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Employment Application Date of Birth Illegal - Excel

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Employment Application Date of Birth Illegal document sample

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									                                       Client Administrative Information - ADMISSION MODULE
Note:    T = TEDS;    G = GPRA;        P = PPG
TEDS     Field Name                       Questions & Description                     Data Type Width                           Value and Label

 T1      providerid   6-digit federal assigned ID                                        Text       8
          episode     System Viariable                                                  Number
            event     System Variavble                                                  Number
           fname      Client’s First Name                                                Text       25
          mname       Client’s Middle Name                                               Text        8
           lname      Client' Last Name                                                  Text       25
 T3         SSN       Social Security Number                                             Text       13
         nameomit     Check here if client did not consent to send name, ssn, and       Number
          Gender      Client’s Sex                                                      Number      1    1. Male
                                                                                                         2. Female
                                                                                                         3. Transgender
                                                                                                         4. Other
 T5         DOB       Client’s Date of Birth                                            Date/Time   10   Format as mm/dd/yyyy
 T2       caseno      Case Number; First and Third initials of First and Last name        Text       4
T2,4,5    clientID    Computer Created Client ID based on unique identifying              Text      12
                      information from the client.
           dateintv   Date of Interview                                                 Date/Time   10
 T7      dateadmin    Date of admission to treatment level of care                      Date/Time   10
 T6      inhouseno    In-House Case Number. This is an optional field used for in-house   Text      15
                      tracking purposes only. Agency may enter their own agency’s
                      case/tracking number in this field.
 T8      clientType   Client Type                                                       Number      1    1. Alcohol/Drug Abuser
                                                                                                         2. Co-Dependant/Family (non-substance abuser)
          treatType   Treatment Type                                                    Number      1    1. Admission in a New Episode
                                                                                                         2. Continuing Care within same Agency
                                                                                                         3. Continuing Care - Transfer from another Agency




                                                                             Page 1
TEDS   Field Name                         Questions & Description                          Data Type Width                            Value and Label
 T9       ALOC        Treatment Level of Care at admission (Numeric Field, Size=2,          Number     1      1. Standard/Traditional Outpatient
                      Value=1 through 15)                                                                     2. Intensive Outpatient
                                                                                                              3. Partial Hospitalization
                                                                                                              4. Transitional Care/Extended Care
                                                                                                              5. Halfway House
                                                                                                              6. Long-Term Residential
                                                                                                              7. Short-Term Residential (Medically Monitored)
                                                                                                              8. Hospital-Based (acute) Residential
                                                                                                              9. Detox-Free-Standing Residential (Sub-Acute)
                                                                                                             10. Detox-Hospital Inpatient
                                                                                                             11. Detox-Outpatient (Non-Methadone)
                                                                                                             12. OPIOID Maintenance-Outpatient
                                                                                                             13. Detox-Methadone Outpatient
                                                                                                             14. Non-traditional program
                                                                                                             15. OPIOID Maintenance - Intensive Outpatient
       Sitelocation   Agency location                                                        Text     50     New Horizon Treatment Services, Inc.
T10    methadone      Is the use of methadone planned as part of this treatment?            Number     1     0. No
                                                                                                             1. Yes
                                                                                                             9. Don’t know
       CFMADMIT       To admit this client to different level of care as Concurrent Care    Number     1     1. check = 1 or
                                                                                                             2. uncheck = Null
GT13     larrange     Living arrangement at the time of admission                           Number     1     1. Homeless-Shelter
                                                                                                             2. Homeless-Streets
                                                                                                             3. Dependent Living/Institution
                                                                                                             4. Independent Living
        address1      Client’s street address, apartment number etc.                         Text     50
        address2      P.O Box number, Mail Stop number etc.                                  Text     50
            city      Client’s city name                                                     Text     50
           state      Client’s 2-letter state name (example, New Jersey = NJ)                Text      2
T12      zipcode      Client’s 5-digit Zip Code                                              Text      5
         d4code       4-digit code next to zipcode (optional)                                Text      4
T11     Municode      Client’s Resident Code (4-digit code, @-digit County Code+2-digit      Text      4
                      Municipality Code)
          phoneno     Client’s phone number                                                  Text     13
            email     Client’s email (if any)                                                Text     30
       contactName    Client’s contact person name                                           Text     14
          contaddr    [Same as Client's address] Contact person’s address                    Text     24
           contcity   Contact person’s city                                                  Text      8
          contstate   Contact person’s state (2-letter state name)                           Text      2
        contzipcode   Contact person’s zip code                                              Text      5
        contd4code    Contact person’s 4-digit code next to zip code                         Text      4
         contphone    Contact person’s phone number                                          Text     13
         contemail    Contact person’s email address                                         Text     30


                                                                                Page 2
TEDS    Field Name                         Questions & Description                    Data Type Width                          Value and Label
         Curaddyy,    Length of time at current address? [Year(s) and Month(s)]        Number    4
        Curaddmm
T18        Ethnic     Latino or Hispanic Origin                                       Number     1      1. Not of Hispanic Origin
                                                                                                        2. Puerto Rican
                                                                                                        3. Mexican
                                                                                                        4. Cuban
                                                                                                        5. Dominican
                                                                                                        6. Other Hispanic: Specify
         Otherhisp    If “Other Hispanic” is selected, specify                         Text      20
GT17   Race1, Race2   Client’s race (Select up to 2 choices)                          Number     1      1. White
                                                                                                        2. Black
                                                                                                        3. Asian
                                                                                                        4. Alaskan Native
                                                                                                        5. American Indian
                                                                                                        6. Native Hawaiian or other Pacific Islander

                      Self Help Groups Ever Participated in: (Check all that apply)

         selfhelp1    Narcotic Anonymous (NA)                                         Number     1
                                                                                                        If check, given value = 1
         selfhelp2    Alcoholic Anonymous (NA)                                        Number     1
                                                                                                        If check, given value = 1
         selfhelp3    None                                                            Number     1
                                                                                                        If check, given value = 1
         selfhelp4    Other                                                           Number     1
                                                                                                        If check, given value = 1
         Religious    What is your religious preference?                              Number     1      1. Protestant
                                                                                                        2. Catholic
                                                                                                        3. Jewish
                                                                                                        4. Islamic
                                                                                                        5. Other
                                                                                                        6. None
                                                                                                        8. Refused
                                                                                                        9. Don't Know
         Relother     If "Other" specify                                               Text
         Veteran      Is the Client a Veteran?                                        Number     1      0. No
                                                                                                        1. Yes
          Katrina     Is the Client a Katrina Evacuee?                                Number     1      0. No
                                                                                                        1. Yes
T15     Hhincome      Clients Household Income                                        Currency   8
T16      Hhsize       Clients Household Size (number of members in clients family)    Number     2
T26     adepisode     Number of past alcohol and drug treatment episode               Number     2
T20        e1         What is the hightest grade you completed in school?             Number     2
 G         e2         Do you have a high school diploma or GED?                       Number     1      0. No
                                                                                                        1. Yes


                                                                             Page 3
 TEDS      Field Name                       Questions & Description                             Data Type Width                           Value and Label
   G           e15      Are you currently enrolled in school or a job training program?          Number     1   1. Not enrolled
                                                                                                                2. Enrolled Full -Time
                                                                                                                3. Enrolled Part -Time
                                                                                                                4. Other
             e15a       If not enrolled                                                                     1   1. Dropped Out
                                                                                                                2. Expelled
                                                                                                                3. Suspended
                                                                                                                4. Medical Leave
                                                                                                                5. Home Study
                                                                                                                6. Other
            e15other    If other specify                                                          Text     50
PGT21,22       e4       Which best describes your CURRENT employment situation?                  Number     2     1. Full-time work or military (35 hours a week or more)
                                                                                                                  2. Part-time (regular hours)
                                                                                                                  3. Part-time (not regular hours)
                                                                                                                  4. Student
                                                                                                                  5. Home Maker
                                                                                                                  6. Retired
                                                                                                                  7. Unemployed: Actively looking for work
                                                                                                                  8. Unemployed: Not looking for work
                                                                                                                  9. Unemployed: Volunteer Work
                                                                                                                10. Unemployed: Living in an institution
                                                                                                                (like a jailor prison, hospital or overnight treatment program)
                                                                                                                11. Disable
  T19         f1a       What is your current marital status?                                     Number     1   1. Never Married
                                                                                                                2. Married
                                                                                                                3. Widowed
                                                                                                                4. Separated
                                                                                                                5. Divorced
              f1b       If not "Married", are you currently living with a significant other ?    Number         0. No
                                                                                                                1. Yes

                                        What is your Current Legal Status?
                                               [Check all that apply]
               l1a      No Legal Problem                                                         Number       1
               l1b      Case Pending                                                             Number       1
               l1c      Drug Court                                                               Number       1
               l1d      Probation                                                                Number       1
               l1e      Parole                                                                   Number       1
                l1f     Jail/Prison Inmate                                                       Number       1
               l1g      DYFS or Family Court                                                     Number       1
               l1h      Other                                                                    Number       1
                l1i     DWI License Suspension                                                   Number       1
            l2nother    If other; Specify                                                         Text       30


                                                                                    Page 4
TEDS     Field Name                         Questions & Description                             Data Type Width                          Value and Label
            Arrest     How many times have you been arrested and charged for an                  Number    3
                       offense in the past 30 days?

