Demographics and Criminal History - CHIP€¦ · Web viewPlease let me know if there is a word or question you do not understand, and I will read it again or explain what I mean

Form BLN Baseline Client Interview

B1. Interview Start Date: m m d d y y y y

B2. Client’s ID #

B3. Interviewer Name_____________________ ______________________ First Last

B4. Interview was conducted in English Spanish

INTERVIEW INTRODUCTION

TIME STARTED: : AM PM

Thank you for agreeing to do this interview today. You are part of a new program____________ [INSERT SITE SPECIFIC PROGRAM NAME], and the answers you give today will help us improve services for you and other inmates getting out of jail.

During today's interview, I'm going to ask you questions about how you have been feeling. I’ll also ask you some questions about your family and friends. I’ll ask you to describe your use of drugs and alcohol, and any past criminal activity. Some of these questions address sensitive topics. We would like you to answer all of the questions, but if there is a question you don't want to answer, we can skip it. You can also stop the interview at any time.

Everything you tell me today is confidential and will be kept private just as explained in the consent form. The answers you give will be shared with our research team, but your name will not be given.

I will try to get through all of the questions quickly. I have to read every question even if you already told me the answer before. The interview should take about 30-45 minutes. During this time I will ask you some questions and write down your answers. Please let me know if there is a word or question you do not understand, and I will read it again or explain what I mean.

Do you have any questions now? May I begin?

WRITE INTERVIEWER COMMENTS HERE [NOTE QUESTION# COMMENT APPLIES TO] :

HRSA Enhancing Linkages to HIV Primary Care Demonstration Form BLN Final 4.16.09 Page 1 of 19

INDEX INCARCERATION DETAILS

ENT1. To make it easier for you to answer the questions in this interview, I need to know the date that you were first locked up for this current (or most recent) incarceration. [INTERVIEWER MAY USE SHOW CARD CALENDAR TO ASSIST RESPONDENT WITH RECALL. IF CLIENT IS NOT IN JAIL DURING INTERVIEW, ASK FOR START DATE OF MOST RECENT INCARCERATION] OPTIONAL PROBE: If you don’t know the exact date, give your best guess.]

Start of Most Recent Incarceration

DON’T KNOW / REFUSED m m d d y y y y

ENT2. INTERVIEWER: CALCULATE TIME PERIOD FOR ENT2 BY COUNTING BACK 30 days FROM THE DATE IN ENT1:

‘30 days before your most recent incarceration’ time period

from to m m d d y y y y m m d d y y y y

[VERIFICATION STATEMENT] “So during our interview, when I ask you questions about the ‘30 days before your most recent incarceration’, I will be referring to the time between ____ and ____.”

ENT3. During this last 30 day time period, did you spend any time locked up in a jail, prison, or hospital?

YES ENT3a. Altogether, about how many days did you spend locked up during that 30-day period? [INTERVIEWER: USE SHOW CARD CALENDAR TO HELP RESPONDENT IDENTIFY THE DURATION OF EPISODES OF INCARCERATION OR COMMITMENT DURING THE 30-DAY PERIOD BEFORE THE INDEX INCARCERATION]

NO Number of days ________ DON’T KNOW / REFUSED

ENT4. Try to think about where you were and what you were doing during that time. Can you tell me what else was going on in your life around that time? Were there any holidays, birthdays, seasons, or other important life events that you remember? We can refer to these events as we go through the interview to help jog your memory about what was going on at that time.

ENT4a. Anchoring Event 1 ___________________________________________________ ENT4b. Anchoring Event 2 ___________________________________________________

[Note for data-entry: responses not submitted to ESC]


HRSA Enhancing Linkages to HIV Primary Care Demonstration Form BLN Final 4.16.09 Page 2 of 19

I. FAMILY/SOCIAL RELATIONSHIPSThe next set of questions asks about your social relationships and your family. F1. What best describes your current relationship/marital status?

[LET RESPONDENT ANSWER IN THEIR OWN WORDS, AND PROBE WITH THE ANSWER CHOICES BELOW IF NECESSARY. CHOOSE ONLY ONE ANSWER]

Single Married. [INCLUDE COMMON-LAW MARRIAGE] F1a. If married, specify □ first marriage □ remarried

Separated In a committed relationship but not living together

Divorced In a committed relationship and living together

Widowed DON’T KNOW / REFUSED

F2. How long have you been ___[INSERT ANSWER FROM F1]_____?

[RECORD DURATION OF RELATIONSHIP STATUS INDICATED IN F1. IF ANSWER IN F1 IS “SINGLE”, RECORD DURATION SINCE MOST RECENT COMMITTED RELATIONSHIP OR SINCE AGE 18, WHICHEVER IS MORE RECENT.]

Years ______ AND/OR Months _______ DON’T KNOW / REFUSED

F3. In the 30 days before your most recent incarceration, did you live with anyone who…F3a. Had an alcohol problem? Yes No DON’T KNOW / REFUSED

F3b. Had a drug problem? Yes No DON’T KNOW / REFUSED

F4. Just before your most recent incarceration, how many children under 18 were in your care?

Number of Children _________ DON’T KNOW / REFUSED

F5. In the 30 days before your most recent incarceration, how bothered or troubled have you been by family problems? [CHOOSE ONE. SEE SHOW CARD 4]

Not at all Slightly Moderately Considerably Extremely

DON’T KNOW / REFUSED

F6. How important to you NOW is treatment or counseling for family problems? [CHOOSE ONE. SEE SHOW CARD 4]



F7. In general, how satisfied or dissatisfied are you with the overall support you get from your friends and family members? [CHOOSE ONE]

Very

Dissatisfied

Somewhat Dissatisfied

Neither Satisfied or Dissatisfied

Somewhat Satisfied

Very

SatisfiedWRITE INTERVIEWER COMMENTS HERE [NOTE QUESTION# COMMENT APPLIES TO] :

HRSA Enhancing Linkages to HIV Primary Care Demonstration Form BLN 4-16-09 Page 3 of 19

II. LIVING CONDITIONSNow I’m going to ask a few questions about your living situation before your most recent incarceration.H1. At any time in the 30 days before your most recent incarceration, did you consider

yourself to be homeless?

