Exhibit 2-2
Simple Screening Instrument for AOD Abuse Interview Form
Note: Boldfaced questions constitute a short version of the screening instrument that can be administered in situations that are not conducive to administering the entire test. Such situations may occur because of time limitations or other conditions.
Introductory statement:
"I'm going to ask you a few questions about your use of alcohol and other drugs during the past 6 months. Your answers will be kept private. Based on your answers to these questions, we may advise you to get a more complete assessment. This would be voluntary - it would be your choice whether to have an additional assessment or not."
During the past 6 months...
Have you used alcohol or other drugs? (Such as wine, beer, hard liquor, pot, coke, heroin or other opiates, uppers, downers, hallucinogens, or inhalants.) (yes/no)
Have you felt that you use too much alcohol or other drugs? (yes/no)
Have you tried to cut down or quit drinking or using drugs? (yes/no)
Have you gone to anyone for help because of your drinking or drug use? (Such as Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, counselors, or a treatment program.) (yes/no)
Have you had any of the following?
Blackouts or other periods of memory loss
Injury to your head after drinking or using drugs
Convulsions, or delirium tremens ("DTs")
Hepatitis or other liver problems
Feeling sick, shaky, or depressed when you stopped drinking or using drugs
Feeling "coke bugs," or a crawling feeling under the skin, after you stopped using drugs
Injury after drinking or using drugs
Using needles to shoot drugs.
Has drinking or other drug use caused problems between you and your family or friends? (yes/no)
Has your drinking or other drug use caused problems at school or at work? (yes/no)
Have you been arrested or had other legal problems? (Such as bouncing bad checks, driving while intoxicated, theft, or drug possession.) (yes/no)
Have you lost your temper or gotten into arguments or fights while drinking or using drugs? (yes/no)
Are you needing to drink or use drugs more and more to get the effect you want? (yes/no)
Do you spend a lot of time thinking about or trying to get alcohol or other drugs? (yes/no)
When drinking or using drugs, are you more likely to do something you wouldn't normally do, such as break rules, break the law, sell things that are important to you, or have unprotected sex with someone? (yes/no)
Do you feel bad or guilty about your drinking or drug use? (yes/no)
Now I have some questions that are not limited to the past 6 months.
Have you ever had a drinking or other drug problem? (yes/no)
Have any of your family members ever had a drinking or drug problem? (yes/no)
Do you feel that you have a drinking or drug problem now? (yes/no)
Thanks for answering these questions.
Do you have any questions for me?
Is there something I can do to help you?
Notes:
Observation Checklist
The following signs and symptoms may indicate an AOD abuse problem in the individual being screened:
Needle track marks
Skin abscesses, cigarette burns, or nicotine stains
Tremors (shaking and twitching of hands and eyelids)
Unclear speech: slurred, incoherent, or too rapid
Unsteady gait: staggering, off balance
Dilated (enlarged) or constricted (pinpoint) pupils
Scratching
Swollen hands or feet
Smell of alcohol or marijuana on breath
Drug paraphernalia such as pipes, paper, needles, or roach clips
"Nodding out" (dozing or falling asleep)
Agitation
Inability to focus
Burns on the inside of the lips (from freebasing cocaine)
Exhibit 2-3
Simple Screening Instrument for AOD Abuse Self-Administered Form
Directions: The questions that follow are about your use of alcohol and other drugs. Your answers will be kept private. Mark the response that best fits for you. Answer the questions in terms of your experiences in the past 6 months.
During the last 6 months...
Have you used alcohol or other drugs? (Such as wine, beer, hard liquor, pot, coke, heroin or other opiates, uppers, downers, hallucinogens, or inhalants)
___
Yes
___
No
Have you felt that you use too much alcohol or other drugs?
___
Yes
___
No
Have you tried to cut down or quit drinking or using alcohol or other drugs?
___
Yes
___
No
Have you gone to anyone for help because of your drinking or drug use? (Such as Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, counselors, or a treatment program.)
___
Yes
___
No
Have you had any health problems? For example, have you:
___Had blackouts or other periods of memory loss?
___Injured your head after drinking or using drugs?
___Had convulsions, delirium tremens ("DTs")?
___Had hepatitis or other liver problems?
___Felt sick, shaky, or depressed when you stopped?
___Felt "coke bugs" or a crawling feeling under the skin after you stopped using drugs?
___Been injured after drinking or using?
___Used needles to shoot drugs?
Has drinking or other drug use caused problems between you and your family or friends?
___
Yes
___
No
Has your drinking or other drug use caused problems at school or at work?
___
Yes
___
No
Have you been arrested or had other legal problems? (Such as bouncing bad checks, driving while intoxicated, theft, or drug possession.)
___
Yes
___
No
Have you lost your temper or gotten into arguments or fights while drinking or using other drugs?
___
Yes
___
No
Are you needing to drink or use drugs more and more to get the effect you want?
___
Yes
___
No
Do you spend a lot of time thinking about or trying to get alcohol or other drugs?