                                                   Pregnancy Questions
            m8         How many times in your life have you been pregnant ?                     Number     2
            m9         How many of these pregnancies resulted in a live birth ?                 Number     2
            m10        Have you given birth to a child in the past 12 months                    Number     1
  P         m11        Are you pregnant now ?                                                   Number     1      0. No
                                                                                                                  1. Yes
                                                                                                                  9. Don't know
            m12        How many of your children are still living today ?                       Number     2

                       HealthCare Coverage (Check all that apply)
T27a,b   Healthcare1   Medicaid                                                                 Number     1      If check, given value = 1
T27a,b   Healthcare2   Medicare                                                                 Number     1      If check, given value = 1
T27a,b   Healthcare3   NJ FamilyCare                                                            Number     1      If check, given value = 1
T27a,b   Healthcare4   VA/Champus                                                               Number     1      If check, given value = 1
T27a,b   Healthcare5   Insurance paid by client or client’s employer (BCBS, Aetna etc.)         Number     1
                                                                                                                  If check, given value = 1
T27a,b   Healthcare6   Other Coverage (eg. Worker’s Compensation)                               Number     1      If check, given value = 1
T27a,b   Healthcare7   Uninsured                                                                Number     1      If check, given value = 1
         Managecare    Is Client in a managed care plan like an HMO or Provider Network,        Number     1      0. No
                       PPO etc                                                                                    1. Yes
                                                                                                                  9. Don’t know
          depchild     Is the client bringing dependent children into treatment?                Number     1      0. No
                                                                                                                  1. Yes
         Hmanychild    If the client is bringing in dependent children to the treatment, then   Number     1
                       ask the number of children that are being brought to the treatment

 T23      refsource    Referral Source (Check only one – Numeric Field)                         Number     1       1. Self
                                                                                                                   2. Family/Friend
                                                                                                                   3. Addiction Services
                                                                                                                   4. Corrections Related Programs
                                                                                                                   5. Intoxicated Drivers Resource Center (IDRC)
                                                                                                                   6. Mental Health
                                                                                                                   7. Medical/Health
                                                                                                                   8. Welfare/Social Services
                                                                                                                   9. Employee Assistance Program
                                                                                                                  10. Hotline
                                                                                                                  11. Other
          refsource    If Addiction Services is selected                                        Number     2      31. Addiction Treatment Program
                                                                                                                  32. County Drug and Alcohol Coordinator
                                                                                                                  33. South Jersey Initiative
                                                                                                                  34. Other

                                                                                 Page 5
TEDS    Field Name                           Questions & Description                      Data Type Width                         Value and Label
         refsource      If "Corrections Related Programs" selected                         Number    2    41. Municipality - Municipal Court
                                                                                                          42. County - Family Court
                                                                                                          43. County - Drug Court
                                                                                                          44. County - Probation
                                                                                                          45. County - Detention Center
                                                                                                          46. County - Other
                                                                                                          47. STATE - NJ Department of Correction
                                                                                                          48. STATE – NJ State Parole Board/ District Office
                                                                                                          49. FEDERAL - US Federal Prison
                                                                                                          50. FEDERAL - US Federal Court
                                                                                                          52. Juvenile Justice Commission (JJC)
                                                                                                          53. Other
        ref41muni       If "Corrections Related Programs and “Municipal Court” is           Text      4   Municipality Code:
                        selected, enter 4-digit municipality code (Character Field)                       County:
         refcounty      If “IDRC” is selected, enter county code of IDRC                    Text      2   5. Intoxicated Drivers Resource Center (IDRC)
                                                                                                                  County/Type
         refsource      If “Mental Health” is selected                                      Text      2   6. Mental Health
                                                                                                              61. Mental Health Screening Center
                                                                                                              62. Mental Health Provider/Clinic
                                                                                                              63. Hospital
                                                                                                              64. Other
                                                                                                              65. MICA Program
       refhospname      If "Mental Health" is selected type the name of the hospital        Text     50
         refsource      If "Medical/Health" is selected                                    Number     2   71. County or Municipal Health Department
                                                                                                          72. Hospital, Crisis Emergency Room
                                                                                                          73. Other Hospital
                                                                                                          74. Health Care Agency/Private Physician
                                                                                                          75. Other
         refsource      If "Welfare/Social Service" is selected                                           81. NJ Dept. of Human Services-DYFS
                                                                                                          82. WFNJ-Substance Abuse Initiative (SAI)
                                                                                                          83. Substance Abuse Research Demonstration
                                                                                                          84. Other
         sbinumber      If Client is referred from Correction Related Program                text    10
       refsource12txt   If “Other” is selected to specify the referral source               Text     50
                        Tobacco Use Questions
T30       tobuse        Does client currently use any tobacco products? (not including     Number      1    0. No
                        nicotine replacement)                                                               1. Yes

                        Tobacco Products used (Check all that apply)
        tobname1        Cigarettes                                                         Number      1
        tobname2        Cigar                                                              Number      1
        tobname3        Pipe                                                               Number      1
        tobname4        Chewing Tobacco                                                    Number      1


                                                                                 Page 6
TEDS    Field Name                         Questions & Description                              Data Type Width                        Value and Label
 T30    cighowmany      Number of cigarettes smoked per day ( Indicate number of                 Number    2    Cigarettes
                        cigarettes-not number of packs, 1 pack = 20 cigarettes; 0 = none)

         atobacco1      Does the client want to stop using tobacco or cut down from their        Number     1    1. Quit
                        current tobacco use?                                                                     2. Cut Down
                                                                                                                 3. No

                        Is client currently using any Nicotine Replacement Therapy?
                        (Check one of the following)
        atobacco5d      No                                                                       Number     1
        atobacco5a      Gum                                                                      Number     1
        atobacco5b      Patch                                                                    Number     1
        atobacco5c      Other                                                                    Number     1
         atobacco2      Does the client have a disease or symptoms that they believe are         Number     1    0. No
                        caused by or made worse by smoking or other tobaco use?                                  1. Yes
         atobacco3      Prior to coming to this facilty, estimate how soon (in minutes) after    Number     3    minutes
                        the client wakes, do they use tobacco or smoke their first
                        cigarette?
         atobacco4      Number of past attempts to stop smoking or stop tobacco use              Number     2    time(s)
PT29a   pdrug, sdrug,   Drug Problem: Name of the Primary Drug,                                  Number     2     1. Alcohol
            tdrug       Secondary Drug, Tertiary Drug(Numeric Field)                                              2. Heroin
                                                                                                                  3. Marijuana/Hashish
                        NOTE: The Primary Drug is mandatory and there                                             4. Cocaine - Powder
                               is no option for "None". The Secondary                                             5. Crack
                               and Tertiary Drug, there is an option for "None"                                   6. Methamphetamines
                        Modification:-                                                                            7. Barbiturates
                        Drug Code number 6 has been splited into "6" as                                           8. Benzodiazepine
                        "Methamphetamines" and "22" as "Other Amphetamines" on                                    9. Ecstacy
                        04/10/06.                                                                                10. GHB
                                                                                                                 11. Hallucinogens - LSD
                                                                                                                 12. Hallucinogens - PCP
                                                                                                                 13. Hallucinogens - Other
                                                                                                                 14. Inhalants
                                                                                                                 15. Ketamine, Special K
                                                                                                                 16. Methadone (non-prescription)
                                                                                                                 17. Opiate - Other
                                                                                                                 18. Oxycontin
                                                                                                                 19. Rohypnol
                                                                                                                 20. Other
                                                                                                                 21. None (For Secondary and Tertiary only)
                                                                                                                 22. Other Amphetemines




                                                                                  Page 7
TEDS      Field Name                          Questions & Description                           Data Type Width                        Value and Label
T29a   pfreq, sfreq, tfreq Frequency of Drug Use for Primary Drug;                               Number    1    1. No use past month
                                                                                                                2. less than weekly
                          NOTE: Frequency use of Primary Drug is mandatory and there                            3. 1 to 2 times per week
                               is no option for "N/A".                                                          4. 3 to 6 times per week
                                                                                                                5. Daily
                                                                                                                7. N/A (For Secondary and Tertiary only)
T29a      pageuse,        Age at first use of Primary Drug                                       Number    2
T29a      saguese
           tageuse        Age at first use of Tertiary Drug                                      Number      2
T29a    proute, sroute,   Route of administration for Primary Drug                               Number      1    1. Oral
            troute                                                                                                2. Inhalation/sniffing
                                                                                                                  3. Smoking
                                                                                                                  4. Intramuscular/sub-cutaneous
                                                                                                                  5. Intravenous
                                                                                                                  7. N/A



                          Controlled Environment
        cenv1, cenv2      In the past 30 days, has client lived in a 24-hour controlled          Number      1    1. No
                          environment such as Prison, Jail, Residential Drug Treatment                            2. Jail
                          Program? (If client has lived in more than one controlled                               3. Alcohol/Drug Treatment
                          environment, select 2 choices)                                                          4. Medical Treatment
                                                                                                                  5. Psychiatric Treatment
                                                                                                                  6. Other
           inpcenv        In the past 30 days, all together how many days did the client live    Number      1
                          in a controlled environment? (enter number of days 0 thru 30)


