Form C6M Follow-up 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
NOTE: This interview is to be administered by project staff other than the primary provider to the client in the community.
INTERVIEW INTRODUCTION
TIME STARTED: : AM PM
Thank you for agreeing to do this interview today. This interview will follow up on questions that you answered when you began in the _____[INSERT NAME OF PROGRAM]______program. The questions I ask today are very similar to questions you answered before. But now, we’re trying to find out what it’s been like for you since you were released from jail.
During today's interview, I'm going to ask you questions about how you have been feeling since you were released from jail on ___ __ [INTERVIEWER: INSERT RELEASE DATE FROM INDEX INCARCERATION]. I’ll also ask you some questions about your family and friends. I’ll ask you to describe your use of drugs and alcohol, criminal activity, reincarceration, and your experiences in the _____[INSERT NAME OF PROGRAM]______program. 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 40 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?
HRSA Enhancing Linkages to HIV Primary Care Demonstration Form C6M FINAL ENG4-16-09 1of 18
RELEASE DATE
REL1. Since you were released from jail on ______did you spend any time locked up in a jail, prison, or hospital? [INTERVIEWER: INSERT RELEASE DATE FROM INDEX INCARCERATION. DO NOT COUNT TRANSFERS BETWEEN CORRECTIONAL FACILITIES.]Yes
No SKIP TO NEXT SECTION
DON’T KNOW / REFUSED SKIP TO NEXT SECTION
REL2. Please tell me the number of separate times you were locked up in a jail, prison or hospital since you were released from jail on ______[INTERVIEWER: INSERT RELEASE DATE FROM INDEX INCARCERATION.]
Number of times: ______DON’T KNOW / REFUSED
REL2a. Altogether, about how many days did you spend locked up since you were released from jail on ______? [INTERVIEWER: USE SHOW CARD CALENDAR TO HELP RESPONDENT IDENTIFY THE DURATION OF EPISODES OF INCARCERATION OR COMMITMENT SINCE RELEASE FROM THE INDEX INCARCERATION.]
Number of days: ______DON’T KNOW / REFUSED
REL2b. Please provide the dates of entry and release for the 3 most recent instances of time spent in a jail, prison, or hospital since you were released from jail on ______[INTERVIEWER: DO NOT REPORT DATES FOR INDEX INCARCERATION.]
Instance / Duration / Facility Type
1st / Entry:
Release: / m m d d y y y y
unknown not released / Jail
Prison
Hospital
Other: ______
DON’T KNOW / REFUSED
2nd / Entry:
Release: / m m d d y y y y
unknown not released / Jail
Prison
Hospital
Other: ______
DON’T KNOW / REFUSED
3rd / Entry:
Release: / m m d d y y y y
unknown not released / Jail
Prison
Hospital
Other: ______
DON’T KNOW / REFUSED
HRSA Enhancing Linkages to HIV Primary Care Demonstration Form C6M FINAL ENG4-16-09 1of 18
I. FAMILY/SOCIAL RELATIONSHIPS
The next set of questions asks about your social relationships and your family.
F1.Whatbest 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 / REFUSEDF3. In the past 30 days, did you live with anyone who…
F3a. Had an alcohol problem? / Yes No DON’T KNOW / REFUSEDF3b. Had a drug problem? / Yes No DON’T KNOW / REFUSED
F4. How many children under 18 are currentlyin your care?
Number of Children / ______/ DON’T KNOW / REFUSEDF5.In the past 30 days, how bothered or troubled have you been by family problems? [CHOOSE ONE. SEE SHOW CARD 4]
Not at all / Slightly / Moderately / Considerably / ExtremelyDON’T KNOW / REFUSED
F6.Howimportant to you NOW is treatment or counseling for family problems? [CHOOSE ONE. SEE SHOW CARD 4]
Not at all / Slightly / Moderately / Considerably / ExtremelyDON’T KNOW / REFUSED
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 Satisfied
WRITE INTERVIEWER COMMENTS HERE [NOTE QUESTION# COMMENT APPLIES TO] :
HRSA Enhancing Linkages to HIV Primary Care Demonstration Form C6M FINAL ENG 1of 18
II. LIVING CONDITIONS
Now I’m going to ask a few questions about where you have been living since you were released from jail.