Yes No DON’T KNOW / REFUSED

H2. In the 30 days before your most recent incarceration, did you mostly live alone or with other people?

With other people Alone SKIP TO H4 D.K. / REFUSED SKIP TO H4

H3. Did you live with… [READ LIST TO RESPONDENT. CHECK ALL THAT APPLY].

Spouse/intimate partner Unrelated adult(s), like friends and roommates Child or children Unrelated adult(s), that are strangers Mother or father DON’T KNOW / REFUSED Other relative(s) – not your mother, father, spouse/partner, or child

H4. In the 30 days before your most recent incarceration, how many days did you sleep… [READ LIST TO RESPONDENT. CHECK ONE ANSWER PER ROW] H4a. In a shelter: 0 1-2 3-5 6-10 more than 10 H4b. In a rented room: 0 1-2 3-5 6-10 more than 10 H4c. On the streets or in a park: 0 1-2 3-5 6-10 more than 10 H4d. In someone else’s home: 0 1-2 3-5 6-10 more than 10 H4e. In an empty building: 0 1-2 3-5 6-10 more than 10 H4f. In a library, bus station, all night movie, airport, or some other public place:

0 1-2 3-5 6-10 more than 10

H5. In the 30 days before your most recent incarceration, was there any time for two or more days, when you didn’t get anything, or barely anything, to eat? [CHOOSE ONE].


H6. Immediately upon release from jail, the first night, where do you expect to live? [ASK QUESTION WITHOUT READING ANSWER CHOICES. PROBE TO CLARIFY IF NEEDED.]

A place where you live alone and pay rent A place shared with others, where you will pay rent Someone else’s place, where you will not pay rent Supported housing PROBE: in housing where services such as food or case management

were provided. Include halfway houses, but not residential in-patient programs. An in-patient medical, mental health, or substance abuse treatment facility Expect to be homeless (in an abandoned building, car, on the street or in a park) A shelter Planning to be transferred to prison Any other place? (Specify: ____________________________________) N/A – BASELINE CONDUCTED AFTER CLIENT RELEASED FROM JAIL






III. HIV and HEALTH Now I will ask you about HIV testing and medical treatment you’ve received for HIV.

HIV1. Did you find out you were HIV-positive for the first time during your current jail stay?

Yes SKIP TO HIV9 No GO TO HIV2 DON’T KNOW / REFUSED

HIV2. Where were you first diagnosed with HIV? [CHOOSE ONE.]

Correctional facility Medical facility in the community Drug treatment program Other (SPECIFY): _____________________ DON’T KNOW / REFUSED

HIV3. During the 30 days before your most recent incarceration, did you have a usual health care provider or place where you get HIV care?


Now I will ask you about your experience taking HIV medications. By HIV medications, I mean medications that people with HIV take to lower their viral load or reduce the amount of HIV in their body. Sometimes this is called HAART. I am not referring to herbs, vitamins, or any medications that you may be taking to prevent infections such as pneumonia.

HIV4. Have you ever taken HIV medications?

Yes GO TO HIV5 No SKIP TO HIV7 DON’T KNOW / REFUSED

HIV5. To what extent do your friends or family members help you remember to take your medication?

Not at all A Little Somewhat A Lot Not Applicable

HIV6. During the 7 days before your most recent incarceration, were you taking any HIV medications?

Yes SKIP TO HIV8 No GO TO HIV7 DON’T KNOW / REFUSED

HIV7. What are the reasons why you have not been taking anti-HIV medications? [ASK OPEN-ENDED AND CHECK OFF RESPONSES.]

My doctor told me I don’t need medications SKIP TO HIV9 My doctor has not prescribed medications SKIP TO HIV9 I cannot afford medications SKIP TO HIV9 I do not want to take medications SKIP TO HIV9 I prefer to use natural or alternative treatments SKIP TO HIV9 I have tried these medications and they do not work for me SKIP TO HIV9 I have tried these medications and there are too many side effects SKIP HIV9 Other_____________________ SKIP TO HIV9 DON’T KNOW / REFUSED SKIP TO HIV9



Now I’m going to ask you about how often you took your prescribed HIV medicines before your most recent incarceration. I will ask you to refer to this hand out [SEE SHOW CARD 5]. Please either make a mark on the line or point to the place that shows your best guess about the percent of HIV medications you took in the 7 days before your most recent incarceration. We would be surprised if this was 100% for most people.

0% means you took none of the doses of your prescribed HIV medications.

50% means you took half of the doses of your prescribed HIV medications.

100% means you took every single dose of your prescribed HIV medications.

HIV8. In the 7 days before your most recent incarceration, what percentage of prescribed HIV medications do you estimate taking?[ASK CLIENT TO REFER TO NUMBER LINE WITH PERCENTAGES. FOLLOW INTERVIEWER MANUAL INSTRUCTIONS TO DETERMINE “% TAKEN” FROM CLIENT RESPONSE. ENTER PERCENTAGE INDICATED ON THE LINE BELOW]

______% TAKEN DON’T KNOW / REFUSED

HIV9. Do you plan to take HIV medications after you are released? [CHOOSE ONE.]

