UNIFORM FACILITY DATA SET (UFDS)

OCTOBER 1, 1998

DRUG AND ALCOHOL SERVICES INFORMATION SYSTEM (DASIS)

P T O A (Office Use Only)

 U.S. Department of Health and Human Services FORM APPROVED:

 Substance Abuse and Mental Health Services Administration

OMB No: 0930-0106

APPROVAL EXPIRES: 8/31/99

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!

It is now possible for every facility to complete at least some portion of the questionnaire--even

if an administrative unit or parent facility has answered for you in the past. Begin at Q1 and

follow the instructions.
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 and prevention programs in the

nation. When substance abuse policy makers and program managers need upto-date national information on characteristics of substance abuse 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

C The reference date for UFDS is October 1, 1998.

C Return the completed questionnaire in the envelope provided.

If you have any questions concerning this questionnaire, or if you need 

additional blank forms, contact:

MATHEMATICA POLICY RESEARCH, INC.

1-888-324-UFDS (8337)

Public burden for this collection of information is estimated to average 50 minutes per response for treatment providers and 3 minutes per response for nontreatment providers (e.g.,

prevention and education), 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 16-105, Parklawn Building, 5600 Fishers Lane, 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 0930-0106.
1

1. On October 1, 1998, which of the following

substance abuse services were provided by

this facility, that is, the facility named on the

front cover?

Please report for only this location

MARK “YES” OR “NO” FOR EACH YES NO

a. Substance Abuse Treatment

(services that focus on initiating

and maintaining an individual’s

recovery from substance abuse

and on averting relapse) ........ . 1 ~ 2 ~

b. Detoxification Services ........ . 1 ~ 2 ~

c. Substance Abuse Prevention

(prevention activities directed at

individuals not identified to be in

need of treatment, such as

information dissemination or

education) ................... . 1 ~ 2 ~

d. Other Substance Abuse Services

(such as intake, assessment, and

referral) ..................... . 1 ~ 2 ~

e. Administrative Services

(such as billing, personnel, and

scheduling) .................. . 1 ~ 2 ~

1a. Did you answer “yes” to any of the services above?

1 ~ Yes ˆ SKIP TO Q2

2 ~ No

1b. When did this facility stop providing substance

abuse services? RECORD MONTH AND YEAR

MONTH:

YEAR: 19

SKIP TO Q38,

-1 ~ Don't know PAGE 10

0 ~ Never provided substance

abuse services

2. Who owns this facility?

MARK ONE ONLY

1 ~ A private-for-profit organization

2 ~ A private non-profit organization

3 ~ State government SKIP TO

4 ~ Local, county or community Q3

government

5 ~ Tribal government

6 ~ Federal government

2a. 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:

_____________________________________)

3. Does this facility operate or participate in a hotline

that provides substance abuse counseling and

referral services?

911 is not considered a hotline

1 ~ Yes

2 ~ No ˆ SKIP TO Q4

3a. Please enter the facility’s hotline telephone

number(s) below.

HOTLINE TELEPHONE NUMBER(S)

(_______)-____________________

(_______)-____________________

4. Did you check “yes” to either “Substance Abuse

Treatment” or “Detoxification Services” in Q1?

1 ~ Yes

2 ~ No ˆ SKIP TO Q38, PAGE 10
2

HOSPITAL SETTING (may include an outpatient 

substance abuse unit on site)

SPECIALTY SUBSTANCE ABUSE TREATMENTSETTINGS

OTHER SETTINGS

5. Which setting (or settings) BEST describes this

substance abuse treatment facility?

C Please report for only the facility named on the front

cover

1 ~ General hospital

2 ~ Psychiatric hospital

3 ~ Other specialized hospital (for example,

alcoholism, maternity, children’s, orthopedic)

4 ~ OUTPATIENT facility specializing in substance

abuse treatment

5 ~ Halfway House

6 ~ RESIDENTIAL (non-hospital) substance abuse

treatment facility

Does this residential facility include a Therapeutic

Community (TC)? A TC is a specific treatment

approach used by some residential facilities.