H1. At any time in the past 30 days, did you consider yourself to be homeless?
Yes / No / DON’T KNOW / REFUSEDH2. In the past 30 days, did you mostly live alone or with other people? [CHOOSE ONE].
With other people / Alone SKIP TO H4 / DON’T KNOW / REFUSEDH3. Did you live with… [READ LIST TO RESPONDENT. CHECK ALL THAT APPLY].
Spouse/intimate partner / Unrelated adult(s), like friends and roommatesChild 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/children
H4. Inthepast 30 days, 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 10H4b. 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 past 30 days, was there any time for two or more days, when you didn’t get anything, or barely anything, to eat? [CHOOSE ONE].
Yes / No / DON’T KNOW / REFUSEDIII. HIV and HEALTH
Now I will ask you about HIV testing and medical treatment you’ve received for HIV.
HIV1. Where were you first diagnosed with HIV? [CHOOSE ONE.]
Correctional facility / Medical facility in the communityDrug treatment program / Other (SPECIFY): ______
DON’T KNOW / REFUSED
HIV2. During the past 30 daysdid you have a usual health care provider or place where you get HIV care?
Yes / No / DON’T KNOW / REFUSEDNow 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.
HIV3. Have you ever taken HIV medications?
Yes GO TO HIV4 / NoSKIP TO HIV6 / DON’T KNOW / REFUSEDHIV4. To what extent do your friends or family members help you remember to take your medication? [CHOOSE ONE].
Not at All / A Little / Somewhat / A Lot / Not ApplicableHIV5. During the last 7 days, were you taking any HIV medications?
Yes SKIP TO HIV7 / NoGO TO HIV6 / DON’T KNOW / REFUSEDHIV6. 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 NEXT SECTIONMy doctor has not prescribed medications SKIP TO NEXT SECTION
I cannot afford medications SKIP TO NEXT SECTION
I do not want to take medications SKIP TO NEXT SECTION
I prefer to use natural or alternative treatments SKIP TO NEXT SECTION
I have tried these medications and they do not work for me SKIP TO NEXT SECTION
I have tried these medications and there are too many side effects SKIP TO NEXT SECTION
Other______ SKIP TO NEXT SECTION
DON’T KNOW / REFUSED SKIP TO NEXT SECTION
Now I’m going to ask you about how often you took your prescribed HIV medicines in the past 7 days. 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 past7 days. 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.
HIV7. In the past 7 days, 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 / REFUSEDIV. MEDICAL STATUS & HEALTH INSURANCE
For 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 / REFUSEDM2. 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 / REFUSEDM3.How long ago was your last hospitalization for a medical problem? [ ENTER THE NUMBER OF YEARS AND MONTHS SINCE THE PATIENT WAS LAST HOSPITALIZED OVERNIGHT FOR A MEDICAL PROBLEM.]
______/ AND/OR ______/ DON’T KNOW / REFUSEDYears / Months
M4. Other than HIV, do you have any chronic medical problems?
NOYES M4a. What chronic medical problems do you have? [ASK OPEN ENDED AND CHECK ALL THAT APPLY]
Tuberculosis / Diabetes
Hepatitis B / Other: (specify)______
Hepatitis C / Other: (specify)______
Asthma / DON’T KNOW / REFUSED
Chronic pain
Hypertension
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 DRUGSSEPARATED BY COMMAS. DO NOT INCLUDE PSYCHIATRIC MEDICINES]
______
______
______
______
M6. How many days have you experienced medical problems in the past 30 days? [ONLY INCLUDE PHYSICAL MEDICAL PROBLEMS, NOT MENTAL HEALTH PROBLEMS.]