Yes SKIP TO NEXT SECTION DON’T KNOW / REFUSED SKIP TO NEXT SECTION

No GO TO HIV10

HIV10. What is the reason why you do not plan to take HIV medications after you are released? [ASK OPEN-ENDED AND CHECK ALL RESPONSES THAT APPLY.]

My doctor told me I don’t need medications My doctor has not prescribed medications I cannot afford medications I do not want to take medications I prefer to use natural or alternative treatments I have tried these medications and they do not work for me I have tried these medications and there are too many side effects Other_____________________ REFUSED



IV. MEDICAL STATUS & HEALTH INSURANCEFor this next set of questions, I’m going to ask about medical issues and health insurance.

M1. In the past 6 months, how many times have you been in an emergency room for your own health problems or injuries?

Number of times: ________ DON’T KNOW / REFUSED

M2. How many times in your life have you been hospitalized overnight for medical problems? [INCLUDE HOSPITALIZATIONS FOR OVERDOSES AND DELIRIUM TREMENS (D.T.s). EXCLUDE DETOX, ALCOHOL/DRUG/PSYCHIATRIC TREATMENT, OR NORMAL CHILDBIRTH, INCLUDING CESAREAN DELIVERY.]

Number of times: ________ DON’T KNOW / REFUSED

M3. How long ago was your last hospitalization for a medical problem? [ENTER THE NUMBER OF YEARS AND MONTHS SINCE THE CLIENT/PATIENT WAS LAST HOSPITALIZED OVERNIGHT FOR A MEDICAL PROBLEM.]

_________ AND/OR _________ DON’T KNOW / REFUSED Years Months

M4. Other than HIV, do you have any chronic medical problems?

NO YES M4a. What chronic medical problems do you have? [ASK OPEN ENDED AND CHECK ALL THAT APPLY]

Tuberculosis Hypertension

Hepatitis B Diabetes

Hepatitis C Other: (specify)____________________

Asthma Other: (specify)____________________

Chronic pain DON’T KNOW / REFUSED

M5. Are you taking any prescribed medications on a regular basis for a medical problem? Only include medications you are taking for a physical/medical problem. Please do not include medications you are taking for psychiatric problems. [REFER TO RESPONSES TO HIV4 AND HIV6 AND PROBE FOR HIV MEDICATIONS. NO NEED TO CAPTURE EXACT DRUG NAMES OR DOSAGES ].

NO YES M5a. What prescribed medications are you taking? [LIST ALL DRUGS SEPARATED BY COMMAS. DO NOT INCLUDE PSYCHIATRIC MEDICINES]

________________________________________________________________________________________________________________________________________________________________________________________________________________________________



M6 How many days have you experienced medical problems in the 30 days before your most recent incarceration? [ONLY INCLUDE PHYSICAL MEDICAL PROBLEMS, NOT MENTAL HEALTH PROBLEMS.]

Number of days: ____________ DON’T KNOW / REFUSED

NOTE TO INTERVIEWER: DO NOT SKIP M7 AND M8 IF M6 = 0. IF M6=0, THEN USE M7 AND M8, DOUBLE-CHECK THAT THE PATIENT REALLY HASN'T HAD PROBLEMS AS FOLLOWS: "So, [CLIENT NAME], it sounds like you haven't had any medical problems in the 30 days before your most recent incarceration...may I assume that you haven't been bothered by any medical problems...?"

M7. How troubled or bothered have you been by these medical problems in the 30 days before your most recent incarceration? [CHOOSE ONE. SEE SHOW CARD 4.]



M8. How important to you now is treatment for these medical problems? [CHOOSE ONE. SEE SHOW CARD 4.]



M9. In the 30 days before your most recent incarceration, did you have any health insurance or benefits to pay for all or part of the cost of your medical care or medications?

YES GO TO M10 NO SKIP TO NEXT SECTION DON’T KNOW / REFUSED SKIP TO NEXT SECTION

M10. What kinds of health insurance or benefits did you have? You can have more than one. [CHECK ALL THAT APPLY. IF NEEDED, INTERVIEWER CAN PROBE WITH LIST.] PROBE: What else?

Medicaid (or name of state’s equivalent e.g. MassHealth) Another public plan (PROBE: VA/MILITARY or CHAMPUS) ADAP (AIDS Drug Assistance Program for HIV medications) Medicare Private Medical Coverage (e.g. through an employer or family member’s employer) Other (Specify): ____________________________________ DON’T KNOW / REFUSED



V. DRUG/ALCOHOL USEThis next set of questions asks about your experience with drugs and alcohol throughout your life and in the 30 days before your most recent incarceration.

[INTERVIEWER CAN REFER TO LOCAL STREET NAMES FOR THESE SUBSTANCES.]

LIFETIME # of years with regular

use

How many days was

(substance) used in 30

days before most recent

incarceration

USUAL OR MOST RECENT ROUTE of ADMINISTRATION

SA1. Alcohol: Beer, wine, liquor - any use at all Oral Nasal Smoke NonIV IV

SA2. Alcohol: Beer, wine, liquor - to intoxication Oral Nasal Smoke NonIV IV

SA3. Heroin Oral Nasal Smoke NonIV IV

SA4. Methadone: Dolophine, LAAM Oral Nasal Smoke NonIV IV

SA4a Buprenorphine or suboxone Oral Nasal Smoke NonIV IV

SA5. Other opiates/ analgesics/Pain killers: Morphine, Dilaudid, Demerol, Percocet, Darvon, Talwin, Codeine, Tylenol (2,3,4), Fentanyl, Robitussin

Oral Nasal Smoke NonIV IV

SA6. Barbiturates: Nembutal, Seconal, Tuinal, Amytal, Pentobarbital, Secobarbital, Phenobarbital, Fiorinal