1 ~ Yes

2 ~ No

7 ~ Community MENTAL health center or other

mental health facility that provides a variety

of services

8 ~ Community Health Center, including Migrant

Health Center, Urban Indian Program, Health

Care for the Homeless Center

9 ~ School (elementary, secondary, college/university)

10 ~ Community or religious organization/agency

that provides a variety of social services

11 ~ Jail, prison or juvenile detention center

12 ~ Other criminal justice (TASC, pretrial diversion,

court referral, probation, parole, community

corrections, drug courts)

13 ~ Private practice—Group

14 ~ Private practice—Solo

15 ~ Other setting (specify type: ) 

6. Is this facility owned or operated by a managed

care organization (for example, an HMO)?

1 ~ Yes ˆ SKIP TO Q7, PAGE 3

2 ~ No

6a. On October 1, 1998, did this facility have letters

of agreement or contracts with managed care

organizations for providing substance abuse

treatment services?

1 ~ Yes, had formal written agreements or

contracts with managed care organizations

2 ~ No formal written agreements or

contracts with managed care

organizations GO TO Q7,

PAGE 3 

-1 ~ Don’t know

6b. With how many managed care organizations did

you have formal written agreements or contracts?

NUMBER:
3

7. As of October 1, 1998, which of these services were being provided at this facility?

MARK ALL THAT APPLY

Assessment Services

 1 ~ Comprehensive substance abuse

assessment/diagnosis

 2 ~ Comprehensive mental health assessment/

diagnosis (for example, psychological/

psychiatric evaluation and testing)

 3 ~ Other (Specify: )

Therapy

 4 ~ Family counseling

 5 ~ Group therapy, not including relapse prevention

 6 ~ Individual therapy

 7 ~ Pharmacotherapies/prescription medication

 8 ~ Relapse prevention groups

 9 ~ Other (Specify: )

Testing (Include testing service even if specimen is

sent to outside source for chemical analysis)

10 ~ Blood alcohol testing (including breathalyzer)

11 ~ Drug/alcohol urine screening

12 ~ Hair analysis

13 ~ Hepatitis testing

14 ~ HIV testing

15 ~ STD testing

16 ~ TB screening

17 ~ Other (Specify: )

Health Services

18 ~ Family planning

19 ~ Medical care (including physical exams)

20 ~ Prenatal care

21 ~ Perinatal care

22 ~ TB treatment

23 ~ Health education (for example, nutrition,

contagious diseases, STD other than HIV/AIDS)

24 ~ HIV/AIDS education/counseling/support

25 ~ Smoking cessation

26 ~ Other (Specify: )

Continuing Care

27 ~ Aftercare counseling

28 ~ Alumni(ae) groups

29 ~ Other (Specify: )

Special Programs for Target Populations

30 ~ Adolescents

31 ~ Dually-diagnosed (mental and substance

abuse disorders)

32 ~ Persons with HIV/AIDS

33 ~ Pregnant/Postpartum women

61 ~ Other women’s groups

34 ~ Other (Specify: )

Transitional Services

35 ~ Assistance with obtaining Social Services

(i.e., Medicaid, WIC, SSI, SSDI)

36 ~ Discharge planning

37 ~ Employment counseling/training

38 ~ Housing assistance

39 ~ Referral to other services

40 ~ Other (Specify: )

Community Outreach

41 ~ Drug and alcohol education

42 ~ Outreach/early intervention

43 ~ Media presentations (T.V., radio, brochures)

44 ~ Membership in a community partnership

program

45 ~ Other (Specify: )

Other Services

46 ~ Academic education/GED classes

47 ~ Acupuncture

48 ~ Case management services

49 ~ Child care

50 ~ Communication skills

52 ~ Domestic violence--family/partner violence

services (physical, sexual and emotional abuse)

53 ~ Home visits

54 ~ Life skills for independent living

55 ~ Outcome follow-up (post-discharge)

56 ~ Parenting/family skills development

57 ~ Self-help groups, including 12-step programs

58 ~ Socialization/recreational services (for example,

scheduled activities such as camping, sporting

events)

59 ~ Transportation assistance to treatment

60 ~ Other (Specify: )
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8. On October 1, 1998, which of the following types

of substance abuse treatment were offered at this

facility?