                          Treatment History
            outpat        In the past 30 days, how many days has the client been treated as      Number      1
                          an outpatient for Alcohol and drug problems? (enter number of
                          days 0 thru 30)
         emergency        In the past 30 days, has the client been treated in an emergency       Number      1    0. No
                          room for alcohol drug problems?                                                         1. Yes
           waitday        How many days did the client wait to enter treatment since first       Number      3
                          requesting admission from this agency? (enter number of days 0

                          Reimbursement Source (Check all that apply, If check, value

                          1. Division of Addiction Services
                          a. Block Grant:
           reim1a1        General DAS Funding                                                    Number      1
           reim1a2        Block Set-Aside, Women's                                               Number      1

                                                                                 Page 8
TEDS     Field Name                          Questions & Description                         Data Type Width   Value and Label
           reim1a3       Block Set-Aside, HIV                                                 Number    1
           reim1a4       Block Set-Aside, Other                                               Number    1

                         b. Special Initiatives:
             reim1b1     Targeted capacity Expansion                                         Number      1
             reim1b2     South Jersey Initiative                                             Number      1
 T28         reim1b3     DYFS/Women and Children                                             Number      1
             reim1b4     Deaf, Hard of Hearing and Disabled                                  Number      1
             reim1b5     DEDR - HIV Prevention                                               Number      1
T25(2)       reim1b6     Work First Substance Abuse Initiative                               Number      1
             reim1b7     Compulsive Gambling                                                 Number      1
             reim1b8     IDRC Expansion Fund                                                 Number      1
             reim1b9     WTC-New Jersey Recovers                                             Number      1
            reim1b10     Other Special Initiatives                                           Number      1
            reim1b11     CWRP Adolescent                                                     Number      1
            reim1b12     CWRP Adult                                                          Number      1
            reim1b13     DUI Initiative                                                      Number      1
         reim1bspecify   If "Other Special Initiatives" is selected, specify reimbursement    Text      50
                         source
                         2. Criminal Justice
                         a. DAS Funded:
T25(1)     reim2a1       Mutual Agreement Program (MAP)                                      Number     1
T25(3)     reim2a2       Drug Court ( Prison Bound) - Residential                            Number     1
T25(3)     reim2a3       Drug Court ( Prison Bound) - Aftercare                              Number     1
T25(3)     reim2a4       Drug Court ( Non-Prison Bound) - OJP                                Number     1
           reim2a5       Juvenile Justice Initiative                                         Number     1
           reim2a6       DWI/DUI Grants                                                      Number     1
                          b. Other funded:
           reim2b1       Residential Community Release Program                               Number     1
           reim2b2       Residential Parole Violator Program                                 Number     1
           reim2b3       Parole Day Reporting/Aftercare                                      Number     1
           reim2b4       Juvenile Justice Commission                                         Number     1
           reim2b5       Administrative Office of the Courts                                 Number     1
           reim2b6       Probation Aftercare - US Dept. of Justice                           Number     1
                         3. Public Assistance:
            reim31       TANF                                                                Number     1
            reim32       General Assistance                                                  Number     1
            reim33       Food Stamps                                                         Number     1
            reim34       Charity Care                                                        Number     1
 T28        reim35       Medicaid                                                            Number     1
 T28        reim36       Medicare                                                            Number     1
            reim37       NJ FamilyCare                                                       Number     1
                         4. County LACADA:
            reim41       Chapter 51                                                          Number     1

                                                                              Page 9
TEDS   Field Name                         Questions & Description                           Data Type Width                   Value and Label
         reim42     Enhancement                                                              Number    1
         reim43     PRCC                                                                     Number    1
         reim44     Direct County Funding                                                    Number    1
         reim45     Sub-Acute Detoxification                                                 Number    1
         reim46     Youth Service Commission                                                 Number    1
         reim47     Other                                                                    Number    1
                    5. Other Funding:
         reim51     Division of AIDS Prevention and Control                                 Number     1
         reim52     Division of Family Health Services                                      Number     1
         reim53     Division of Mental Health Services                                      Number     1
T28      reim54     Division of Youth and Family Services (DYFS)                            Number     1
         reim55     Ryan White                                                              Number     1
         reim56     Private Insurance                                                       Number     1
         reim57     Client Fees or Family Payment                                           Number     1
         reim59     No reimbursement Source/No fee
         reim58     Other                                                                   Number      1
       reim58oth    If "Other" is selected, specify                                          Text      50


                                                   Gambling Screen

         gmb1       Have you often spent a lot of time thinking about past gambling         Number     1      0. No
                    ventures or bets ?                                                                        1. Yes
         gmb2       Have you ever lied to family members, friends or others about how       Number     1      0. No
                    often you gamble or how much money you lost gambling ?                                    1. Yes
         gmb3       After losing at gambling, do you try to return as quickly as possible   Number     1      0. No
                    to win back your losses ?                                                                 1. Yes

                                             Take the Survey
       Gproblem     1) Pass or Fail                                                         Number            0. No problem
                                                                                                              1. Problem
         DSM4       2) DSM-IV Score for gambling                                            Number
         OEAT       3) OEAT Score for gambling                                              Number
                                      End of Admission Module




                                                                             Page 10
TEDS   Field Name                        Questions & Description                             Data Type Width                         Value and Label
                                          Client Administrative Information - DISCHARGE MODULE
T7,9   Dadmdate     Admission Date for this Discharge ( Date Field mm/dd/yyyy)       Date/Time          10
 T8      Dloc       Level of Care at the time of Discharge ( Numeric Field, Size = 2, Number             2      1. Standard/Traditional Outpatient
                    Value = 1 through 15)                                                                       2. Intensive Outpatient
                                                                                                                3. Partial Hospitalization
                                                                                                                4. Transitional Care/Extended Care
                                                                                                                5. Halfway House
                                                                                                                6. Long-Term Residential
                                                                                                                7. Short-Term Residential (Medically Monitored)
                                                                                                                8. Hospital-Based (acute) Residential
                                                                                                                9. Detox-Free-Standing Residential (Sub-Acute)
                                                                                                               10. Detox-Hospital Inpatient
                                                                                                               11. Detox-Outpatient (Non-Methadone)
                                                                                                               12. OPIOID Maintenance-Outpatient
                                                                                                               13. Detox-Methadone Outpatient
                                                                                                               14. Non-traditional program
                                                                                                               15. OPIOID Maintenance - Intensive Outpatient
 T1    ProviderID   The first 6-digit identifies Fed. Assigned ID to uniquely identify the     Text     8
                    Provider and the last 2-digit identifies the sequential number of the
                    agency's sites. (Character Field, Size = 8)
        Dfname      Client First Name (Character Field, Size = 25)                             Text     25
        Dmname      Client Middle Name (Character Field, Size = 25)                            Text     25
        Dlname      Client Last Name (Character Field, Size = 25)                              Text     25
       Daddress1    Client's street address, apartment number etc. (Character Field,           Text     50
       Daddress2    P.O. Box number, Mail Stop number etc. (Character Field, Size =            Text     50
         Dcity      Client city of residence (Character Field, Size = 25)                      Text     25
         Dstate     Client state of residence (Character Field, Size = 2)                      Text      2
          Dzip      Client zip code of residence (Character Field, only numbers                Text      5
                    allowed, Size = 5)
       Disd4code    4-digit code after the zip code (Character Field, only numbers            Text       4
         Dtelno     allowed,telephone number (Character Field, size = 13 - format
                    Client's Size = 4)                                                        Text      13
        Demail      (609)-292-1466 )
                    Client's email address (Character Field, Size = 30)                       Text      30
 T4     Dgender     Client sex;                                                              Number      1     1. Male
                                                                                                               2. Female
 T3    Dsocsecno    Social Security Number (Character Field, Size = 11 - format 111-       Text         11     3. Transgender
 T2     Dcaseno     Client Case Number (The same case number at admission)                 Text          4
 T5    Dbirthdate   Client's date of birth (Date Field, Size = 8 - Format mm/dd/yyyy)    Date/Time      10
 T6    Dinhouseno   This is an optional field used for in-house tracking purposes only.    Text         15
                    Agency may enter their own agency's case/tracking number in this
                    field. (Character Field, Size = 8, Alpha-Numeric allowed)
        Ddisdate    Date of discharge from the treatment level of care (Date Field, Size Date/Time      10
                    = 8 - Format mm/dd/yyyy)

                                                                              Page 11
TEDS   Field Name                         Questions & Description                        Data Type Width                          Value and Label
 T10     Dtoday      Date of discharge date entered (Date Field, Size = 8 - Format       Date/Time  10
                     mm/dd/yyyy)
       Dcontname     Name of person to contact or follow-up (Character Field, Size =       Text     50
                     50)
        Dcontaddr    Street address/PO box of contact person (Character Field, Size =      Text     50
        Dcontcity    Contact city of residence (Character Field, Size = 50)                Text     50
        Dcontstate   Contact state of residence (Character Field, Size = 2)                Text      2
         Dcontzip    Contact 5-digit zip code of residence (Character Field, only          Text      5
                     numbers allowed, Size = 5)
       Dcontd4code   Contact 4-digit code after the 5-digit zip code (Character Field,     Text     4
                     only numbers allowed, Size=5)
       Dcontphone    Contact phone number (Character Field, Size = 13 - format (609)-      Text     13
                     292-1466)
       Dcontemail    Contact email address (Character Field, Size = 30)                    Text     30

