UNIFORM FACILITY DATA SET (UFDS)

OCTOBER 1, 1999

DRUG AND ALCOHOL SERVICES INFORMATION SYSTEM (DASIS)

P T O A (Office Use Only)

I:\JimD files\UFDS Report\1999\99UFDS-PuertoRico-q6.wpd FINAL--2/3/00

Prepared by Mathematica Policy Research, Inc.

 U.S. Department of Health and Human Services

 Substance Abuse and Mental Health Services Administration

Is the information shown above complete and correct?

1 ~ Yes

2 ~ No L PLEASE CROSS OUT THE INCORRECT INFORMATION AND

ENTER THE CORRECT INFORMATION

PLEASE READ BEFORE TURNING THE PAGE!

Every facility should complete its own questionnaire. Complete this booklet for only the facility and location listed above.
Why is completing this questionnaire important?

Your participation makes a difference. The UFDS survey is the ONLY source of

data on ALL known substance abuse treatment programs in the nation. When

substance abuse policymakers and program managers need up-to-date national

information on characteristics of substance abuse treatment programs and the

numbers and types of clients served, they rely on the UFDS. UFDS data are used

to formulate the Nation’s annual drug control strategy and to make many other

important decisions regarding substance abuse policy.

This survey is sponsored by the Substance Abuse and Mental Health Services

Administration (SAMHSA), U.S. Department of Health and Human Services.

Instructions

1. If your facility is administratively linked to other facilities, please answer for

ONLY the facility printed on the cover.

C Return the completed questionnaire in the envelope provided.

If you have any questions or need additional blank forms, contact Barbara Holland

at:

MATHEMATICA POLICY RESEARCH, INC.

1-888-324-UFDS (8337)
1

1. Was this facility offering substance abuse services

on October 1, 1999? This could include treatment,

prevention, administrative, or other non-treatment

services.

1 ~ Yes ! SKIP TO Q.2

0 ~ No

1b. (If No) When did this facility stop offering

substance abuse services?

RECORD MONTH AND YEAR

Month Year

 SKIP TO

Q.23

-1 ~ Don’t know (PAGE 4)

0 ~ Never offered substance abuse

services

2. On October 1, 1999, which of the following

substance abuse services were being offered

by this facility:

MARK “YES” OR “NO” FOR EACH YES NO

a. Substance Abuse Prevention

(activities such as information

dissemination or education directed

at individuals not identified as

needing treatment) ............... 1 ~ 0 ~

b. Intake, Assessment, or Referral

Services for substance abuse

treatment ...................... 1 ~ 0 ~

c. Either Substance Abuse Treatment

or Detoxification (By treatment, we

mean services that focus on

initiating and maintaining an

individual’s recovery from substance

abuse and averting relapse) ......... 1 ~ 0 ~

d. Administrative Services such as billing,

personnel, and scheduling .......... 1 ~ 0 ~

2a. Did you check “yes” to “Substance Abuse

Treatment or Detoxification in Q.2c?

1 ~ Yes ! SKIP TO Q.3

0 ~ No

Does this facility operate a halfway house for

substance abuse clients at this location?

1 Yes ! SKIP TO Q.15 (PAGE 3)

0 No ! SKIP TO Q.23 (PAGE 4)

3. Does this facility offer a special program for

DUI/DWI or other drunk driver offenders?

1 ~ Yes

0 ~ No ! SKIP TO Q.5

4. (If Yes) Does this facility offer substance abuse

treatment services to clients other than DUI/DWI

clients?

1 ~ Yes

0 ~ No

5. Is this facility owned or operated by . . .

MARK ONE ONLY

1 ~ A private-for-profit organization,

Is this a solo practice, that is an office with a

single practitioner or therapist?

1 ~ Yes SKIP TO Q.6 (PAGE 2)

0 ~ No

2 ~ Private non-profit organization,

3 ~ State government, SKIP TO

4 ~ Local, county or community Q.6 (PAGE 2)

government,

5 ~ Tribal government, or

6 ~ Federal government?

5a. Which federal government agency?

MARK ONE ONLY

1 ~ Department of Veterans Affairs

2 ~ Department of Defense

3 ~ Bureau of Prisons

4 ~ Indian Health Service 

5 ~ Other (Specify:

)
2

6. Does this facility operate or participate in a

substance abuse hotline?

C A hotline is a telephone service that provides

information and referral and immediate counseling,

frequently in a crisis situation

C For the purpose of this study, 9-1-1 is not considered

a hotline

1 ~ Yes

0 ~ No ! SKIP TO Q.7

6a. (If Yes) Please enter this facility’s hotline

telephone number(s) below.

HOTLINE TELEPHONE NUMBER(S)

( )- 

( )- 

7. Does this facility operate a halfway house for

substance abuse clients at this location?

1 ~ Yes

0 ~ No

8. Is the primary focus of this facility to provide

substance abuse treatment services, mental

health services or something else?

MARK ONE ONLY

1 ~ Substance Abuse Treatment

Services ! SKIP TO Q.8b

2 ~ Mental Health Service ! SKIP TO Q.8b

3 ~ Something Else

8a. What is the primary focus of this facility?

 

 

 

 

8b. Is this facility located in, or operated by, a

hospital?

1 ~ Yes

0 ~ No ! SKIP TO Q.9

8c. (If Yes) What type of hospital is it . . .

MARK ONE ONLY

1 ~ General hospital

2 ~ Psychiatric hospital

3 ~ Other specialized hospital (such as alcoholism,

maternity, children’s, orthopedic)

9. Does this facility dispense methadone or LAAM at

this location?

