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

DRUG AND ALCOHOL SERVICES INFORMATION SYSTEM (DASIS)

UNIFORM FACILITY DATA SET (UFDS)

OCTOBER 1, 1997

This questionnaire asks about the facility listed below. Please check the accuracy of the information. Update

items that are blank or inaccurate by entering the correct information in the space provided on the lower half of

this page. If you are reporting data for the first time, please provide all of the information requested.

IF NO CHANGES ARE NEEDED (ALL INFORMATION IS COMPLETE AND CORRECT), MARK (X) THIS BOX  ̃ G

Don’t Don’t

Know Know

STATE ID -1 ~ NFR ID - -1 ~

EIN ID:** -1 ~ FDA ID - -1 ~

**The EIN ID number is your employer identification number or your federal tax identification number. Your accounting or personnel departments may have this number.

Facility Director's Name

Facility Name

Mailing Address

City State ZIP Code 

Street Name

City State ZIP Code 

County Telephone No. Ext. (if any) 

Facility Director's Telephone No. Ext. (if any) Facility Fax Number: TTY/TDD Number:
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 up-todate 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.

19 1

1 9

Instructions

C The reference date for UFDS is October 1, 1997.

C Use a # 2 pencil. If you wish to change an answer, please erase cleanly. 

C See example below for the proper way to record a number in a box.

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)

Correct Incorrect

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, 1997 was the facility named on the 3. Does this facility operate or participate in a 

cover providing substance abuse treatment, hotline that provides substance abuse 

prevention, administrative, or other counseling and referral services?

nontreatment services?

~ 1 Yes  ̃ SKIP TO Q.2

~ 2 No

1a. (If No) When did this facility close or stop and hours of operation. If 24 hours, check the

providing substance abuse services? RECORD box.

MONTH AND YEAR

MONTH: |___|___|

YEAR: 19 |___|___| SKIP TO Q.27, PAGE 10

~ -1 Don't Know

2. Who is the owner of this substance abuse

facility?

MARK ONE ONLY services were provided by this facility at this site?

~ 1 A Private-for-Profit Organization

~ 2 A Private Non-Profit Organization

~ 3 State Government SKIP TO

~ 4 Local County or Community 

Q.3

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:

 )

911 is not considered a hotline

~ 1 Yes

~ 2 No  ̃ SKIP TO Q.4

3a. Please enter the hotline telephone number(s)

24

PHONE NUMBER(S): HOURS OF OPERATION HOURS

( )- ~ 

Weekdays

 ~ 

Weekends

( )- ~ 

Weekdays

 ~ 

Weekends

4. On October 1, 1997, which of the following

MARK ALL THAT APPLY

~ 1 Substance Abuse Treatment (services that focus 

on initiating and maintaining an individual’s

recovery from substance abuse and on averting 

relapse, including detoxification)

~ 2 Substance Abuse Prevention (prevention 

activities directed at individuals not identified to be 

in need of treatment, such as information dissemination

or education)

~ 3 Other Substance Abuse Services (such as 

intake, assessment, and referral)

~ 4 Administrative Services (such as billing, 

personnel, and scheduling)

5. Did you check box 1 in Q.4?

~ 1 Yes

~ 2 No  ̃ SKIP TO Q.27, PAGE 10

5a. Is a drunk driving or DUI/DWI program the ONLY

substance abuse service provided by this facility?

1 ~ Yes  ̃ SKIP TO Q.27, PAGE 10

2 ~ No
2

6. Which ONE category best describes the SETTING of 7. Is this facility owned or operated by a managed

this substance abuse treatment facility? care organization (for example, an HMO)?