SA7. Other sedative/ hypnotic/ tranquilizer: Benzodiazepines = Valium, Librium, Ativan, Serax, Tranxene, Dalmane, Halcion, Xanax, Miltown, Other = Chloral Hydrate, Quaaludes


SA8. Cocaine: Cocaine Crystal, Free-Base Cocaine or Crack, and "Rock Cocaine" Oral Nasal Smoke NonIV IV

SA9. Amphetamines: Monster, Crank, Benzedrine, Dexedrine, Ritalin, Preludin, Methamphetamine, Speed, Ice, Crystal, Tina


SA10. Cannabis: Marijuana, Hashish Oral Nasal Smoke NonIV IV

SA11. Hallucinogens: LSD (Acid), Mescaline, Psilocybin (Mushrooms), Peyote, Green, PCP (Phencyclidine), Angel Dust, Ecstasy


SA12. Inhalants: Nitrous Oxide (Whippits), Amyl Nitrite (Poppers), Glue, Solvents, Gasoline, Toluene, Etc.


SA13. More than one substance per day (Incl. Alcohol).

[LIST ANY OTHER SUBSTANCES THAT ARE MENTIONED AS DRUGS THAT ARE BEING ABUSED BY RESPONDENT: ________________________________________________________________]

Antidepressants Ulcer Meds, including Zantac, Tagamet Asthma Meds, including Ventolin Inhaler, Theodur Other Meds, including Antipsychotics, Lithium



SA14. How many times in your life have you had alcohol DT’s?:[DELIRIUM TREMENS (DT’s) : OCCURS 24-48 HOURS AFTER LAST DRINK, OR SIGNIFICANT DECREASE IN ALCOHOL INTAKE, SHAKING, SEVERE DISORIENTATION, FEVER, HALLUCINATIONS, USUALLY REQUIRE MEDICAL ATTENTION]

Number of times: ____________ DON’T KNOW / REFUSED

SA15. How many times in your life have you been treated for…[INCLUDE DETOXIFICATION, HALFWAY HOUSES, IN/OUTPATIENT COUNSELING, AND AA OR NA (IF 3+ MEETINGS WITHIN A ONE-MONTH PERIOD)]

SA15a. Alcohol abuse: Number of times: ____ DON’T KNOW / REFUSED

SA15b. Drug abuse: Number of times: ____ DON’T KNOW / REFUSED

IF SA15 = 0 FOR BOTH ALCOHOL ABUSE AND DRUG ABUSE, SKIP TO SA 17

SA16. How many of these were detox only…:

SA16a. Alcohol abuse: Number: ______ DON’T KNOW / REFUSEDSA16b. Drug abuse: Number: ______ DON’T KNOW / REFUSED

SA17. How much money would you say you spent in the 30 days before your most recent incarceration on:

SA17a. Alcohol abuse: $ ______ DON’T KNOW / REFUSED

SA17b. Drug abuse: $ ______ DON’T KNOW / REFUSED

SA 18. How many days were you treated as an outpatient for alcohol or drugs in the 30 days before your most recent incarceration? [INCLUDE NA, AA (IF 3+ MEETINGS WITHIN A ONE-MONTH PERIOD)]


SA 19. How many days in the 30 days before your most recent incarceration have you experienced alcohol problems?


SA 20. How many days in the 30 days before your most recent incarceration have you been troubled or bothered by any alcohol problems?




SA 21. How troubled or bothered were you in the 30 days before your most recent incarceration by these alcohol problems? [CHOOSE ONE. SEE SHOW CARD 4.]



SA 22. How important to you now is treatment for these alcohol problems? [CHOOSE ONE. SEE SHOW CARD 4.]



SA 23. How many days in the 30 days before your most recent incarceration have you experienced drug problems?


SA 24. How troubled or bothered were you in the 30 days before your most recent incarceration by drug problems? [CHOOSE ONE. SEE SHOW CARD 4.]



SA 25. How important to you now is treatment for these drug problems? [CHOOSE ONE. SEE SHOW CARD 4.]





VI. PSYCHIATRIC STATUSNow I’m going to ask questions about your feelings and mental health.

How many times in your life have you been treated in a hospital or inpatient setting/outpatient or private client/patient for any psychological or emotional problems?:

NUMBER OF

TIMESDON’T KNOW /

REFUSED

PS1. In a hospital or inpatient setting? _______PS2. As an outpatient or private patient? _______

PS3. Do you receive a pension (i.e., income/benefits) for a psychiatric disability?


Have you had a significant period (that was not a direct result of drug/alcohol use) in which you have:

30 days before most

recent incarceration

In Your Lifetime

Yes No Yes NoPS 4. Experienced serious depressionPS 5. Experienced serious anxiety or tensionPS 6. Experienced hallucinationsPS 7. Experienced trouble understanding, concentrating or rememberingPS 8. Experienced trouble controlling violent behaviorPS 9. Experienced serious thoughts of suicidePS 10. Attempted suicidePS 11. Been prescribed medication for any psychological emotional

problem

PS 12. How many days in the past 30 days before your most recent incarceration have you experienced these psychological or emotional problems? [BE SURE TO HAVE THE CLIENT/PATIENT RESTRICT HIS/HER RESPONSES TO THOSE PROBLEMS COUNTED IN ITEMS PS4 THROUGH PS10.]

_________ days

PS 13. How much have you been troubled or bothered by these psychological or emotional problems in the past 30 days before your most recent incarceration? [CHOOSE ONE. SEE SHOW CARD 4.]



PS 14. How important to you now is treatment for these psychological problems? [CHOOSE ONE. SEE SHOW CARD 4.]