                     At the time of Admission the Client has the following                                 To be able to update reimbursement source in admission at
                     Reimbursement                                                                         the time of discharge. Update only in admission
 G        De15       Are you currently enrolled in school or a job training program      Number            1. Not enrolled
                                                                                                           2. Enrolled Full -Time
                                                                                                           3. Enrolled Part -Time
                                                                                                           4. Other
         De15a       If not enrolled                                                                       1. Dropped Out
                                                                                                           2. Expelled
                                                                                                           3. Suspended
                                                                                                           4. Medical Leave
                                                                                                           5. Home Study
                                                                                                           6. Other
        De15oth      If other, Specify                                                    Text
 P     Dempstatus    Employment status of client at the time of discharge (Numeric       Number     2        1. Full-time work or military (35 hours a week or more)
                     Field, Size = 1, Value = 1 through 9)                                                   2. Part-time (regular hours)
                                                                                                             3. Part-time (not regular hours)
                                                                                                             4. Student
                                                                                                             5. Home Maker
                                                                                                             6. Retired
                                                                                                             7. Unemployed: Actively looking for work
                                                                                                             8. Unemployed: Not looking for work
                                                                                                             9. Unemployed: Volunteer Work
                                                                                                           10. Unemployed: Living in an institution,
                                                                                                           (like a jailor prison, hospital or overnight treatment program)
                                                                                                           11. Disable




                                                                             Page 12
TEDS   Field Name                       Questions & Description                         Data Type Width                       Value and Label
  G    Dlivestatus   Living arrangement at discharge (Numeric Field, Size = 1)           Number    1    1. Homeless-Shelter
                                                                                                        2. Homeless-Streets
                                                                                                        3. Dependent Living/Institution
                                                                                                        4. Independent Living
T19     Dusing1      Is Client using drugs or alcohol at Discharge?                      Number      1   Yes, Alcohol (Check Box)
T19     Dusing2      Is Client using drugs or alcohol at Discharge?                      Number      1   No Alcohol & No Drugs (Check Box)
T19     Dusing3      Is Client using drugs or alcohol at Discharge?                      Number      1   Yes, Drugs (Check Box)
T19     Dusing4      Is Client using drugs or alcohol at Discharge?                      Number      1   Unknown (Check Box)
        Ddrug1       Name of the Primary Drug at discharge (Drug Code)                   Number      2    1. Alcohol
                     Modification:-                                        Drug                           2. Heroin
                     Code number 6 has been splited into "6" as "Methamphetamines"                        3. Marijuana/Hashish
                     and "22" as "Other Amphetamines".                                                    4. Cocaine - Powder
                                                                                                          5. Crack
                                                                                                          6. Methamphetamines
                                                                                                          7. Barbiturates
                                                                                                          8. Benzodiazepine
                                                                                                          9. Ecstacy
                                                                                                         10. GHB
                                                                                                         11. Hallucinogens - LSD
                                                                                                         12. Hallucinogens - PCP
                                                                                                         13. Hallucinogens - Other
                                                                                                         14. Inhalants
                                                                                                         15. Ketamine, Special K
                                                                                                         16. Methadone (non-prescription)
                                                                                                         17. Opiate - Other
                                                                                                         18. Oxycontin
                                                                                                         19. Rohypnol
                                                                                                         20. Other
                                                                                                         21. None
                                                                                                         22. Other Amphetemines
 P       Dfreq1      Frequency of Primary Drug Use at Discharge;                         Number      1   1. No use past month
                                                                                                         2. less than weekly
                                                                                                         3. 1 to 2 times per week
                                                                                                         4. 3 to 6 times per week
                                                                                                         5. Daily
                                                                                                         7. N/A
        Droute1      Route of Administration for Primary Drug at Discharge;              Number      1   1. Oral
                                                                                                         2. Smoking
                                                                                                         3. Inhalation/sniffing
                                                                                                         4. Intramuscular/sub-cutaneous
                                                                                                         5. Intravenous
                                                                                                         7. N/A


                                                                              Page 13
TEDS   Field Name                     Questions & Description                      Data Type Width                          Value and Label
         Ddrug2     Name of the Secondary Drug at discharge (Drug Code)             Number    2       1. Alcohol
                    Modification:-                                                                    2. Heroin
                    Drug Code number 6 has been splited into "6" as                                   3. Marijuana/Hashish
                    "Methamphetamines" and "22" as "Other Amphetamines".                              4. Cocaine - Powder
                                                                                                      5. Crack
                                                                                                      6. Methamphetamines
                                                                                                      7. Barbiturates
                                                                                                      8. Benzodiazepine
                                                                                                      9. Ecstacy
                                                                                                     10. GHB
                                                                                                     11. Hallucinogens - LSD
                                                                                                     12. Hallucinogens - PCP
                                                                                                     13. Hallucinogens - Other
                                                                                                     14. Inhalants
                                                                                                     15. Ketamine, Special K
                                                                                                     16. Methadone (non-prescription)
                                                                                                     17. Opiate - Other
                                                                                                     18. Oxycontin
                                                                                                     19. Rohypnol
                                                                                                     20. Other
                                                                                                     21. None
                                                                                                     22. Other Amnphetemines
 P       Dfreq2     Frequency of Secondary Drug Use at Discharge;                  Number     1      1. No use past month
                                                                                                     2. less than weekly
                                                                                                     3. 1 to 2 times per week
                                                                                                     4. 3 to 6 times per week
                                                                                                     5. Daily
                                                                                                     7. N/A
        Droute2     Route of Administration for Secondary Drug at Discharge;                         1. Oral
                                                                                                     2. Smoking
                                                                                                     3. Inhalation/sniffing
                                                                                                     4. Intramuscular/sub-cutaneous
                                                                                                     5. Intravenous
                                                                                                     7. N/A




                                                                         Page 14
TEDS   Field Name                       Questions & Description                         Data Type Width                          Value and Label
         Ddrug3     Name of the Tertiary Drug at discharge (Drug Code)                   Number    2       1. Alcohol
                    Modification:-                                                                         2. Heroin
                    Drug Code number 6 has been splited into "6" as                                        3. Marijuana/Hashish
                    "Methamphetamines" and "22" as "Other Amphetamines".                                   4. Cocaine - Powder
                                                                                                           5. Crack
                                                                                                           6.Methamphetamines
                                                                                                           7. Barbiturates
                                                                                                           8. Benzodiazepine
                                                                                                           9. Ecstacy
                                                                                                          10. GHB
                                                                                                          11. Hallucinogens - LSD
                                                                                                          12. Hallucinogens - PCP
                                                                                                          13. Hallucinogens - Other
                                                                                                          14. Inhalants
                                                                                                          15. Ketamine, Special K
                                                                                                          16. Methadone (non-prescription)
                                                                                                          17. Opiate - Other
                                                                                                          18. Oxycontin
                                                                                                          19. Rohypnol
                                                                                                          20. Other
                                                                                                          21. None
                                                                                                          22. Other Amphetamines
 P       Dfreq3     Frequency of Tertiary Drug Use at Discharge;                        Number     1      1. No use past month
                                                                                                          2. less than weekly
                                                                                                          3. 1 to 2 times per week
                                                                                                          4. 3 to 6 times per week
                                                                                                          5. Daily
                                                                                                          7. N/A
        Droute3     Route of Administration for Tertiary Drug at Discharge;                               1. Oral
                                                                                                          2. Smoking
                                                                                                          3. Inhalation/sniffing
                                                                                                          4. Intramuscular/sub-cutaneous
                                                                                                          5. Intravenous
                                                                                                          7. N/A
                    What is your Current Legal Status? [Check all that apply]:
          Dl1a      No Legal Problem                                                    Number     1
          Dl1b      Case Pending                                                        Number     1
          Dl1c      Drug Court                                                          Number     1
          Dl1d      Probation                                                           Number     1
          Dl1e      Parole                                                              Number     1
          Dl1f      Jail/Prison Inmate                                                  Number     1
          Dl1i      DWI License Suspension                                              Number     1
          Dl1g      DYFS or Family Court                                                Number     1
          Dl1h      Other, Specify: L2nother                                            Number     1
                                                                              Page 15
TEDS   Field Name                          Questions & Description                           Data Type Width   Value and Label
          Dl1oth      If other; Specify                                                        Text     30
 P       Darrest      How many times has client been arrested and charged for an              Number     3
                      offense in the past 30 days (or, since admission if client in Tx. less
                      than 30 days)?