MARK ONE

~ 1 General hospital, may include an

outpatient substance abuse unit on site

~ 2 Psychiatric hospital, may include an

outpatient substance abuse unit on 

site

~ 3 Other specialized hospital, may

include an outpatient substance

abuse unit on site (for example,

alcoholism, maternity, children’s,

orthopedic)

~ 4 Solo practice SKIP

TO Q.7

~ 5 Group practice

~ 6 School (elementary, secondary,

college/university)

~ 7 Jail, prison or juvenile detention

center

~ 8 Other criminal justice (TASC,

pretrial diversion, court referral,

probation, parole, community

corrections)

~ 9 Other setting

6a. More specifically would you describe this facility 

as:

MARK YES OR NO FOR EACH

YES NO

1 ~ 2 ~ a. OUTPATIENT substance abuse treatment

facility

1 ~ 2 ~ b. Community MENTAL health center or other

mental health facility that provides a variety

of services

1 ~ 2 ~ c. Community Health Center, including Migrant

Health Center, Urban Indian Program, 

Health Care for the Homeless Center

1 ~ 2 ~ d. Halfway House

1 ~ 2 ~ e. Therapeutic Community

1 ~ 2 ~ f. Other RESIDENTIAL substance abuse

treatment facility

1 ~ 2 ~ g. Community or religious organization/agency 

that provides a variety of social services

1 ~ 2 ~ h. Other (Specify: )

~ 1 Yes

~ 2 No

8. On October 1, 1997, 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  ̃ SKIP TO Q.9

~ -1 Don’t know  ̃ SKIP TO Q.9

8a. With how many managed care organizations

did you have formal written agreements or

contracts?

Number: 

9. On October 1, 1997 was this facility structured

as a parent organization or master site with one

or more affiliate sites that provide substance

abuse treatment services?

~ 1 Yes

~ 2 No  ̃ SKIP TO Q.10, PAGE 3

9a. On October 1, 1997, how many affiliate sites did

this facility have that provide substance abuse

treatment services?

Number: 
3

10. On October 1, 1997, was this facility an affiliate of a parent organization or master site?

~ 1 Yes

~ 2 No  ̃ SKIP TO Q.10b

10a. Please provide the following information for the parent organization/master site.

Organization: 

Contact Name: 

Mailing Address: 

City: State: 

ZIP: Telephone Number: ( ) - 

10b. The rest of this questionnaire should be answered for those services, activities, etc. provided at this site

by the facility listed on the cover of this questionnaire. Parent organizations or master sites should not

include affiliate sites in their responses. Can you respond for only the services, activities, etc. provided at

this site?

~ 1 Yes  ̃SKIP TO Q.11

~ 2 No

10c. If responding for only this site is not possible, for approximately how many sites will you be reporting in

total?

MARK ONE ONLY

~ 2 sites

~ 3-5 sites

~ 6-10 sites

~ More than 10 sites

11. Waiting Lists. If a program is full, does this facility maintain a formal waiting list of people waiting for

substance abuse services?

C Formal waiting list: a record of the names, addresses, and telephone numbers of applicants eligible for admission. 

The list must include the date of application and nature of follow-up contacts.

~ 1 Yes

~ 2 No ! SKIP TO Q.12, PAGE 4

11a. On October 1, 1997, how many people were on the waiting list?

Number on 

Waiting List: ,
4

12. Number of Active Clients on October 1, 1997. In each of the categories listed below, please enter the number

of active clients who were receiving substance abuse treatment at this facility on October 1, 1997:

C DO NOT count codependents, parents, other relatives, friends (i.e., “collaterals”), or other nontreatment clients.

IF NONE, 

NUMBER CHECK BOX

a. Hospital Inpatients - Detoxification on October 1, 1997and were not discharged that day ...... , ~

b. Hospital Inpatients - Rehabilitation on October 1, 1997and were not discharged

that day .......................................................................... , ~

c. Residential (24-Hour Care) - Detoxification on October 1, 1997 and were not discharged 

that day .......................................................................... , ~

d. Residential (24-Hour Care) - Rehabilitation on October 1, 1997 and were not discharged

that day .......................................................................... , ~

e. Outpatients (Less Than 24-Hour Care) who received a substance abuse treatment service 

between September 1 and October 1, 1997 and were still enrolled on October 1,

1997. . .DO NOT INCLUDE CLIENTS WHOSE ONLY SERVICE IS ATTENDING A DUI/DWI PROGRAM .......... , ~

f. Intensive Outpatients* who received a substance abuse treatment service—including day

treatment—between September 1 and October 1, 1997 and were still enrolled on October 1,

1997 *(Services provided to a client that last 2 hours or more per day/3 or more days a week) ............ , ~

g. TOTAL NUMBER OF ACTIVE CLIENTS (add a - f) , 

Q.12g

12h. Are the numbers entered in the TOTAL box Q.12g actual active client counts for October 1, 1997 or your best estimate?