VII. CRIMINAL JUSTICE HISTORY/LEGAL STATUS QUESTIONS

This next set of questions is about your involvement with the criminal justice system during your lifetime. When answering these questions, include involvement in the criminal justice system as a juvenile or youth.

CJ1. Have you been sentenced since you came to jail, not including past sentences? (FOR CLIENTS WHO ARE NOT IN JAIL, REFER TO MOST RECENT INCARCERATION)


CJ2. At what age were you first arrested?

Age: ____________ DON’T KNOW / REFUSED

CJ3. At what age did you first go to jail or juvenile detention center?

Age: ____________ DON’T KNOW / REFUSED

CJ4. Have you ever been on parole or probation? This includes your experience as a juvenile and an adult. [CHECK ALL THAT APPLY]

Yes -Probation Yes-Parole No DON’T KNOW / REFUSED

CJ5. In your whole life, how many times have you been arrested? Include arrests as a juvenile and an adult.

Number of times: ____________ DON’T KNOW / REFUSED

CJ6. In your whole life, how much time have you spent locked up in jails, prisons or juvenile facilities? Include all jail and prison sentences, as well as time served before going to trial. Don’t include time spent under supervision while out in the community like parole, probation or any type of electronic monitoring. Has it been…?

[SELECT ONE.]

Less than 6 months DON’T KNOW / REFUSED

At least 6 months, but not more than 2 years

At least 2, but not more than 5 years

At least 5, but not more than 10 years

10 years or more



VIII. EMPLOYMENT/SUPPORT STATUS

Now I’m going to ask you about your educational and employment history.

E1. What is the highest grade or level of school you’ve completed? [SELECT ONE.]

No formal education

Less than High School Diploma or G.E.D.: [CIRCLE HIGHEST GRADE LEVEL COMPLETED]

Grade: 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th

High School Diploma or GED Received

College [INDICATE THE NUMBER OF YEARS COMPLETED.]: Years: 1 2 3 4 >04


E1a. Have you completed any training or technical education?

[INCLUDE FORMAL/ORGANIZED TRAINING ONLY. FOR MILITARY TRAINING, ONLY INCLUDE TRAINING THAT CAN BE USED IN CIVILIAN LIFE, LIKE ELECTRONICS OR COMPUTER TRAINING.]

No Yes Enter the number of months of formal or organized training that client has completed ______months

E2. Do you have a profession, trade or skill? PROBE: “any job training through a formal on-the-job training program or a training school”

NO Yes Specify:_____________________________________

E3. Do you have a valid driver’s license?

NO SKIP TO E5 YES

E4. [ONLY IF E3 IS “YES”] Do you have an automobile available for use?

NO YES

E5. How long was your longest full-time job? _______ AND ______ Years Months

E6. How many days were you paid for working in the 30 days before your most recent incarceration? [INCLUDE “UNDER THE TABLE” WORK]




E7. In the 30 days before your most recent incarceration, did someone contribute to your support in any way? [REGULAR CASH, HOUSING, OR FOOD FROM A FRIEND OR FAMILY INCLUDING A SPOUSE]

NO SKIP TO E9 YES

E8. [ONLY IF E7 IS “YES”] Did this constitute the majority of your support?

NO YES

E9. Which of these describes your usual or most common employment situation in the past 3 years?

Full time (40 hours/week) Military Service

Part time (regular hours) Retired/Disability

Part time (irregular, daywork) Unemployed

Student In controlled environment

Now I’m going to ask about how much money you received from various sources, like jobs, public assistance, or from any other means that you get money.

How much money did you receive from the following sources in the 30 days before your most recent incarceration?

E10. Employment (net income) $________ DON’T KNOW / REFUSED

E11. Unemployment compensation $________ DON’T KNOW / REFUSED

E12. Public Assistance (e.g. TANF, food stamps, AFDC) $________ DON’T KNOW / REFUSED

E13. Pension, benefits, or social security $________ DON’T KNOW / REFUSED

E14. Mate, family or friends (cash money given to you for personal expenses) $________ DON’T KNOW / REFUSED

E15. Illegal (cash money from drug dealing, stealing, selling stolen goods, etc) $________ DON’T KNOW / REFUSED



IX. Health and Well-Being (SF12v2)

The first few questions ask about your health and well-being. This information will help us get a sense of how you have been feeling and how well you are able to do your usual activities. [READ EACH QUESTION VERBATIM. FOR EACH OF THE FOLLOWING QUESTIONS, MARK AN IN THE ONE BOX THAT BEST DESCRIBES THE CLIENT’S ANSWER.]

SF1. In general, would you say your health is: [SEE SHOW CARD 1]

Excellent Very good Good Fair Poor

1 2 3 4 5

SF2. The following questions are about activities you might do during a typical day. We know that not everyone does these types of activities. Try to answer the question as best you can even if you don’t do these types of activities. Does your health now limit you in these activities? If so, how much?

Yes,Limited a

lot

Yes,Limited a little

No, notLimited at all

a. Moderate activities, such as moving a table, pushing a vacuum cleaner, sweeping a floor, or walking.