MARK ONE ONLY

1 ~ Yes

0 ~ No

10. Does this facility offer treatment for alcohol abuse,

drug abuse or both?

MARK ONE ONLY

1 ~ Both alcohol and drug abuse

2 ~ Alcohol abuse only

3 ~ Drug abuse only

11. Some facilities have specially designed substance

abuse treatment programs or groups for particular

kinds of clients. Does this facility offer a specially

designed substance abuse treatment program or

group especially for . . .

MARK “YES” OR “NO” FOR EACH YES NO

a. Adolescents? .................. 1 ~ 0 ~

b. Dually-diagnosed clients (both

mental and substance abuse

disorders)? .................... 1 ~ 0 ~

c. Persons with HIV/AIDS? ........... 1 ~ 0 ~

d. Pregnant or postpartum women? ..... 1 ~ 0 ~

e. Other women’s groups? ........... 1 ~ 0 ~

f. Some other type of substance

abuse client? ................... 1 ~ 0 ~

(Specify: 

)
3

11a. Does this facility offer a specially designed

substance abuse treatment program or group for

criminal justice clients?

1 ~ Yes

0 ~ No ! SKIP TO Q.12

11b. (If Yes) Does this facility only treat persons who

are currently incarcerated in a prison, jail or

detention center?

1 ~ Yes

0 ~ No

12. On October 1, 1999 which of the following hospital

inpatient substance abuse services did this facility

offer?

MARK ONE ONLY

1 ~ Both detoxification and rehabilitation

2 ~ Detoxification only

3 ~ Rehabilitation only

0 ~ Neither

13. On October 1, 2000 which of the following nonhospital residential substance abuse services did

this facility offer?

MARK ONE ONLY

1 ~ Both detoxification and rehabilitation

2 ~ Detoxification only

3 ~ Rehabilitation only

0 ~ Neither

14. On October 1, 2000 which of the following

outpatient substance abuse treatment services

did this facility offer?

MARK ALL THAT APPLY

1 ~ Ambulatory detoxification

2 ~ Day treatment/partial hospitalization program

3 ~ Intensive outpatient treatment

What minimum number of hours per week

defines intensive outpatient treatment at

this facility? __________

4 ~ Any other outpatient treatment

0 ~ Neither

15. Which of the following types of payments are

accepted by this facility:

MARK “YES” OR “NO” FOR EACH YES NO

a. Cash or self-payment? ............ 1 ~ 0 ~

b. Medicare payments? ............. 1 ~ 0 ~

c. Medicaid payments? ............. 1 ~ 0 ~

d. State-administered health insurance

plan other than Medicaid? .......... 1 ~ 0 ~

e. Federal military insurance, such

as CHAMPUS, CHAMP-VA or

TRICARE? ..................... 1 ~ 0 ~

f. Private health insurance? .......... 1 ~ 0 ~

g. Indian Health Service programs? ..... 1 ~ 0 ~

16. Does this facility receive any other public funds

such as federal, state, county, or local government 

funds to subsidize substance abuse treatment

programs?

1 ~ Yes

0 ~ No

17. Does this facility offer fully subsidized or free care

to some or all of its clients?

1 ~ Some clients are fully subsidized

2 ~ All clients are fully subsidized

3 ~ No clients are fully subsidized

17b. Does this facility use a sliding fee scale?

1 ~ Yes

0 ~ No

18. On October 1, 1999, did this facility have

agreements or contracts with managed care

organizations for providing substance abuse

treatment services?

1 ~ Yes

0 ~ No
4

19. A variety of organizations accredit or certify

substance abuse facilities. Is this facility

accredited, certified, or otherwise approved

by any of the following . . .

MARK “YES” OR “NO” FOR EACH YES NO

a. Joint Commission of Accreditation

of Health Care Organizations or

J-C-A-H-O? .................... 1 ~ 0 ~

b. Commission on Accreditation of

Rehabilitation Facilities or CARF? .... 1 ~ 0 ~

c. National Committee on Quality

Assurance or N-C-Q-A? ........... 1 ~ 0 ~

19d. Is this facility licensed or certified by your state

substance abuse agency?

1 ~ Yes

0 ~ No

19e. Are any staff members at this facility licensed or

certified addiction counselors?

1 ~ Yes

0 ~ No

20. What telephone number(s) should a potential

client call to schedule an intake appointment?

INTAKE TELEPHONE NUMBERS

( )- 

( )- 

21. Does this facility have a Web site?

1 ~ Yes

0 ~ No ! SKIP TO Q.23

22. (If Yes) What is the home page address or URL?

RECORD BELOW

 

23. In case we have any questions, please provide the

following information about the person primarily

responsible for completing this form.

Name: 

Phone Number: (_______) - - 

FAX Number: (_______) - - 

OR ~ No FAX Number

E-mail Address: 

OR ~ No E-mail Address

24. Facilities participating in this survey that are

licensed or approved through their State

substance abuse agency will be listed in

SAMHSA's National Directory of Drug Abuse and

Alcoholism Treatment Programs. This Directory

will be available on SAMHSA's Internet Web site. 

The Internet address is www.samhsa.gov/oas. 

Currently, you can view the 1998 National

Directory at this same Internet address. Would you

also like to receive a paper copy of the 1999

Directory when it is published?

1 ~ Yes

0 ~ No

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, INC.

ATTN: Barbara Holland

P.O. Box 2393

Princeton, NJ 08543-2393
NOTES