MARK “YES” OR “NO” FOR EACH YES NO

a. Outpatient detoxification ........ . 1 ~ 2 ~

b. Intensive outpatient treatment .... . 1 ~ 2 ~

c. All other outpatient treatment .... . 1 ~ 2 ~

d. Hospital inpatient detoxification ... . 1 ~ 2 ~

e. Hospital inpatient rehabilitation ... . 1 ~ 2 ~

f. Non-hospital residential 

(24 hour care) detoxification ..... . 1 ~ 2 ~

g. Non-hospital residential

(24 hour care) rehabilitation ..... . 1 ~ 2 ~

9. On October 1, 1998, was this facility part of a

network of administratively-linked facilities that

provide substance abuse treatment?

1 ~ Yes

2 ~ No ˆ SKIP TO Q12

10. The next questions ask about the number of clients

treated at this facility on October 1, 1998. Which

statement below best describes your ability to

provide client count data for the facility named on

the front cover?

MARK ONE ONLY

1 ~ Can only provide client counts

that combine this facility with others ˆ GO TO Q11

2 ~ Can provide separate client counts

for this facility ˆ SKIP TO Q12

3 ~ Cannot provide any client counts for 

this facility; clients counts are only

available from another facility in the 

network ˆ RECORD NAME AND PHONE

NUMBER OF PERSON TO

CONTACT FOR CLIENT COUNTS

Name:

 

 SKIP TO

Phone: Q38,

 PAGE 10

 

11. How many facilities are included in the client data

you will be reporting?

NUMBER OF FACILITIES:

PLEASE MARKTHE FACILITIES COUNTED IN Q11ON THEYELLOW

NETWORK FACILITY SHEET INCLUDED IN YOUR QUESTIONNAIRE

PACKET. THEN RETURN TO Q12 AND ANSWER THE REST OF

THE QUESTIONNAIRE FOR THAT GROUP OF FACILITIES.

IF YOU DID NOT RECEIVE THE YELLOW NETWORK FACILITY

SHEET, CALL THEUFDS HOTLINE AT 1-888-324-UFDS(8337).

ONE WILL BE FAXED TO YOU IMMEDIATELY. UPON RECEIPT OF

THE FORM, FOLLOW THE INSTRUCTIONS ABOVE.

12. 12 Month Unduplicated Client Count. In the

12 months between October 1, 1997 and

September 30, 1998, (or the most recent 12-month

period for which data are available), how many

individual clients received substance abuse

treatment at this facility?

C Count all clients who received any treatment during

the 12-month period, even if their treatment began

before that time

C Count each client only once

NUMBER:

13. 12 Month Admissions. During the 12 months

between October 1, 1997 and September 30, 1998

(or the most recent 12-month period for which

data are available), how many admissions for

substance abuse treatment were there at this

facility?

C If a client was admitted more than once during this

12-month period, count each time that person was

admitted. For example, if the same person was

admitted three times during the year, count this as

three admissions

C Moving to a different level of care also counts as an

admission

NUMBER:
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14. Were outpatient substance abuse treatment

services offered on October 1, 1998? (See Q8,

PAGE 4)

1 ~ Yes ˆ GO TO Q15 BELOW

2 ~ No ˆ SKIP TO Q18, PAGE 6

15. In the 30 days between September 1 and October 1,

1998, how many clients at this facility received the

following outpatient substance abuse treatment

services . . .

C Only count those still enrolled on October 1, 1998

C For each category with no clients, enter zero, “0”.

NUMBER

a. Outpatient detoxification . .

b. Intensive outpatient care (Include

persons who received services

for 2 or more hours per day

on 3 or more days per

week) .................

c. Other outpatient care

(excluding intensive) .....

d. TOTAL OUTPATIENTS

(add a, b, & c)

(Q15d) 

(IF Q15d EQUALS ZERO: SKIP TO Q18, PAGE 6)

16. On October 1, 1998, how many of the TOTAL

OUTPATIENTS reported in Q15d were receiving

methadone or LAAM at this location?