___
Yes
___
No
When drinking or using drugs, are you more likely to do something you wouldn't normally do, such as break rules, break the law, sell things that are important to you, or have unprotected sex with someone?
___
Yes
___
No
Do you feel bad or guilty about your drinking or drug use?
___
Yes
___
No
The next questions are about your lifetime experiences.
Have you ever had a drinking or other drug problem?
___
Yes
___
No
Have any of your family members ever had a drinking or drug problem?
___
Yes
___
No
Do you feel that you have a drinking or drug problem now?
Exhibit 3-1
Simple Screening Instrument for Infectious Diseases Field Version
Have you seen a doctor or other health care provider in the past 3 months? (yes/no)
Do you live on the street or in a shelter? (yes/no)
Have you ever been in jail? (yes/no)
Have you ever been told you have a positive HIV test [test for the AIDS virus]? (yes/no)
Women: Have you missed your last two periods? (yes/no)
Have you ever had a positive skin test for TB? I mean a test where you got a shot in your forearm, and a few days later a hard bump like a blister appeared. (yes/no)
Have you ever been told you have TB? Has anybody you know or have lived with been diagnosed with TB in the past year? (yes/no)
Within the last 30 days, have you had any of the following symptoms lasting for more than 2 weeks?
Fever
Drenching night sweats that were so bad you had to change your clothes or the sheets on the bed
Productive cough
Coughing up blood
Shortness of breath
Lumps or swollen glands in the neck or armpits
Losing weight without meaning to
Diarrhea (runs) lasting more than a week
Do you live with someone who has any of the following symptoms?
Coughing up blood
Drenching night sweats
Do you know or are you close to anyone with these symptoms? (yes/no)
Do you use needles to shoot drugs? (yes/no)
Do you use coke or crack? (yes/no)
In the last 6 months, have you had any VDs [venereal diseases, STDs, sexually transmitted diseases], like syphilis, the clap [gonorrhea], chlamydia, or NGU [nongonococcal urethritis, trichomoniasis, trick]? (yes/no)
Have you, or anyone you've had sex with, had any of the following symptoms within the last 30 days?
Sore or ulcer on the penis/vagina ["down there"]?
Rash, spots, or other skin problems, especially on your palms or the soles of your feet? Women:
A vaginal discharge that is different from what you usually have?
Pain when you have vaginal sex? Men:
Discharge from the penis?
Have you had sex with more than two people - at different times - in the past 6 months? I mean any type of vaginal, rectal, or oral contact, like you went down on your partner or he/she went down on you, with or without a condom. (yes/no)
Have you used your rectum for sex? (yes/no) [Use regionally appropriate terminology to indicate penile penetration, as opposed to other types of sexual contact.]
In the past 6 months, have you had sex with someone in return for anything, like money, alcohol or other drugs, a place to stay, or just to survive? (yes/no)
Have you ever been forced to have sex against your will? (yes/no)
Exhibit 3-2
Simple Screening Instrument for Infectious Diseases Annotated Version
All of the questions in the screening instrument are worded so that an answer of "yes" indicates an increased risk for the disease appearing in brackets after the question. Following each question are the indications for what type of referral should be made when an increased risk is identified. Whenever possible, care should be taken to refer to the least number of agencies possible. For example, STD and HIV testing may be available at STD clinics, prenatal care sites, or comprehensive health centers. Also following each question is background information pertaining to the question and the rationale for its inclusion.
Letters refer to the following categories:
A = Needs supporting data based on pilot studies
B = General medical evaluation
C = TB screening
D = STD assessment
E = Prenatal care
F = HIV counseling, testing, referral, and partner notification
G = HIV care/early intervention
Suggested language is incorporated throughout the questionnaire to introduce the screening questions and explain to the respondent why they are being asked. By no means does this wording have to be repeated verbatim to every respondent. The most important goal is to ensure that the concepts expressed by these narrative passages are successfully communicated. The interviewer should always take into account regional and cultural variations in terminology and should use the language that is most comfortable for the person being interviewed. Possible alternative terms are sometimes indicated in quotes within brackets.
Suggested Introductory Statement
A lot of people who use drugs have health problems that they don't even know they have. I want to find out whether you might have any health problems that we can help you with.
Even if you don't feel sick, there could still be something going on with your health that we can do something about before it turns into a bigger problem. To find out, I need to ask you some questions, to get some information from you.
I want you to know that my agency will not give this information to anyone without your permission. [This latter statement can be repeated to the client if a need for referral is identified as a result of the screening; in addition, something like the following statement should also be made when referring a client: I need to ask you to sign this paper so I can tell (the facility to receive the referral) what your answers were. All this paper does is let me tell them why you're going there. I won't do it unless you say it's OK.]
Based on your answers to these questions, we may advise you to get a physical exam. This would be voluntary - it would be your choice whether to have the exam or not. If you do get an exam, there are some diseases that, if you are found to have them, must be reported to the health department.
Administration of the Screening Instrument
First, I'm going to ask you a couple of general questions about whether you've seen a doctor lately, and about where you live.