Number of days:______/ DON’T KNOW / REFUSEDNOTE 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 past thirty days...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 past 30 days? [CHOOSE ONE. SEE SHOW CARD 4.]
Not at all / Slightly / Moderately / Considerably / ExtremelyDON’T KNOW / REFUSED
M8.How important to you now is treatment for these medical problems? [CHOOSE ONE. SEE SHOW CARD 4.]
Not at all / Slightly / Moderately / Considerably / ExtremelyDON’T KNOW / REFUSED
M9.In the past 6 months have you had any health insurance or benefits to pay for all or part of the cost of your medical care or medications?
YESGO TO M10NO SKIP TO NEXT SECTION
DON’T KNOW / REFUSED SKIP TO NEXT SECTION
M10.What kinds of health insurance or benefits have you had in the past 6 months? 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 USE
This next set of questions asks about your experience with alcohol and drugs throughout your life and in the past 30 days.
[INTERVIEWER CAN REFER TO LOCAL STREET NAMES FOR THESE SUBSTANCES.] / LIFETIME# of years with regular use / How many days was (substance) used in the past 30 days / 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 / Oral Nasal Smoke NonIV IV
SA7. Other sedative/ hypnotic/ tranquilizer: Benzodiazepines = Valium, Librium, Ativan, Serax, Tranxene, Dalmane, Halcion, Xanax, Miltown, Other = Chloral Hydrate, Quaaludes / Oral Nasal Smoke NonIV IV
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 / Oral Nasal Smoke NonIV IV
SA10. Cannabis: Marijuana, Hashish / Oral Nasal Smoke NonIV IV
SA11. Hallucinogens: LSD (Acid), Mescaline, Psilocybin (Mushrooms), Peyote, Green, PCP (Phencyclidine), Angel Dust, Ecstasy / Oral Nasal Smoke NonIV IV
SA12. Inhalants: Nitrous Oxide (Whippits), Amyl Nitrite (Poppers), Glue, Solvents, Gasoline, Toluene, Etc. / Oral Nasal Smoke NonIV IV
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]
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]
SA15b. Drug abuse: Number of times: ____ / DON’T KNOW / REFUSED
IF SA15 = 0 FOR BOTH ALCOHOL ABUSE AND DRUG ABUSE, SKIP TOSA 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 past 30 days on:
SA17a. Alcohol abuse: $ ____ / DON’T KNOW / REFUSEDSA17b. Drug abuse: $ ____ / DON’T KNOW / REFUSED
SA 18. How many days were you treated as an outpatient for alcohol or drugs in the past 30 days? [INCLUDE NA, AA (IF 3+ MEETINGS WITHIN A ONE-MONTH PERIOD)]
Number of days: ______/ DON’T KNOW / REFUSEDSA 19.How many days in the past 30 days have you experienced alcohol problems?
Number of days: ______/ DON’T KNOW / REFUSEDSA 20. How many days in the past 30 days have you been troubled or bothered by any alcohol problems?
Number of days: ______/ DON’T KNOW / REFUSEDSA 21. How troubled or bothered were you in the past 30 days by these alcohol problems? [CHOOSE ONE. SEE SHOW CARD 4.]
Not at all / Slightly / Moderately / Considerably / ExtremelyDON’T KNOW / REFUSED
SA 22. How important to you now is treatment for these alcohol problems? [CHOOSE ONE. SEE SHOW CARD 4.]
Not at all / Slightly / Moderately / Considerably / ExtremelyDON’T KNOW / REFUSED
SA 23.How many days in the past 30 days have you experienced drug problems?
Enter Number: ______/ DON’T KNOW / REFUSEDSA 24. How troubled or bothered were you in the past 30 days by drug problems? [CHOOSE ONE. SEE SHOW CARD 4.]
Not at all / Slightly / Moderately / Considerably / ExtremelyDON’T KNOW / REFUSED
SA 25. How important to you now is treatment for these drug problems? [CHOOSE ONE. SEE SHOW CARD 4.]