~ THIS FACILITY DOES NOT DISPENSE METHADONE OR

LAAM ! GO TO Q17

NUMBER

a. Methadone clients at

this location .............

b. LAAM clients at this

location ................

17. How many of the total outpatients in Q15d were in

each of the following gender, race/ethnicity, and

age categories?

C For each category with no clients, enter zero, “0”.

17a. GENDER

a. Male ........................

b. Female .....................

c. Don’t know ...................

TOTAL OUTPATIENTS (add a-c) ...

[Should equal the number in Q15d, if not please reconcile.]

17b. RACE/ETHNICITY

a. White .......................

b. Black or African American .......

c. Hispanic .....................

d. Asian or Pacific Islander ........

e. American Indian or Alaska Native.

f. Other .......................

g. Don’t know ...................

TOTAL OUTPATIENTS (add a-g) ...

[Should equal the number in Q15d, if not please reconcile.]

17c. AGE

a. Under 18 years ..............

b. 18-20 .....................

c. 21-24 .....................

d. 25-34 .....................

e. 35-44 .....................

f. 45-64 .....................

g. 65 and over .................

h. Don’t know .................

TOTAL OUTPATIENTS (add a-h) ...

[Should equal the number in Q15d, if not please reconcile.]
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18. Were hospital inpatient substance abuse

treatment services offered on October 1, 1998?

(See Q8, PAGE 4)

1 ~ Yes ˆ GO TO Q19 BELOW

2 ~ No ˆ SKIP TO Q23, PAGE 7

19. On October 1, 1998, how many beds were

designated for hospital inpatient substance

abuse treatment clients? This is often referred

to as “maximum capacity.”

C Include both occupied beds and unoccupied beds

MAXIMUM CAPACITY:

20. On October 1, 1998, how many clients at this facility

received the following hospital inpatient substance

abuse treatment services . . .

C Do not count those discharged on October 1, 1998

C For each category with no clients, enter zero, “0”.

NUMBER

a. Hospital inpatient--

detoxification ............

b. Hospital inpatient--

rehabilitation ............

c. TOTAL INPATIENTS

(add a & b)

(Q20c) 

(IF Q20c EQUALS ZERO: SKIP TO Q23, PAGE 7)

21. On October 1, 1998, how many of the TOTAL

INPATIENTS reported in Q20c were receiving

methadone or LAAM at this location?

~ THIS FACILITY DOES NOT DISPENSE METHADONE

OR LAAM ! GO TO Q22

NUMBER

a. Methadone clients at

this location .............

b. LAAM clients at this

location ................

22. How many of the total hospital inpatients in Q20c

were in each of the following gender, race/ethnicity,

and age categories?

C For each category with no clients, enter zero, “0”.

22a. GENDER

a. Male ........................

b. Female .....................

c. Don’t know ...................

TOTAL INPATIENTS (add a-c) .....

[Should equal the number in Q20c, if not please reconcile.]

22b. RACE/ETHNICITY

a. White .......................

b. Black or African American .......

c. Hispanic .....................

d. Asian or Pacific Islander ........

e. American Indian or Alaska Native. .

f. Other .......................

g. Don’t know ...................

TOTAL INPATIENTS (add a-g) .....

[Should equal the number in Q20c, if not please reconcile.]

22c. AGE

a. Under 18 years ..............

b. 18-20 .....................

c. 21-24 .....................

d. 25-34 .....................

e. 35-44 .....................

f. 45-64 .....................

g. 65 and over .................

h. Don’t know .................

TOTAL INPATIENTS (add a-h) .....

[Should equal the number in Q20c, if not please reconcile.]
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23. Were non-hospital residential substance abuse

treatment services offered on October 1, 1998?

(See Q8, PAGE 4)

1 ~ Yes ˆ GO TO Q24 BELOW

2 ~ No ˆ SKIP TO Q28, PAGE 8

24. On October 1, 1998, how many beds were

designated for non-hospital residential substance

abuse treatment clients? This is often referred

to as “maximum capacity.”