                      Target Population
                      Does the client belong to any of the following target
                      populations?
        Dtgpop1       Active DYFS Case                                                    Number        1
        Dtgpop2       Compulsive Gambler                                                  Number        1
        Dtgpop3       DWI/DUI - Alcohol only                                              Number        1
        Dtgpop4       DWI/DUI - Drug only or combination                                  Number        1
        Dtgpop5       DWI/DUI - Boaters and Non-auto                                      Number        1
        Dtgpop6       AIDS Diagnosis                                                      Number        1
        Dtgpop7       HIV Infected                                                        Number        1
        Dtgpop8       Blind/Visually Impaired                                             Number        1
        Dtgpop9       Deaf/Hard of Hearing                                                Number        1
        Dtgpop10      Disabled - Physical                                                 Number        1
        Dtgpop11      Disabled - Congnitive/Developmental Disability                      Number        1
        Dtgpop12      Mental Illness/Co-occurring Disorder                                Number        1
PT16    Dpsych1,      Psychiatric Diagnosis (required for Mental Health Agencies;          Text      6 each
        Dpsych2       optional for others)
        Dtgpop13      None of the above                                                   Number        1

                      Significant Problems
                      Significant Problems and Conditions Present at Admission or
                      Identified During Treatment?
T14    Dprobnotapp    Not Applicable                                                      Number        1
T14      DprobA       Mental Health Problem                                               Number        1
T14      DprobB       Compulsive Gambling                                                 Number        1
T14      DprobC       Physical Disability/Handicap                                        Number        1
T14      DprobD       Victim of Physical Abuse/Neglect                                    Number        1
T14      DprobE       Victim of Sexual Abuse                                              Number        1
T14      DprobF       Pregnancy                                                           Number        1
T14      DprobG       Suicide Attempt                                                     Number        1
T14      DprobH       Runaway Behavior                                                    Number        1
T14      DprobI       Neglect/Abuse of Client's Children                                  Number        1
T14      DprobJ       Child of Substance Abuser                                           Number        1
T14      DprobK       Batterer                                                            Number        1
T14      DprobL       Criminal Activity                                                   Number        1
T14      DprobM       Other                                                               Number        1
T14    Dprobspecify   If "Other" ; specify                                                 Text        50

                      Tobacco Use Questions

                                                                            Page 16
TEDS   Field Name                       Questions & Description                    Data Type Width            Value and Label

       Dtobyesno    Does the agency have the tobacco free policy?                  Number     1      0. No
                    If "Yes" …                                                                       1. Yes
       Dtobacco1    The client believes the tobacco free policy has                Number     1      0. No
                    helped them to address their own tobacco use.                                    1. Yes
       Dtobacco2    The client is known to have smoked or used                     Number     1      0. No
                    tobacco during treatment at this facility.                                       1. Yes
       Dtobacco3    The client plans to abstain from all tobacco                   Number     1      0. No
                    products after discharge from this facility.                                     1. Yes
       Dtobacco4    The client palns to seek help or treatment for                 Number     1      0. No
                    tobacco after discharge from this facility.                                      1. Yes
       Dtobacco5    The client is leaving the facility prematurely                 Number     1      0. No
                    mainly because of problems with the tobacco                                      1. Yes
                    free policy.
       Dtobacco6    Number of days the client used Nicotine                        Number     1      0. No
                    Replacement (nicotine patch or gum) while                                        1. Yes
                    in the facility.

T15                 Non-Agency Referrals for Substance Abuse Services :
        Dnaref1     Employee/Student Assist. Program (EAP)                         Number      1
        Dnaref2     Alcoholics Anonymous (AA)                                      Number      1
        Dnaref3     Narcotics Anonymous (NA)                                       Number      1
        Dnaref4     Family - Oriented Self - Help Program                          Number      1
        Dnaref5     Other Self - Help Program                                      Number      1
       Dnarefoth    If "Other Self-Help Program" is selected, specify               Text      50

                    Non-Agency Referrals for Other Supportive Services(Check all
                    that apply)
T17     Drefssa     None                                                           Number     1
        Drefssb     Clergy                                                         Number     1
        Drefssc     Educational                                                    Number     1
        Drefssd     Legal                                                          Number     1
        Drefsse     Medical                                                        Number     1
        Drefssf     Mental Health                                                  Number     1
        Drefssg     Public Welfare                                                 Number     1
        Drefssh     Pre-Natal                                                      Number     1
        Drefssi     Family Services                                                Number     1
        Drefssj     Vocational Rehab.                                              Number     1
        Drefssk     Housing                                                        Number     1
        Drefssl     Social Services                                                Number     1
        Drefssm     Employment                                                     Number     1
        Drefssn     Food Stamps/Food                                               Number     1
        Drefsso     Women's Center                                                 Number     1
        Drefssp     Gambling                                                       Number     1
                                                                      Page 17
TEDS     Field Name                        Questions & Description                    Data Type Width   Value and Label
           Drefssq    Tobacco                                                          Number     1
           Drefssr    HIV/AIDS Services                                                Number     1
           Drefsss    TB Services                                                      Number     1
           Drefsst    Other                                                            Number     1
          Drefssoth   If other, specify:                                                Text     50

T11        Dunits     Units of Service for Client - Non-Residential (days/sessions)   Number     4

T12       Dunitsco    Units of Service for Codependents Not Reported Separately       Number     4
                      (days/sessions)
                      1. Medication Prescribed to Treat Substance Abuse (Check all
                       that apply)
          Mpnone       None                                                           Number     1
         MpAntabuse Antabuse                                                          Number     1
        MpMethadone Methadone                                                         Number     1
          MpLaam       LAAM                                                           Number     1
       MpBuprenorphine Buprenorphine                                                  Number     1
        MpPsychmed Psychotropic Medication                                            Number     1
        MpOthermed Other                                                              Number     1


                      2. Services Received by Agency during the treatment (Check
                      all that apply):
           Anger      Anger Management/Resolution Interventions                       Number     1
         Childprotect Case Mgmt:DYFS or Other Child Protective Services               Number     1
            Court     Case Mgmt: Meeting with Judge or Court                          Number     1
        Parole_Prob Case Mgmt: Meeting with Parole or Probation Officer               Number     1
           Welfare    Case Mgmt: Public Assistance (TANF, WIC, Food Stamps, etc.)     Number     1
       Casemgmtother Case Mgmt: Other                                                 Number     1
       Familycounsel Family or Other Counseling                                       Number     1
        Groupcounsel Group Counseling                                                 Number     1
         Indcounsel   Individual Counseling                                           Number     1
          Education   Education Services                                              Number     1
         Houseassist  Housing Assistance                                              Number     1
       Job_Vocational Job or Vocational Training                                      Number     1
            Legal     Legal Assistance or Services                                    Number     1
           Medical    Medical Testing or Services                                     Number     1
        Mentalhealth Mental Health Testing or Services                                Number     1
          Parenting   Parenting/Family Interventions                                  Number     1
            Food      Personal Needs: Food, Clothing                                  Number     1
        Rape_trauma Rape/Sexual Abuse Interventions                                   Number     1
T26           AA      Self Help: Alcoholics Anonymous                                 Number     1
             NA       Self Help: Narcotics/Cocaine Anonymous and other                Number     1
        AIDSService HIV/AIDS Service                                                  Number     1

                                                                          Page 18
TEDS    Field Name                         Questions & Description                        Data Type Width                          Value and Label
  P      TBService    TB Services                                                          Number    1
           Other      Other                                                                Number    1

                                                    TB Test

         Servtoday   Date of Data Entry                                                   Date/Time   10
       Anyman Tbtest Was any Mantoux Tuberculin Skin Test given during treatment           Number      1    1. Positive at this facility, Date : datepost1
                     (TST)?                                                                                 2. Documented positive at other facility, Date : datepost2
                                                                                                            3. Negative, Date : dateneg
                                                                                                            4. Refused
                                                                                                            5. Not offered
                                                                                                            6. Mantoux TST Given, Not Read
                                                                                                            7. Other, Specify : Ifother
                                                                                                            8. Unknown
         datepost1    TST positive at this Agency Facility on this date                   Date/Time   10
         datepost2    TST documented positive at Other Facility on this date              Date/Time   10
          dateneg     TST negative at this Agency Facility on this date                   Date/Time   10
           Ifother    If other specify                                                      Text      50
         TbstartTx    TB treatment Started? [Complete only if TST is "Positive"]           Number      1    1. Yes. Date Started : Txstartdate
                                                                                                            2. No, [Check Reason below]
        Txstartdate   If TST is positive and TB treatment started, enter the start date   Date/Time   10
         Tbreason     If TB treatment is not started, check reason below:                  Number      1    1. Documented Prior Adequate Treatment
                                                                                                            2. Refused
                                                                                                            3. Discharged Prior to starting
                                                                                                            4. Referred for Treatment to: refertxto
                                                                                                            5. Medically Contra-indicated; Specify : ifmedcontr
          Refertxto   Refer for treatment to: specify agency name                           Text      50
         Ifmedcontr   IF medically contra-indicated, specify reason                         Text      50
           Heptest    Was patient tested for Hepatitis at this or any other Facility       Number      1    1. Positive at this facility, Date : Hepdatepost1
                      during Treatment?                                                                     2. Positive at other facility, Date : Hepdatepost2
                                                                                                            3. Negative, Date : Hepdateneg
                                                                                                            4. Refused
                                                                                                            5. Not offered
                                                                                                            6. Hep. Test Done, Not Read
                                                                                                            7. Other, Specify : Hepifother
                                                                                                            8. Unknown

                      If Hepatitis positive at this facility, check Hepatitis Type:
           Pthisa     Type A                                                               Number     1
           Pthisb     Type B                                                               Number
           Pthisc     Type C                                                               Number
           Pthisd     Type D                                                               Number
           Pthise     Type E                                                               Number