Have you seen a doctor or other health care provider in the past 3 months? (yes/no)
[Indication: A]
Do you live on the street or in a shelter? (yes/no)
[Risk: TB, HIV]
[Indications: C, F]
Have you ever been in jail? (yes/no)
[Risk: TB, possibly HIV]
[Indications: C, F (depending on locality)]
Now I want to ask you some specific questions about certain kinds of diseases. The reason for these questions is that the diseases we're talking about are better treated if they are caught early.
You've probably heard about the AIDS virus - that you can have it without being sick. That's an example of the kinds of things we're looking for. It's much better to find out about it early, because treatment works better in early cases. [Women: "This is especially important if there is a chance that you could be pregnant, because your baby could get sick or die if you have HIV."]
Have you ever been told you have a positive HIV test [test for the AIDS virus]? (yes/no)
[Risk: HIV]
[Indication: G]
Women: Have you missed your last two periods? (yes/no)
[Risk: Pregnancy complicated by STDs or HIV]
[Indications: D, E, F]
Have you ever had a positive skin test for TB? I mean a test where they gave you a shot in your forearm, and a few days later a hard bump like a blister appeared. (yes/no)
[Risk: TB]
[Indication: C]
Have you ever been told you have TB? Has anybody you know or have lived with been diagnosed with TB in the past year? (yes/no)
[Risk: TB]
[Indication: C]
Within the last 30 days, have you had any of the following symptoms lasting for more than 2 weeks?
Fever
Drenching night sweats that were so bad you had to change your clothes or the sheets on the bed
Coughing up blood
Shortness of breath
Lumps or swollen glands in the neck or armpits
Losing weight without meaning to
Diarrhea (runs) lasting more than a week
[Risk: TB, possibly HIV-related syndromes]
[Indications: B, C, F]
Are you now living with someone with any of the following?
Coughing up blood
Drenching night sweats
Active TB
[Risk: TB, possibly HIV-related syndromes]
[Indication: C]
Now I need to find out a little bit about what kind of drugs you use. This is because some types of drug use increase your risk of getting certain diseases.
Do you use needles to shoot drugs? (yes/no)
[Risk: HIV]
[Indication: F]
Do you use coke or crack? (yes/no)
[Risk: Syphilis, HIV]
[Indications: D, F]
I'm going to ask you these next questions because, as you probably know, there are certain types of infections - like VD - that you can get from having sex with other people. Some of these questions are pretty personal, but you should know that I am not here to judge you. Don't worry about saying "yes" to any of these questions if that's the true answer. The only thing I'm interested in is finding out if you're at risk for a disease that we can treat you for.
In the last 6 months, have you had any VDs [venereal diseases, STDs, sexually transmitted diseases], like syphilis, the clap [gonorrhea], chlamydia, or NGU [nongonococcal urethritis, trichomoniasis, trick]? (yes/no)
[Risk: HIV, STDs]
[Indication: D, F]
Have you, or anyone you've had sex with, had any of the following symptoms within the last 30 days?
[Risk: STDs, HIV]
[Indications: D, F]
Sore or ulcer on the penis/vagina ["down there"]
Rash or spots, especially on your palms or on the soles of your feet?
Women:
A vaginal discharge that is different from what you usually have
Pain when you have vaginal sex
Men:
Discharge from the penis
[Questions 12--15 refer to activities that are associated with increased behavioral risk for STDs, especially those that are asymptomatic. They should be asked in a nonjudgmental manner.]
Have you had sex with more than two people - at different times - in the past 6 months? I mean any type of vaginal, rectal, or oral contact, like you went down on your partner or he/she went down on you, with or without a condom. (yes/no)
[Risk: STDs, HIV]
[Indications: D, F]
Have you used your rectum for sex? (yes/no) [Use regionally appropriate terminology to indicate penile penetration, as opposed to other types of sexual contact.]
[Risk: HIV]
[Indication: F]
In the past 6 months, have you had sex with someone in return for anything, like money, alcohol or other drugs, a place to stay, or just to survive? (yes/no)
[Risk: STDs, HIV]
[Indications: D, F]
1Have you ever been forced to have sex against your will? (yes/no)
[Risk: STDs, HIV]
[Indication: A]
Exhibit 5-1
Consent for the Release of Confidential Information
I,
(Name of client)
authorize
(Name or general designation of program making disclosure)
to disclose to
(Name of person or organization to which disclosure is to be made)
the following information:
(Nature of the information, as limited as possible)
The purpose of the disclosure authorized herein is as follows:
(Purpose of disclosure, as specific as possible)
I understand that my records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R.
Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows: (Specification of the date, event, or condition upon which consent expires)
Date:
(Signature of participant)
(Signature of parent, guardian, or authorized representative, when required)
Exhibit 5-2
Prohibition on Redisclosing Information Concerning Clients Receiving Treatment for AOD Abuse
This notice accompanies a disclosure of information concerning a client in alcohol/drug abuse treatment, made to you with the consent of such client. This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.
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