C Include both occupied beds and unoccupied beds

MAXIMUM CAPACITY:

25. On October 1, 1998, how many clients at this 

facility received the following non-hospital

residential (24-hour care) substance abuse

treatment services . . .

C Only count those not discharged on October 1,

1998

C For each category with no clients, enter zero, “0”.

NUMBER

a. Residential (24 hr)--

detoxification ............

b. Residential (24 hr)--

rehabilitation ............

c. TOTAL RESIDENTIAL

(add a & b) ...........

(Q25c) 

(IF Q25c EQUALS ZERO: SKIP TO Q28, PAGE 8)

26. On October 1, 1998, how many of the TOTAL

RESIDENTIAL clients reported in Q25c were

receiving methadone or LAAM at this location?

~ THIS FACILITY DOES NOT DISPENSE METHADONE

OR LAAM ! GO TO Q27

NUMBER

a. Methadone clients at

this location .............

b. LAAM clients at this

location ................

27. How many of the total residential clients in Q25c

were in each of the following gender, race/ethnicity,

and age categories?

C For each category with no clients, enter zero, “0”.

27a. GENDER

a. Male ........................

b. Female .....................

c. Don’t know ...................

TOTAL RESIDENTIAL CLIENTS

(add a-c) .......................

[Should equal the number in Q25c, if not please reconcile.]

27b. RACE/ETHNICITY

a. White .......................

b. Black or African American .......

c. Hispanic .....................

d. Asian or Pacific Islander ........

e. American Indian or Alaska Native. .

f. Other .......................

g. Don’t know ...................

TOTAL RESIDENTIAL CLIENTS

(add a-g) .......................

[Should equal the number in Q25c, if not please reconcile.]

27c. AGE

a. Under 18 years ..............

b. 18-20 .....................

c. 21-24 .....................

d. 25-34 .....................

e. 35-44 .....................

f. 45-64 .....................

g. 65 and over .................

h. Don’t know .................

TOTAL RESIDENTIAL CLIENTS

(add a-h) .......................

[Should equal the number in Q25c, if not please reconcile.]
8

**BASE THIS PERCENTAGE ON ALL CLIENTS, NOT ONLY THE FEMALE CLIENTS

28. Approximately what percent of all the substance abuse treatment clients enrolled at this facility on October 1,

1998 were being treated for:

~ THIS FACILITY HAD NO SUBSTANCE ABUSE TREATMENT CLIENTS ON OCTOBER 1, 1998: SKIP TO Q30, PAGE 9

C Include all substance abuse clients reported at Q15d (outpatients), Q20c (hospital inpatients), and Q25c

(non-hospital residential)

C Your response should add to 100 percent

a. Both Alcohol and Drug Abuse ............. .00%

b. Alcohol Abuse Only ..................... .00%

c. Drug Abuse Only ....................... .00%

100%

29. Approximately what percent of all the substance abuse treatment clients enrolled at this facility on October 1,

1998, were in the following categories:

C Include all substance abuse clients reported at Q15d (outpatients), Q20c (hospital inpatients), and Q25c

(non-hospital residential)

C Clients can be counted in more than one category

Don’t

Percent Or Know

a. Injection drug users at the time of admission ................................ % ~

b. Known to have an active case of Tuberculosis (TB) ........................... % ~

c. HIV positive .......................................................... % ~

d. Had previously received substance abuse treatment from this or another facility .... % ~

e. Covered by managed care arrangements ................................... % ~

f. Criminal justice referred clients (excluding DUI/DWI) .......................... % ~

g. Pregnant women** .................................................... % ~

h. Mothers with dependent children under 18 years old** ........................ % ~
9

$

** Unspecified: Only use if you are unable to distinguish between revenue from

managed care and non-managed care sources. DO NOT DOUBLE COUNT REVENUE.

*Should Equal Q30 Revenue

or Funding Amount

30. What was this facility’s total substance abuse treatment revenue or funding for the MOST RECENT 12-month

fiscal reporting period for which data are available? Include all sources such as client payments, insurance, 

government funds, and donations.