                                                                               Page 19
TEDS    Field Name                           Questions & Description                       Data Type Width                        Value and Label
       Hepdatepost1   Hepatitis Test positive at this Agency Facility on this date         Date/Time  10
                      If Hepatitis positive at other facility, check Hepatitis Type:
         Pothera      Type A                                                                Number     1
         Potherb      Type B                                                                Number
         Potherc      Type C                                                                Number
         Potherd      Type D                                                                Number
         Pothere      Type E                                                                Number
       Hepdatepost2   Hepatitis Test positive at Other Facility on this date               Date/Time  10
        Hepdateng     Hepatitis Test negative at this agency on this date                  Date/Time  10
        Hepifother    If other specify                                                       Text
        Hepstarttx    Hepatitis treatment Started? [Complete only if TEST is Number                    1   1.Yes. Date Started : Hepstartdate
                      "Positive"]                                                                          2.No, [Check Reason below]
       Hepstartdate   If Hepatitis test is positive and Hepatitis treatment started, enter Date/Time  10
        Hepreason     If Hepatitis treatment is not started, check on of the following      Number     1   1. Prior Adequate Treatment
                      reasons                                                                              2. Refused
                                                                                                           3. Discharged Prior to starting
                                                                                                           4. Referred for Treatment to: Heprefertxto
                                                                                                           5. Medically Contra-indicated; Specify: Hepifmedcontr
       Heprefertxto   Refer for treatment to:specify agency                                  Text     50
       Hepmedcontr    If medically contra-indicated, specify reason                          Text     51
         HIVtest      Did Client have HIV test while in the treatment at this facility?     Number     1   1. Tested
                                                                                                           2. Offered but refused
                                                                                                           3. Not Offered
                                                                                                           4. Unknown
 P      HIVResult     If tested, did client get HIV test result?                            Number     1   1. Yes
                                                                                                           2. Client Refused Result
                                                                                                           3. Client Discharged before Results Given
         Urintest     Was any urine analyzed for illegal drugs?                             Number     1   1. Yes
                                                                                                           2. No
                                                                                                           3. Unknown
        Hmnytest      If Yes, how many tests were done?                                     Number     5
        Hmnyplus      If Yes, how many tests were positive for drugs?                       Number     5

T18                               Evaluation of Client Goal Acheivement
                                      (Each Item must be answered)
         Dgoal1       Alcohol/Drug Problem;                                              Number       1    1. Achieved
                                                                                                           2. Partially Achieved
                                                                                                           3. Not Achieved
                                                                                                           4. Not Applicable




                                                                           Page 20
TEDS   Field Name                         Questions & Description                      Data Type Width                         Value and Label
         Dgoal2      Educational;                                                       Number     1   1. Achieved
                                                                                                       2. Partially Achieved
                                                                                                       3. Not Achieved
                                                                                                       4. Not Applicable
         Dgoal3      Employment/Vocational;                                             Number     1   1. Achieved
                                                                                                       2. Partially Achieved
                                                                                                       3. Not Achieved
                                                                                                       4. Not Applicable
         Dgoal4      Legal;                                                             Number     1   1. Achieved
                                                                                                       2. Partially Achieved
                                                                                                       3. Not Achieved
                                                                                                       4. Not Applicable
         Dgoal5      Family Situation/Social                                            Number     1   1. Achieved
                                                                                                       2. Partially Achieved
                                                                                                       3. Not Achieved
                                                                                                       4. Not Applicable
         Dgoal6      Psychological/Mental Health                                        Number     1   1. Achieved
                                                                                                       2. Partially Achieved
                                                                                                       3. Not Achieved
                                                                                                       4. Not Applicable
         Dgoal7      Physical Health                                                    Number     1   1. Achieved
                                                                                                       2. Partially Achieved
                                                                                                       3. Not Achieved
                                                                                                       4. Not Applicable
       lastcontact   Date of Last Face-to-Face Client Contact :                        Date/Time  10
T13     Dreason      Reason for Discharge;                                              Number      1    1. Treatment plan completed at this level of care
                                                                                                         2. Treatment plan not completed
T13    Dncreason     If treatment plan not completed, click arrow to select reason:     Number            1. Quit or dropped out
                                                                                                          2. Needs different level of care
                                                                                                          3. Unable to meet client's non-substance abuse treatment
                                                                                                         needs
                                                                                                          4. Administrative Discharge/Rule Non-compliance
                                                                                                          5. Exhaustion of insurance benefits or ability to pay
                                                                                                          6. Loss of eligibility for Medicaid or Medicare
                                                                                                          7. Incarcerated - status revocation
                                                                                                          8. Incarcerated - Charge prior to entering treatment
                                                                                                          9. Incarcerated - Charge since entering treatment
                                                                                                         10. Medical Discharge/Hospitalized
                                                                                                         11. Deceased
                                                                                                         12. Other
       Dreasonoth    If "Other" is selected, specify                                     Text      50




                                                                             Page 21
TEDS     Field Name                        Questions & Description                           Data Type Width                          Value and Label
          Dconcare     Continutinuing Care Type                                               Number    1    1. No continuing substance abuse treatment needed
                                                                                                             2. Refused continuing care
                                                                                                             3. Transfer to different level of care within same agency and
                                                                                                             clinic site
                                                                                                             4. Transfer to a new clinic site location within same agency
                                                                                                             5. Continuing care coordinated with new agency

       Dconcarenjsams Continuing Care within NJSAMS Tx. Agency/Site ID:                       Number       8
        Dconcareloc Continuing Care - Level of Care being provided                            Number       1     1. Standard/Traditional Outpatient
                                                                                                                 2. Intensive Outpatient
                                                                                                                 3. Partial Hospitalization
                                                                                                                 4. Transitional Care/Extended Care
                                                                                                                 5. Halfway House
                                                                                                                 6. Long-Term Residential
                                                                                                                 7. Short-Term Residential (Medically Monitored)
                                                                                                                 8. Hospital-Based (acute) Residential
                                                                                                                 9. Detox-Free-Standing Residential (Sub-Acute)
                                                                                                                10. Detox-Hospital Inpatient
                                                                                                                11. Detox-Outpatient (Non-Methadone)
                                                                                                                12. OPIOID Maintenance-Outpatient
                                                                                                                13. Detox-Methadone Outpatient
                                                                                                                14. Non-traditional program                            15.
                                                                                                                OPIOID Maintenance - Intensive Outpatient
        Dconcareout    Continuing Care (Non-NJSAMS Tx. Agency/Private Clinic, etc)             Text        1
         Drefssoth     Specify (Non-NJSAMSAgency/Private Clinic):                              Text       30
        Sendconsent    Client signed consent to release records for referral to continuing    Number       1    0. No
                       care?                                                                                    1. Yes
                                          End of Discharge Module
                                       End of Client Administration




                                                                               Page 22
TEDS     Field Name                          Questions & Description                             Data Type Width                         Value and Label
                           Assessment Module - Addiction Severity
                                       Index (ASI)

                                        Employment/Support Status

       CounselorName Name of Counselor/Interviewer                                                 Text      25
       Assessmentdate Date of Assesment                                                          Date/Time   10

             e13         Do you have a valid drivers license?                                     Number     1     0. No
                                                                                                                   1. Yes
             e14         Do you have an automobile available?                                     Number     1     0. No
                                                                                                                   1. Yes
              e3         Does anyone contribute to the MAJORITY of your support in any Number                1     0. No
                         way? (Like giving you money, food, housing)                                               1. Yes
             e3a         If yes, who is the person?                                    Number                1     1. Spouse/Partmer
                                                                                                                   2. Parent/Foster Parent
                                                                                                                   3. Brother/Sister
                                                                                                                   4. Grandparent
                                                                                                                   5. Other Relative
                                                                                                                   6. Unrelated Other
              e5         Have you ever held a full-time job?                                      Number     1     0. No
                                                                                                                   1. Yes, If Yes
       e5year, e5month If Yes, how long did you hold your longest full-time job? ( Full-time      Number     2
                       = 35 + hourse per week, not necessarily your most recent job.)

              e6         In the past 30 days, how many days were you paid for working?            Number     2
                         [Include "under the table" work, paid sick days and vacation. If
                         worked a 5 - day work week, answer would be 20 days, not 30]

             e6a         Usual or Last Occupation                                                 Number     1      1. Higher Executives; Large Proprietor; Major Professionals
                                                                                                                    2. Business Mgrs, Medium Proprietor, Lesser Professionals
                                                                                                                    3. Admin. Personnel; Small or Minor Professionals
                                                                                                                    4. Clerical/Sales Workers; Technician
                                                                                                                    5. Skilled Manual Employees
                                                                                                                    6. Machine Operators; Semi-skilled
                                                                                                                    7. Unskilled Labor
                                                                                                                    8. Disabled
                                                                                                                    9. Welfare
                                                                                                                   10. None, No work History
              e7         Do you have a profession, trade or skill? (Did you get training or go    Number     1     0. No
                         to school to learn skills you could put on a job application)                             1. Yes



                                                                                 Page 23
TEDS   Field Name                      Questions & Description                     Data Type Width                        Value and Label
                    During the past 6 months, did you receive the following public
                    assistance benefits? (Check all that apply)

          e8a       Temporary Aid to Needy Families - TANF (welfare assistance for       Number
                    people with children)
          e8b       General Assistance - GA (welfare assistance for people without       Number
                    children)
          e8c       SSI or Disability Insurance (Social Security Disability)             Number
          e8d        Food Stamps or WIC                                                  Number
          e8e       Did not receive any Public Assistance                                Number
       e8receive    In the past 6 months, how many months have you received any          Number     2
                    public assistance benefits?