~ 1 Actual count ~ 2 Estimate

13. Approximately what percentage of the clients in the Q.12g TOTAL box were being treated on October 1,

1997 for:

a. Alcohol Abuse Only ................ .00%

b. Drug Abuse Only .................. .00%

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

TOTAL CLIENTS 100 %

14. Did you enter a number larger than zero in either the Hospital Inpatient (Q.12a or Q.12b) or Residential—24

Hour Care (Q.12c or Q12.d) categories in Q.12?

~ 1 Yes ~ 2 No  ̃ SKIP TO Q.15, PAGE 5

14a. On October 1, 1997, how many of the beds at this facility could have been used for:

NUMBER OF BEDS

a. Hospital Inpatient Substance Abuse Treatment .......................... , ~ NONE 

b. Non-Hospital Residential (24-Hour) Substance Abuse Treatment ........... , ~ NONE 
5

CHARACTERISTICS OF ACTIVE CLIENTS ON OCTOBER 1, 1997

15. Please complete the following table for the number of active clients reported in Q.12 (page 4).

C Enter the TOTAL from Q.12g into the three TOTAL boxes in Column 1 below.

C Column 1. Enter the number of active clients for each age, race, and sex category in Column 1. For each category with no clients, enter zero,

“0."

C Columns 2-4. For each age, race, and sex category with a number greater than zero in Column 1 complete Columns 2-4 to show how many

clients were in each of the three types of care. The SUM of each row in Columns 2, 3 and 4 MUST EQUAL the Column 1 total for that row.

NUMBER OF ACTIVE CLIENTS BY TYPE OF CARE 

1 2 3 4

HOSPITAL INPATIENT RESIDENTIAL (24-HOUR CARE) OUTPATIENT

Client Category TOTAL From Q.12a + Q.21b From Q.12c + Q.12d From Q.21e + Q.12f

AGE

Under 18 years ................ |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

18-20 ....................... |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

21-24 ....................... |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

25-34 ....................... |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

35-44 ....................... |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

45-64 ....................... |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

65 and Over .................. |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

Don’t Know .................. |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

TOTAL NUMBER OF 

ACTIVE CLIENTS ............ |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

 (from Q.12g)

RACE/ETHNICITY

White, not of Hispanic Origin ..... |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

Black, not of Hispanic Origin ..... |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

Hispanic ..................... |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

Asian or Pacific Islander ......... |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

American Indian/Alaskan Native . . |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

Other ....................... |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

Don’t Know .................. |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

TOTAL NUMBER OF 

ACTIVE CLIENTS ............ |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

 (from Q.12g)

GENDER

Male ........................ |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

Female ...................... |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

Don’t Know .................. |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

TOTAL NUMBER OF 

ACTIVE CLIENTS .............. |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__| |__|,|__|__|__|

 (from Q.12g)

15a. Are the numbers entered in Q.15 actual active client counts for October 1, 1997 or your best estimate?

~ 1 Actual active client counts

~ 2 Estimate
6

16. Does this facility dispense the opioid substitutes methadone or LAAM at this site?

~ 1 Yes  ̃ (Make certain your FDA ID number on the cover has been recorded and is correct)

~ 2 No  ̃ SKIP TO Q.17

16a. On October 1, 1997, approximately how many of the clients in the TOTAL box at Q.12g (page 4) were

receiving:

Number

a. Methadone at this site ................................... |___|,|___|___|___|

b. LAAM at this site ....................................... |___|,|___|___|___|

17. On October 1, 1997, about how many of the clients recorded in the TOTAL box at Q.12g were:

C Provide your answers either as numbers or percentages. Your best estimate is fine. If a reasonable estimate is

not possible, mark the “Unknown” box.