C If substance abuse treatment revenue is combined with other revenue, please provide your best estimate of the

substance abuse treatment portion

Total Substance Abuse Treatment Revenue or Funding:

31. From which of the following sources did this facility receive the substance abuse treatment revenue or funding

reported above? Mark Yes or No for each.

C Even if you cannot provide a revenue or funding total in Q30, please mark the sources and estimate percentages below

C If you marked category “6” (Federal government) in Q2, you should have revenues to report in category “e1” below

C FOR EACH SOURCE MARKED “YES”: Enter the dollar amount or estimated percentage of substance abuse treatment

revenue or funding received directly from that source

MARK

YES OR NO

FOR EACH

REVENUE SOURCES Yes No

DOLLAR

AMOUNT OR

ESTIMATED

PERCENT

a. Client payments (self-payment, deductibles, copayments) ........ . 1 ~ 2 ~ $ % 

b. Private health insurance

1. Fee-for-service (not HMO, PPO, or managed care) ........... . 1 ~ 2 ~ $ % 

2. HMO/PPO/Managed care payments ...................... . 1 ~ 2 ~ $ % 

3. Private health insurance, unspecified** ................... . 1 ~ 2 ~ $ % 

c. Medicaid

1. Not managed care--Title XIX, including all Federal,

State, and local matching Medicaid funds .................. . 1 ~ 2 ~ $ % 

2. Managed care payments--Title XIX, including all

Federal, State, and local matching Medicaid funds ........... . 1 ~ 2 ~ $ % 

3. Medicaid, unspecified** ................................ . 1 ~ 2 ~ $ % 

d. Medicare .............................................. . 1 ~ 2 ~ $ % 

e. Government funds

1. Federal (for example, VA, CHAMPUS--not

including Medicare) ................................... . 1 ~ 2 ~ $ % 

2. State--including Federal block grant funds funneled through

the State and any State-only medical assistance ............. . 1 ~ 2 ~ $ % 

3. Local--not including Medicaid ............................ . 1 ~ 2 ~ $ % 

f. Other public funds, source unspecified ....................... . 1 ~ 2 ~ $ % 

g. Other funds (such as funds from charities, donations, fundraising events) - (specify largest source: _________________) ... . 1 ~ 2 ~ $ % 

h. Unknown .............................................. . 1 ~ 2 ~ $ % 

TOTAL * 100%
10

32. What 12-month reporting period was used to

answer Q30?

~ DID NOT ANSWER Q30 ! SKIP TO Q35

FROM: 19 

 Month Year

TO: 19

 Month Year

33. Does Q30 report revenue or funding for only this

facility or for this facility and others?

1 ~ Only this facility ! SKIP TO Q37

2 ~ This facility and others

34. Are the facilities you included in Q30 the same

facilities you included in your client counts (Q11)?

1 ~ All of the facilities are the same

2 ~ Some of the facilities are the same SKIP TO

-1 ~ Don’t know Q37

35. Is there another organization that can provide the

revenue or funding information for your facility?

1 ~ Yes

2 ~ No ˆ SKIP TO Q37

36. Please provide the following information for that

organization.

Name of Organization 

Name of Contact Person 

Telephone (________) - 

Ext. (if any) 

37. In addition to funding received for providing

substance abuse treatment services, did you

receive any Federal or State funding earmarked for

prevention activities during the same 12-month

period reported in Q30 or your most recent fiscal

year?

1 ~ Yes

2 ~ No

-1 ~ Don’t Know

38. Please provide the following information about the

person primarily responsible for completing this

form.

Name: 

Telephone Number: (_______) - 

FAX Number: (________)-

OR ~ No FAX Number 

Internet Address: 

OR ~ No Internet Address

39. When completed, the 1998 National Directory of

Drug Abuse and Alcoholism Treatment and

Prevention Programs and the 1998 UFDS Data

Report will be available on SAMHSA’s home page at

www.samhsa.gov. If you would like to receive a

paper copy of the National Directory or the UFDS

Data Report, please indicate below.

1 ~ Yes, I would like to receive a copy of the Directory

2 ~ Yes, I would like to receive a copy of the 1998

UFDS Data Report

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 Rogers

P.O. Box 2393

Princeton, NJ 08543-2393