1 2 3

b. Climbing several flights of stairs 1 2 3

SF3. During the past 30 days , how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health? [SEE SHOW CARD 2]

All of the time

Most of the time

Some of the time

A little of the time

None of the time

a. Accomplished less than you would like 1 2 3 4 5

b. Were limited in the kind of work or other activities 1 2 3 4 5



SF4. During the past 30 days , how much of the time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? [SEE SHOW CARD 2]

All of the time

Most of the time

Some of the time


None of the time

a. Accomplished less than you would like 1 2 3 4 5

b. Did work or other activities less carefully than usual 1 2 3 4 5

SF5. During the past 30 days , how much did pain interfere with your normal work (including both work within and outside of your living space)? [SEE SHOW CARD 3]

Not at all A little bit Moderately Quite a bit Extremely

1 2 3 4 5

SF6. These questions are about how you feel and how things have been with you during the past 30 days . For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 30 days ... [SEE SHOW CARD 2]

All of the time

Most of the time

Some of the time


None of the time

a. Have you felt calm and peaceful? 1 2 3 4 5

b. Did you have a lot of energy? 1 2 3 4 5

c. Have you felt downhearted and blue? 1 2 3 4 5

SF7. During the past 30 days , how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, family visits, etc.)? [SEE SHOW CARD 2]All of the

timeMost of the

timeSome of the

timeA little of the

timeNone of the

time

1 2 3 4 5



X. DEMOGRAPHICSNow I’m going to ask about your personal background. Some of the answers to these questions might seem obvious, but I have to ask all the questions anyway.

D1. What is your gender? [SELECT ONE]

Male Transgender (Male to Female) Female Transgender (Female to Male)

D2. What is the month and year when you were born? I don’t need your full date of birth.

________ / ________ MONTH YEAR


D3. Are you of Latino(a) or of Hispanic/Spanish ethnicity or origin? [SELECT ONE]


D4. What is your race? [CHECK ALL THAT APPLY]

White American Indian or Alaskan Native Black Other: (specify)___________________ Asian DON’T KNOW / REFUSED Native Hawaiian or Pacific Islander

D5. In what country or geographic territory were you born? [SELECT ONE]

United States Dominican Republic Puerto Rico

Canada Haiti Other (specify):________

China Jamaica DON’T KNOW / REFUSED

Cuba Mexico

D6. What language do you speak most of the time, with friends and family? [SELECT ONE]

English Other: (specify)___________________

Spanish REFUSED

D7. Do you think of yourself as: straight/heterosexual, bisexual, gay/homosexual, lesbian/homosexual, unsure, or in some other way? [IF PERSON STOPS YOU TO IDENTIFY WHICH ONE APPLIES, NO NEED TO GO THROUGH WHOLE LIST. SELECT ONE.]

Heterosexual/Straight Other (specify):____________________ Bisexual Unsure Gay/Homosexual REFUSED Lesbian/Homosexual



INTERVIEWER SHOULD COMPLETE QUESTIONS B4 to B7 IMMEDIATELY AFTER COMPLETING INTERVIEW (BEFORE OPTIONAL MODULES ARE ADMINISTERED).

B4. Interview End Date: m m d d y y y y

B5. Interview End Time : AM PM

B6.

Interview conducted in one sitting?

Yes

No B6a. How many sittings? Number of sittings __________

B7. Where was interview conducted: Jail

Community

Both Locations

-- END OF CORE BASELINE INTERVIEW --



OPTIONAL MODULES:

OPTIONAL MODULE I: Childhood Trauma Questionnaire

Sites that have opted to use the childhood trauma questionnaire should use the separate hard copies of this instrument.

OPTIONAL MODULE II: SOCIAL SUPPORT (Source: Huba et al.)

This module is included with this BLN client interview.

OPTIONAL MODULE III: RISK BEHAVIORS: Sexual behaviors and injection drug use behaviors (Source: developed by COMPASS/Miriam Hospital team and based on various instruments)

This module is included with this BLN client interview.


HRSA Enhancing Linkages to HIV Primary Care Demonstration Form BLN 4-16-09 Opt Mods 1 of 1

OPTIONAL MODULE II. SOCIAL SUPPORT

Now I’m going to ask you questions about support from other people.

SSA. About how many close friends and close relatives do you have (people you feel at ease with and can talk to about what is on your mind)? ENTER NUMBER______

FOR THE NEXT SET OF STATEMENTS, RATE HOW OFTEN EACH OF THE KINDS OF SUPPORT IS AVAILABLE TO THE CLIENT IF HE/SHE NEEDS IT BY USING THE SCALE PROVIDED: [1=NONE OF THE TIME, 2=A LITTLE OF THE TIME, 3=SOME OF THE TIME, 4=MOST OF THE TIME, 5=ALL OF THE TIME.] READ THE QUESTIONS AS STATED AND CHECK ONE RESPONSE FOR EACH ROW.

[SS1] People sometimes look to others for companionship, assistance, or other types of support. How often is each of the following kinds of support available to you if you need it? [SELECT ONE RESPONSE FOR EACH LINE. SEE SHOW CARD 6.]

None of the time

1


2

Some of the time

3

Most of the time

4

All of the time

5

[SS1A] a. Someone to help if you were confined to bed. [SS1B] b. Someone you can count on to listen to you when you

talk.

[SS1C] c. Someone to give you advice about a crisis. [SS1D] d. Someone to take you to the doctor if you needed it. [SS1E] e. Someone who shows you love and affection. [SS1F] f. Someone to have a good time with. [SS1G] g. Someone to give you information to help you

understand a situation.

[SS1H] h. Someone to confide in or talk to about yourself or your problems.

[SS1I] i. Someone who hugs you. [SS1J] j. Someone to get together with for relaxation. [SS1K] k. Someone to prepare your meals if you were unable to

do it for yourself.

[SS1L] l. Someone whose advice you really want. [SS1M] m. Someone to do things with to get your mind off

things.

[SS1N] n. Someone to help with daily chores if you were sick. [SS1O] o. Someone to share your most private worries and

fears with.

[SS1P] p. Someone to turn to for suggestions about how to deal with personal problems.

[SS1Q] q. Someone to do something enjoyable with. [SS1R] r. Someone to understand your problems. [SS1S] s. Someone to love and make you feel wanted.