                    How much money did you receive from the following sources
                    in the past 30 days?

          e9a       Employment (Net "take home" pay, include any "under the table"       Currency   4
                    money)
          e9b       Unemployment Compensation                                            Currency
          e9c       Public Assistance/TANF/General Welfare/SSI                           Currency
 G        e9d       Retirement (Pension, Benefits or Social Security                     Currency
          e9e       Disability                                                           Currency
          e9f       Illegal (Cash obtained from drug dealing, stealing,fencing stolen    Currency
                    goods,illegal gambling, prostitution, etc.)
          e10       In the past 30 days, how many days have you experienced              Number     2
                    employment problems? [Problems include trouble finding work,
                    worry about being fired or laid off or not liking the work you do]
          e11       In the past 30 days, how troubled or bothered have you been by       Number     1   1. Not at all
                    these employment problems?                                                          2. Slightly
                                                                                                        3. Moderately
                                                                                                        4. Considerably
                                                                                                        5. Extremely
          e12       How important to you NOW is counseling for these employment          Number     1   1. Not at all
                    problems?                                                                           2. Slightly
                                                                                                        3. Moderately
                                                                                                        4. Considerably
                                                                                                        5. Extremely
                                      End of Employment Status




                                                                          Page 24
TEDS   Field Name                       Questions & Description                            Data Type Width                      Value and Label
                                                                        Medical Status

 G        m14       How would you rate your overall physical health right now?             Number     1      1. Excellent      4. Fair
                                                                                                             2. Very Good      5. Poor
                                                                                                             3. Good
                    How many times have you been hospitalized overnight for
                    medical problems: [Do not include hospital stays for alcohol
                    or drug problems, emotional problems or normal child birth]

          m1a       Number of times hospitalized in the past 6 months?                     Number     3
          m1b       Number of times hospitalized in your lifetime?                         Number     3
 G        m15       In the past 30 days, how many nights have you spent in the             Number     3
                    hospital because of medical problems? [Note: Indicates that the
                    client was admitted and stayed over night] [If none enter "0"]

                    In the past 30 days, how many times were you treated for
                    medical problems:
          m16       in an emergency room? [If None enter "0"]                              Number
          m17       as an outpatient? (In a doctor or clinic office) [If None enter "0"]   Number
          m2        Do you have any chronic medical problems which continue to             Number     1      0. No
                    interfere with your life? [Chronic Medical Condition: A serious                          1. Yes
                    physical condition that requires regular care like diabetes,
                    epilepsy, chronic back pain, high blood pressure, etc.]
          m3        Are you taking any medication, prescribed by a Doctor for a            Number     1      0. No
                    physical condition on a regular basis? [Note: Include medicines                          1. Yes
                    prescribed whether or not you are currently taking them]
          m4        Do you receive a pension for a physical disability? [From any          Number     1      0. No
                    source such as the VA, social security, or workman's                                     1. Yes
                    compensation]
          m5        In the past 30 days, how many days have you experienced                Number     2
                    medical problems? (Including flu, colds or more serious problems)

          m6        In the past 30 days, how troubled or bothered have you been by Number             1      1. Not at all
                    these medical problems?                                                                  2. Slightly
                                                                                                             3. Moderately
                                                                                                             4. Considerably
                                                                                                             5. Extremely
          m7        How important to you NOW is treatment for these medical                Number     1      1. Not at all
                    problems?                                                                                2. Slightly
                                                                                                             3. Moderately
                                                                                                             4. Considerably
                                                                                                             5. Extremely
                                          End of Medical Status

                                                                           Page 25
TEDS   Field Name                       Questions & Description                            Data Type Width   Value and Label
                                                                     Drug & Alcohol Use

GT29                In the past 30 days, have you used the following drug?
          d1a       Alcohol (Beer, Liquor, Wine, etc)                                      Number     2
          d1b       Heroin                                                                 Number     2
          d1c       Marijuana/Hashish (Pot, Hash, etc.)                                    Number     2
          d1d       Cocaine - Powder                                                       Number     2
          d1e       Crack                                                                  Number     2
          d1f       Methamphetamines (Speed, Uppers, Ritalin, Benzedrine,                  Number     2
                    Dexedrine, Preludine, and Other Amines, and Related Drugs)
          d1fa      Other Amphetamines                                                     Number     2
          d1g       Barbituarates (Phenobarbial, Seconal, Nembutal, Barbs, Reds,           Number     2
                    etc.)
          d1h       Benodiazepines (Xanax, Valium, Ativan, Tranquilizers, Sleeping         Number     2
                    Pills, Diazepam, Flurazepam, Chlordiazepoxide, Clorazepate,
                    Lorazepam, Alpraolam, Oxazepam, Emazepam, Triazolam,
                    Clonazepam, Halazepam)
           d1i      Ecstacy (XTC, MDMA)                                                    Number     2
           d1j      GHB                                                                    Number     2
          d1k       Hallucinogens - LSD (Acid)                                             Number     2
           d1l      Hallucinogens - PCP (Angel Dust)                                       Number     2
          d1m       Hallucinogens - Other (Peote, Mushrooms, Mescaline, Psilocybin         Number     2
                    etc.)
          d1n       Inhalants (Poppers, Amyl Nitrate, Nitrous Oxide (whipits), Paint       Number     2
                    Thinner, Chloral Hydrate, Glue, Ether, lacidyl, Doriden, Chloroform,
                    Gasoline etc.)
          d1o       Ketamine, Special K                                                    Number     2
          d1p       Methadone (Non-Prescription)                                           Number     2
          d1q       Opiate - Other (Codeine, Dilaudid, Morphine, Demorol, Opium and        Number     2
                    Other Drug with Morphine like effects)
          d1r       Oxycontin                                                              Number      2
          d1s       Rohypnol (Roche, Rope, Roach)                                          Number      2
          d1t       Other, Specify: D1tother                                               Number      2
        d1tother    If "Other", specify                                                     Text      50
          d1u       More than 1 substance per day (Includes alcohol)                       Number      2

                    In your lifetime, have you used the following drug?
         d1a1       Alcohol (Beer, Liquor, Wine, etc)                                      Number     2
         d1b1       Heroin                                                                 Number     2
         d1c1       Marijuana/Hashish (Pot, Hash, etc.)                                    Number     2
         d1d1       Cocaine - Powder                                                       Number     2
         d1e1       Crack                                                                  Number     2



                                                                           Page 26
TEDS   Field Name                         Questions & Description                        Data Type Width          Value and Label
           d1f1     Methamphetamines (Speed, Uppers, Ritalin, Benzedrine,                 Number     2
                    Dexedrine, Preludine, and Other Amines, and Related Drugs)
         d1f1b      Other Amphetanines                                                    Number     2
         d1g1       Barbituarates (Phenobarbial, Seconal, Nembutal, Barbs, Reds,          Number     2
                    etc.)
         d1h1       Benodiazepines (Xanax, Valium, Ativan, Tranquilizers, Sleeping        Number     2
                    Pills, Diazepam, Flurazepam, Chlordiazepoxide, Clorazepate,
                    Lorazepam, Alpraolam, Oxazepam, Emazepam, Triazolam,
                    Clonazepam, Halazepam)
          d1i1      Ecstacy (XTC, MDMA)                                                   Number
          d1j1      GHB                                                                   Number     2
         d1k1       Hallucinogens - LSD (Acid)                                            Number     2
          d1l1      Hallucinogens - PCP (Angel Dust)                                      Number     2
         d1m1       Hallucinogens - Other (Peote, Mushrooms, Mescaline, Psilocybin        Number     2
                    etc.)
         d1n1       Inhalants (Poppers, Amyl Nitrate, Nitrous Oxide (whipits), Paint      Number     2
                    Thinner, Chloral Hydrate, Glue, Ether, lacidyl, Doriden, Chloroform,
                    Gasoline etc.)
         d1o1       Ketamine, Special K                                                   Number     2
         d1p1       Methadone (Non-Prescription)                                          Number     2
         d1q1       Opiate - Other (Codeine, Dilaudid, Morphine, Demorol, Opium and Number           2
                    other Drug with Morphine like effects)
         d1r1       Oxycontin                                                             Number     2
         d1s1       Rohypnol (Roche, Rope, Roach)                                         Number     2
         d1t1       Other, Specify: D1tother                                              Number    50
         d1u1       More than 1 substance per day (Includes alcohol)                      Number
          d3        How old were you when you first used an illegal drug?                 Number     2
          d4        In the past 30 days, how many days has the client used illegal Number            2
                    drugs?
 G        d4a       In the past 30 days has the client injected illegal drugs?            Number     1   0. No
                                                                                                         1. Yes
T24       d5        In your life, how many times have you been treated for drug           Number     2
                    problems? [This includes detox, halfway houses,
                    inpatient/outpatient, counseling, and Alcoholics Anonymous (AA)
                    or Narcotics Anonymous (NA)]
          d6        How many of these times were for drug detox only(with no other        Number     2
                    treatment)?
          d7        In the past 30 days, how much money would you say you spent on Currency          5
                    drugs (only count actual MONEY you spent)?
          d8        In the past 30 days, how many days have you experienced drug          Number     2
                    problems? ( like craving, withdrawal symptoms, disturbing side
                    effects, or wanting to stop and not being able to)



                                                                        Page 27
TEDS   Field Name                        Questions & Description                             Data Type Width                    Value and Label
            d9      In the past 30 days, how troubled or bothered have you been by            Number    1    1. Not at all
                    these drug problems?                                                                     2. Slightly
                                                                                                             3. Moderately
                                                                                                             4. Considerably
                                                                                                             5. Extremely
          d10       How important to you NOW is treatment for these drug problems?            Number    1    1. Not at all
                                                                                                             2. Slightly
                                                                                                             3. Moderately
                                                                                                             4. Considerably
                                                                                                             5. Extremely
          a11       How old were you when you first used alcohol?                             Number    2
          a12       How old were you when you first got drunk from drinking alcohol?          Number    2