C For 17a and 17b, the number entered should not exceed the total number of females reported in Q.15.

C The active clients in Q.12 can be reported more than once in categories a-h below.

Number OR Percentage Unknown 

 

a. Pregnant? ............................................. |___|,|___|___|___| |___|___|___| .00 % ~ -1

b. Women with dependent children? .......................... |___|,|___|___|___| |___|___|___| .00 % ~ -1

c. Injection drug users at the time of admission? ................. |___|,|___|___|___| |___|___|___| .00 % ~ -1

d. Known as having an active case of tuberculosis (TB)? .......... |___|,|___|___|___| |___|___|___| .00 % ~ -1

e. HIV positive? ........................................... |___|,|___|___|___| |___|___|___| .00 % ~ -1

f. Clients who had previously received substance

abuse treatment from you or another facility? ................. |___|,|___|___|___| |___|___|___| .00 % ~ -1

g. Covered by managed care arrangements .................... |___|,|___|___|___| |___|___|___| .00 % ~ -1

h. Criminal justice referred clients (excluding DUI/DWI) ........... |___|,|___|___|___| |___|___|___| .00 % ~ -1

18. From October 1, 1996 to September 30, 1997—or during the most recent 12-month period for which

information is available— what was this facility’s:

C DO NOT INCLUDE NONTREATMENT CLIENTS

12 - MONTH 

a. Total number of substance abuse treatment admissions—count every admission for the year, ADMISSIONS 

which includes each admission for clients readmitted for treatment or clients entering more than 

one type of care ..................................................................... |___|___|,|___|___|___|

b. Unduplicated count of substance abuse treatment clients—count every client treated during that 12 - MONTH 

time period—both new clients and clients already receiving treatment. HOWEVER, count each CLIENTS 

client only once, even if a client was readmitted or treated more than once during the

time period. . . . . . . (This count should be no less than the total reported at Q.12g) ................ |___|___|,|___|___|___|

19. Is the number entered in: Actual Best

Count Estimate

a. Q.18a an actual admissions count for the year or your best estimate? ............. ~ 1 ~ 2

b. Q.18b an actual unduplicated count for the year or your best estimate? ........... ~ 1 ~ 2
7

20. As of October 1, 1997, which of these services were being provided at this substance abuse facility?

MARK ALL THAT APPLY Programs for Special Groups

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: )

~ 30 Adolescents

~ 31 Dually-diagnosed (mental and substance abuse

disorders)

~ 32 Persons with HIV/AIDS

~ 33 Pregnant/Postpartum women

~ 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

~ 32 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

~ 51 Detoxification from substance of abuse

~ 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: )
8

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

revenue from managed care and non-managed care sources.

DO NOT DOUBLE COUNT REVENUE.

21. Using the MOST RECENT 12 - month fiscal reporting period for which data are available, what was the

substance abuse treatment revenue or funding for this facility? Include all sources such as client

payments, insurance, government funds, and donations.

C If these data are obtained from a financial report with the information recorded in thousands of dollars, please 

remember to add three zeroes when recording these figures.

C If substance abuse treatment revenue is summed together with other revenue, please provide your best estimate for 

the substance abuse treatment portion.

Total Substance Abuse Treatment Revenue or Funding: $ |___|___|___| , |___|___|___| , |___|___|__| .00

21a. What 12 - month reporting period was used to answer Q.21?

FROM: |___|___| |___|___| 19 |___|___| THROUGH: |___|___| |___|___| 19 |___|___|

Month Day Year Month Day Year

22. How much of the substance abuse treatment revenue or funding reported in Q.21 was paid directly to this

facility by:

C Provide your answers either as numbers or percentages.

C If you marked category “6” (Federal government) in Q.2, you should have revenues or funding to report in category “e” below.