HRSA Enhancing Linkages to HIV Primary Care Demonstration Form BLN 4-16-09 SS 1 of 1

OPTIONAL MODULE III. RISK BEHAVIORS

Sexual Behavior Now I'd like to talk with you about your sex life--things like who your partners were, and what you did with them. We'll be talking about some really personal things but remember: everything you tell me is confidential, and there are no right or wrong answers. Before we get into the specifics, let's briefly go over the definitions of some terms that I'm going to be using, so that we're sure that we're using them in the same way. This may be helpful to you in answering the questions that I will be asking.

[SEE SHOW CARD 7 FOR DESCRIPTIONS OF SEX BEHAVIOR]When I say: I mean:

Vaginal Sex: When a male inserts his penis into a female's vaginaReceptive Anal Sex: When a male puts his penis into your anus or butt.Receptive oral sex: When a male puts his penis into your mouth.[For men only] Insertive Anal Sex:

When you put your penis into the anus or butt of your partner.

OK. Do you have any questions? Remember, if at any time you are unsure about any of the terms that I use, please ask me about it. Are you ready?

RB1. How many people did you have sex with during the 30 days before your most recent incarceration? Only include people you had vaginal or anal sex with.

Number of people _______ [IF “0”, SKIP TO RB24]

DON’T KNOW/NOT SURE REFUSED

RB2. During the 30 days before your most recent incarceration, did you have vaginal or anal sex with only men, only women, or with both men and women?

Only men

Only women

Both men and women

DON’T KNOW/NOT SURE

REFUSED

RB3. Approximately how many times did you have vaginal or anal sex during the 30 days before your most recent incarceration?

Number of times _______ DON’T KNOW/NOT SURE REFUSED


HRSA Enhancing Linkages to HIV Primary Care Demonstration Form BLN 4-16-09 RB 1 of 10

MAIN PARTNER

RB4. In the 30 days before your most recent incarceration, did you have sex with someone who you consider to be your main sex partner, that is a partner who you felt committed to above anyone else?

Yes No SKIP TO RB13 REFUSED SKIP TO RB13

RB5. Is this person a man or a woman?

Man Woman REFUSED

RB6. What is the HIV status of this partner?

HIV-positive

HIV-negative

Do not know the status of this partner

REFUSED

RB7. Thinking back about the last time you had vaginal or anal sex with this person, did you and this partner use a condom?

Yes

No

DON’T KNOW/DON’T REMEMBER

REFUSED

RB8. Thinking back about the last time you had vaginal or anal sex with this person, were you under the influence of alcohol or drugs?

Yes

No


REFUSED



RB9. During the 30 days before your most recent incarceration, how often did you and your main sex partner have vaginal sex? [READ ALL RESPONSE OPTIONS. SELECT ONE RESPONSE]. SEE SHOW CARD 8.

Never SKIP TO RB11 At least once/day

Several times/week

About once/week

Several times/month

About once/month

Less than once/month

DON’T KNOW

REFUSED

RB10. Of the times that you and your main sex partner had vaginal sex during the 30 days before your most recent incarceration, how often did you and your partner use a condom? [READ ALL RESPONSE OPTIONS. SELECT ONE RESPONSE. SEE SHOW CARD 9.]

Never

Sometimes

Most of the time

Every time

DON’T KNOW

REFUSED

RB11. During the 30 days before your most recent incarceration, how often did you and your main sex partner have anal sex? [READ ALL RESPONSE OPTIONS. SELECT ONE RESPONSE. SEE SHOW CARD 8.]

Never SKIP TO RB13 At least once/day

Several times/week

About once/week

Several times/month

About once/month

Less than once/month

DON’T KNOW

REFUSED



RB12. Of the times that you and your main sex partner had anal sex during the 30 days before your most recent incarceration, how often did you and your partner use a condom? [READ ALL RESPONSE OPTIONS. SELECT ONE RESPONSE. SEE SHOW CARD 9.]

Never

Sometimes

Most of the time

Every time

DON’T KNOW

REFUSED

NON-MAIN PARTNER

RB13. In the 30 days before your most recent incarceration, did you have vaginal or anal sex with someone who was not your main partner or whom you did not consider to be your main partner at the time? [SELECT ONE RESPONSE.]

Yes

No SKIP TO RB24 REFUSED SKIP TO RB24

RB14. How many non-main partners did you have vaginal or anal sex with during the 30 days before your most recent incarceration?

Number of non-main partners: ____________ DON’T KNOW/NOT SURE

REFUSED

RB15. Were these non-main partner(s) men or women? [ASK OPEN-ENDED AND LET RESPONDENT ANSWER. SELECT ONE RESPONSE.]

Men

Women

Both men and women

DON’T KNOW/NOT SURE

REFUSED



RB16. What is/are the HIV status(es) of this/these partner(s)? [CHECK ALL THAT APPLY. PROBE TO CONFIRM THAT THE RESPONDENT’S ANSWER REFLECTS ALL NON-MAIN PARTNERS]

HIV-positive / HIV-infected

HIV-negative

Do not know the HIV status of this/these partner(s)

REFUSED

RB17. Thinking back about the last time you had vaginal or anal sex with any non-main partner, were condoms used? [SELECT ONE RESPONSE.]

Yes

No


REFUSED

RB18. Thinking back about the last time you had vaginal or anal sex with any non-main partner, were you under the influence of alcohol or drugs? [SELECT ONE RESPONSE.]

Yes

No


REFUSED

RB19. Thinking about all the non-main sex partners you had during the 30 days before your most recent incarceration, how often did you have vaginal sex? [READ ALL RESPONSE OPTIONS. SELECT ONE RESPONSE. SEE SHOW CARD 8.]

