN: ______________

If no SSN, other government identifier:

Decline to share

Finally, we’d like for you to share up to three contacts who will know how to get in touch with you in case we can’t reach you. We would call these friends or relatives only if we cannot reach you. We would tell them that we are a researcher at Abt Associates, that you provided them as someone who would know how to get in touch with them and ask them if they have any updated contact information. We would not share that you are participating in the study, any details about the services you are receiving, or anything else about you.

Friend or family contact #1

Name

Relationship

Cell phone number

Home phone number

Work phone number

Email address

Mailing address

Friend or family contact #2

Name

Relationship

Cell phone number

Home phone number

Work phone number

Email address

Mailing address

Friend or family contact #3

Name

Relationship

Cell phone number

Home phone number

Work phone number

Email address

Mailing address

Close/Thank you

[The survey will close with a thank you to the participant that includes reminders about the gift card and the next time point we will reach out.]

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Liz Yadav
File Modified	0000-00-00
File Created	2023-09-25

Instr.1_R3_Baseline_Survey

Replication of Recovery and Reunification Interventions forFamilies-Impact Study (R3-Impact)