REVENUE OR FUNDING SOURCES DOLLAR AMOUNT OR ESTIMATED 

 PERCENT 

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

b. Private health insurance

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

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

3. Private health insurance, unspecified** ............................. $ %

c. Medicaid

1. Not managed care—Title XIX, including all Federal, State, and Local 

matching Medicaid funds ....................................... $ %

2. Managed care payments—Title XIX, including all Federal, State, and 

Local matching Medicaid funds .................................. $ %

3. Medicaid, unspecified** ......................................... $ %

d. Medicare ....................................................... $ %

e. Government funds

1. Federal (for example, VA, CHAMPUS—not including Medicare) ........ $ %

2. State—including Federal block grants or any other State-only medical 

assistance ................................................... $ %

3. Local—not including Medicaid ................................... $ %

f. Other public funds, source unspecified ............................... $ %

g. Other funds (such as funds from charities, donations, fund-raising events) - 

(Specify Largest Source: _________________) ....................... $ %

h. Unknown ....................................................... $ %

Total $ * 100% 

 *Should Equal Q.21 Revenue or 

Funding Amount
9

NFR ID # - ~ -1 Don't Know

State ID # ~ -1 Don't Know

Name 

 

Location Address 

 

 

City 

State ZIP Code |___|___|___|___|___|

Telephone (|__|__|__|)-|__|__|__|-|__|__|__|__|

Ext. (if any) 

NFR ID # - ~ -1 Don't Know

State ID # ~ -1 Don't Know

Name 

 

Location Address 

 

 

City 

State ZIP Code |___|___|___|___|___|

Telephone (|__|__|__|)-|__|__|__|-|__|__|__|__|

Ext. (if any) 

23. To answer Q.22, did you primarily use:

MARK ONE ONLY

~ 1 An audited financial statement for the substance abuse treatment facility on the cover

~ 2 An unaudited financial statement for the substance abuse treatment facility on the cover

~ 3 The annual budget for the substance abuse treatment facility on the cover

~ 4 A financial statement, budget, or records from an administrative parent

~ 5 Estimates based on other records, budgets, or statements

~ 6 Other estimates

24. Does the revenue or funding information reported in Q.22 include revenues or funding for a site OTHER

THAN the one identified on the cover of this questionnaire?

~ 1 Yes

~ 2 No  ̃ SKIP TO Q.25

24a. Please complete a block below for each site whose revenue or funding information is included in Q.22. 

Make a photocopy of this page if more address blocks are needed or send your own printout.

25. Were you able to provide revenue or funding sources in Q.22 for at least 75 percent of the total reported

revenue?

~ 1 Yes  ̃ SKIP TO Q.26, PAGE 10

~ 2 No

25a. Is there another organization that can provide the revenue or funding information for your facility?

~ 1 Yes  ̃ GO TO Q.25b, PAGE 10

~ 2 No  ̃

Please explain:

SKIP TO Q.26, PAGE 10
10

Name of Organization 

 

Mailing Address 

 

City State ZIP Code 

Name (Contact Person) 

Telephone (|__|__|__|)-|__|__|__|-|__|__|__|__| Ext. (if any) 

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: Pat Nemeth

P.O. Box 2393

Princeton, NJ 08543-2393

25b. Please provide the following information for that organization.

26. In addition to the funding you 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 Q.21a, page 8?

~ 1 Yes

~ 2 No

~ -1 Don’t Know

27. Please provide the following information about the person primarily responsible for completing this form.

1. Name: 

2. Telephone Number:(_______) - 

3. FAX Number:(_______) - OR ~ No FAX Number

4. Internet Address: OR ~ No Internet Address

28. When completed, you will be able to access the 1997 National Directory and the 1997 UFDS Data Report on

the World Wide Web via SAMHSA’s home page at www.samhsa.gov. If you would like to receive a paper

copy of the National Directory or the data report, or the National Directory on diskette, please indicate

below.

~ 1 National Directory - paper copy

~ 2 National Directory - diskette (requires minimum of 8 MB RAM and 386 or higher processor)

~ 3 Report of UFDS survey findings - paper copy

Questar Q400707