Never SKIP TO RB21

At least once/day Several times/week About once/week Several times/month About once/month Less than once/month DON’T KNOW REFUSED



RB20. Of the times that you had vaginal sex with any non-main sex partner during the 30 days before your most recent incarceration, how often were condoms used? [READ ALL RESPONSE OPTIONS. SELECT ONE RESPONSE. SEE SHOW CARD 9.]

Never

Sometimes Most of the time Every time DON’T KNOW REFUSED

RB21. Thinking about all the non-main sex partners you had during the 30 days before your most recent incarceration, how often did you have anal sex? [READ ALL RESPONSE OPTIONS. SELECT ONE RESPONSE. SEE SHOW CARD 8.]

Never SKIP TO RB23 At least once/day Several times/week About once/week Several times/month About once/month Less than once/month DON’T KNOW REFUSED

RB22. Of the times that you had anal sex with any non-main sex partner during the 30 days before your most recent incarceration, how often were condoms used? [READ ALL RESPONSE OPTIONS. SELECT ONE RESPONSE. SEE SHOW CARD 9.]

Never Sometimes Most of the time Every time DON’T KNOW REFUSED

RB23. During the 30 days before your most recent incarceration, did you give or receive money and/or drugs in exchange for vaginal, oral, or anal sex? [SELECT ONE RESPONSE.]

Yes No



REFUSED

Injection Drug Use

The next set of questions is about using a needle to inject drugs. This would include drugs such as heroin, cocaine, amphetamines, or steroids, but does not include any drug taken under a doctor’s orders.

RB24. Have you ever, even once, used a needle to inject any drug? DO NOT include anything you took under a doctor’s orders. [SELECT ONE RESPONSE.]

Yes

No SKIP TO END OF RISK BEHAVIOR MODULE REFUSED

RB25. In the 30 days before your most recent incarceration, have you used a needle to inject any drug? [SELECT ONE RESPONSE.]

Yes

No SKIP TO END OF RISK BEHAVIOR MODULE REFUSED

RB26. In the 30 days before your most recent incarceration, how often did you inject with a needle that you knew or suspected someone else had used first? [READ ALL RESPONSE OPTIONS. SELECT ONE RESPONSE. SEE SHOW CARD 9.]

Never SKIP TO RB28 Almost Never

Sometimes

Most of the time

Every time

DON’T KNOW

REFUSED

RB27. The last time you used a needle to inject a drug, did you use a needle that you knew or suspected someone else had used before?

Yes

No

DON’T KNOW

REFUSED

RB28. When you injected drugs during the 30 days before your most recent incarceration, how often did you use a new, sterile needle? By sterile, I mean that it had never been used before, not even by you. [READ ALL RESPONSE OPTIONS. SELECT ONE RESPONSE. SEE SHOW CARD 9.]



Never SKIP TO RB30

Sometimes

Most of the time Every time DON’T KNOW REFUSED

RB29. The last time you used a needle to inject any drug, was it a new, sterile needle? By sterile, I mean that it had never been used before, not even by you. [SELECT ONE RESPONSE.]

Yes

No

DON’T KNOW

REFUSED

RB30. In the 30 days before your most recent incarceration, how often did you use cottons, a cooker, or rinse water that you knew or suspected someone else had used before? [READ ALL RESPONSE OPTIONS. SELECT ONE RESPONSE. SEE SHOW CARD 9.]

Never SKIP TO RB32 Sometimes

Most of the time

Every time

DON’T KNOW

REFUSED

RB31. The last time you used a needle to inject a drug, did you use cottons, a cooker, or rinse water that you knew or suspected someone else had used before?

Yes

No

DON’T KNOW

REFUSED

RB32. In the 30 days before your most recent incarceration, how often did someone else use a needle after you used it? [READ ALL RESPONSE OPTIONS. SELECT ONE RESPONSE.] SEE SHOW CARD 9.



Never SKIP TO RB34

Sometimes

Most of the time

Every time

DON’T KNOW

REFUSED

RB33. The last time you used a needle to inject a drug, did someone else use a needle after you used it? [SELECT ONE RESPONSE.]

Yes

No

DON’T KNOW

REFUSED

RB34. In the 30 days before your most recent incarceration, how often did someone else use cottons, cooker or rinse water after you? [READ ALL RESPONSE OPTIONS. SELECT ONE RESPONSE. SEE SHOW CARD 9.]

Never SKIP TO RB36

Sometimes


RB35. The last time you used a needle to inject a drug, did someone else use the cottons, cooker or rinse water after you? [SELECT ONE RESPONSE.]

Yes

No

DON’T KNOW

REFUSED

RB36. In the 30 days before your most recent incarceration, how often did you inject drugs that had been divided in somebody else's syringe? This is sometimes called “backloading”,



“frontloading”, or “splitting”. [READ ALL RESPONSE OPTIONS SELECT ONE RESPONSE. SEE SHOW CARD 9.]

Never SKIP TO RB38

Sometimes


RB37. The last time you used a needle to inject a drug, did you inject drugs that had been divided in somebody else's syringe? [SELECT ONE RESPONSE.]

Yes

No

DON’T KNOW

REFUSED

RB38. In the 30 days before your most recent incarceration, how often did you use your syringe to divide drugs between you and someone else? This is sometimes called “frontloading”, “backloading”, or “splitting”. [READ ALL RESPONSE OPTIONS. SELECT ONE RESPONSE. SEE SHOW CARD 9.]

Never SKIP TO END OF RISK BEHAVIOR MODULE

Sometimes


RB39. The last time you used a needle to inject a drug, did you use your syringe to divide drugs between you and someone else?

Yes

No

DON’T KNOW

REFUSED



Documents

Demographics and Criminal History - CHIP€¦ · Web viewPlease let me know if there is a word or question you do not understand, and I will read it again or explain what I mean