 G        a13       In the past 30 days, how many days has the client used alcohol?           Number     2

         a13a       In the past 30 days, how many days has the client used alcohol to         Number     2
                    intoxication? (Enter number of days)
          a14       How many times in your life have you had alcohol DT's? [Note:             Number     2
                    DT's (Delieium Tremens) happen a day or two after your last drink
                    or after you drink a lot less than usual. They include shaking, fever,
                    hallucinations, and confusion/disorientation.]
          a15       In your life, how many times have you been treated for alcohol            Number     2
                    problems? [This includes detox, halfway house,
                    inpatient/outpatient, counseling and Alcoholics Anonymouse (AA)]

          a16       How many of these treatments were alcohol detox only?                    Number      2
          a17       In the past 30 days, how much money have you spent on alcohol            Currency    5
                    (only count actual MONEY spent)?
          a18       In the past 30 days, how many days have you experienced alcohol           Number     2
                    problems? (Like craving, withdrawal symptoms, disturbing effects
                    of use, or wanting to stop and not being able to)

          a19       In the past 30 days, how troubled or bothered have you been by            Number     1    1. Not at all
                    these alcohol problems?                                                                   2. Slightly
                                                                                                              3. Moderately
                                                                                                              4. Considerably
                                                                                                              5. Extremely
          a20       How important to you NOW is treatment for these alcohol                   Number     1    1. Not at all
                    problems?                                                                                 2. Slightly
                                                                                                              3. Moderately
                                                                                                              4. Considerably
                                                                                                              5. Extremely



                                                                             Page 28
TEDS   Field Name                        Questions & Description                       Data Type Width                     Value and Label
  G       ad21      In the past 30 days, how many nights has the client spent in the    Number    2
                    hospital because of alcohol or drug problems?




                    In the past 30 days, how many times were you treated for
                    alcohol or drug problems:
         ad22       in an emergency room?                                              Number
         ad23       as an outpatient? (In a doctor or clinic office)                   Number     2
                    In the past 30 days, to what extent…
         ad24       Has your use of alcohol or other drugs caused you to reduce or     Number     1      1. Not at all
                    give up important activities?                                                        2. Somewhat
                                                                                                         3. Considerably
                                                                                                         4. Extremely
         ad25       Has your use of alcohol or other drugs caused you to have          Number     1      1. Not at all
                    emotional problems?                                                                  2. Somewhat
                                                                                                         3. Considerably
                                                                                                         4. Extremely
                                      End of Drug and Alcohol Use




                                                                           Page 29
TEDS   Field Name                       Questions & Description                Data Type Width   Value and Label
                                          Legal Status
 P                  How many times have you been ARRESTED and CHARGED
                    with the following offense in your lifetime?
           l2a1     Shoplifting                                       Number               2
           l2b1     Parole/Probation Violation                        Number               2
           l2c1     Drug Charges                                      Number               2
           l2d1     Forgery                                           Number               2
           l2e1     Weapon Offenses                                   Number               2
            l2f1    Burglary/Larceny/Breaking and Entering            Number               2
           l2g1     Robbery                                           Number               2
           l2h1     Assault                                           Number               2
            l2i1    Domestic Violence/Child Abuse                     Number               2
            l2j1    Prostitution                                      Number               2
           l2k1     Contempt of Court                                 Number               2
            l2l1    Driving Under the influence (alcohol or drugs)    Number               2
          l2m1      Disorderly Conduct                                Number               2
           l2n1     Other                                             Number               2
        l2n1other   If other specify                                   Text               50

 P                  How many times have you been ARRESTED and CHARGED
                    with the following offense in the past 6 months?

           l2a2     Shoplifting                                                Number      2
           l2b2     Parole/Probation Violation                                 Number      2
           l2c2     Drug Charges                                               Number      2
           l2d2     Forgery                                                    Number      2
           l2e2     Weapon Offenses                                            Number      2
            l2f2    Burglary/Larceny/breaking and Entering                     Number      2
           l2g2     Robbery                                                    Number      2
           l2h2     Assault                                                    Number      2
            l2i2    Domestic Violence/Child Abuse                              Number      2
            l2j2    Prostitution                                               Number      2
           l2k2     Contempt of Court                                          Number      2
            l2l2    Driving Under the influence (alcohol or drugs)             Number      2
          l2m2      Disorderly Conduct                                         Number      2
           l2n2     Other                                                      Number      2
        l2n2other   If other; Specify                                           Text      51

 G                  How many times have you been ARRESTED and CHARGED
                    with the following offense in the past 30 days?
          l2a3      Shoplifting                                                Number     2
          l2b3      Parole/Probation Violation                                 Number     2
          l2c3      Drug Charges                                               Number     2

                                                                     Page 30
TEDS   Field Name                        Questions & Description                               Data Type Width                          Value and Label
           l2d3     Forgery                                                                     Number     2
           l2e3     Weapon Offenses                                                             Number     2
            l2f3    Burglary/Larceny/breaking and Entering                                      Number     2
           l2g3     Robbery                                                                     Number     2
           l2h3     Assault                                                                     Number     2
            l2i3    Domestic Violence/Child Abuse                                               Number     2
            l2j3    Prostitution                                                                Number     2
           l2k3     Contempt of Court                                                           Number     2
            l2l3    Driving Under the influence (alcohol or drugs)                              Number     2
          l2m3      Disorderly Conduct                                                          Number     2
           l2n3     Other                                                                       Number     2
        l2n3other   If other; Specify                                                            Text     50
             l4     How many of these charges resulted in convictions? [Convictions             Number     4
                    include fines, probation, jail or prison, suspended sentences and
                    guilty pleas]
           l5       In your life, how much time have you spent in jail or prison all           Number     1      1. None
                    together?                                                                                    2. less than 1 year
                                                                                                                 3. 1 to less than 3 years
                                                                                                                 4. 3 to less than 6 years
                                                                                                                 5. 6 years or more
           l6       In the past 6 months, how many months have you spent in jail or            Number     3
                    prison all together? [If you spent no time in jail or prison, enter "0",
                    If you spent some time in jail or prison but it was less than a
                    month, enter "1"]
 G         l7       In the past 30 days, how many nights have you spent in jail or             Number     2
                    prison?
          l10       Presently, are you awaiting charges, trial or sentence?                    Number     1      0. No
                                                                                                                 1. Yes
          l11       In the past 30 days, how many days have you engaged in illegal             Number     2
                    activities for profit? [If None enter "0"]
           l8       How serious do you feel your present legal problems are?                   Number     1      1. Not at all
                                                                                                                 2. Slightly
                                                                                                                 3. Moderately
                                                                                                                 4. Considerably
                                                                                                                 5. Extremely
           l9       How important to you NOW is counseling or referral for these legal         Number     1      1. Not at all
                    problems?                                                                                    2. Slightly
                                                                                                                 3. Moderately
                                                                                                                 4. Considerably
                                                                                                                 5. Extremely
                                            End of Legal Status




                                                                               Page 31
TEDS   Field Name                          Questions & Description                           Data Type Width                          Value and Label
                                                                  Family/Social Relationship
        f1a, f1b                        moved to admission module
           f2       Are you satisfied with your current maritial status ? [Note: Satisfied   Number     1      0. No
                    means you generally like your marital status]                                              1. Yes
                                                                                                               9. Don’t know/Indifferent

                    Check all the people you usually lived with in the past three
                    years (Check box, if checked, value=1):
          f3a       Spouse/Sex Partner                                                       Number     1
          f3b       Children                                                                 Number     1
          f3c       Parents                                                                  Number     1
          f3d       Other Family                                                             Number     1
          f3e       Friends                                                                  Number     1
          f3f       Alone                                                                    Number     1
          f3g       Jail, hospital, halfway house, live-in treatment program                 Number     1
           f4       Have you been satisfied with your usual living arrangements              Number     1      0. No
                    during the past 3 years? [Note: Satisfied means you generally like                         1. Yes
                    your living situation]                                                                     9. Don’t know/Indifferent
           f5       How many children do you have, aged 17 or less, whether they live        Number     2
                    with you or not? [Includes all children by birth, adoption, step-
                    children, etc.]
           f6       Are any of your children living with someone else because of a           Number     1      0. No
                    child protection court order?                                                              1. Yes
          f6a1      Do you have an active case with DYFS?                                    Number     1      0. No
                                                                                                               1. Yes
           f7       Do you live with anyone who has a current alcohol problem?               Number     1      0. No
                                                                                                               1. Yes
           f8       Do you live with anyone who uses illegal drugs or non-prescribed         Number     1      0. No
                    drugs illegally?                                                                           1. Yes

                    Did anyone physically abuse you or cause you physical harm:

          f9a       in the past 30 days?                                                     Number     1      0. No
                                                                                                               1. Yes
          f9b       in your life?                                                            Number     1      0. No
                                                                                                               1. Yes


                    Did anyone ever force sexual advances or sexual acts on you:

          f10a      in the past 30 days?                                                     Number     1      0. No
                                                                                                               1. Yes



                                                                             Page 32
TEDS   Field Name                        Questions & Description                        Data Type Width                   Value and Label
           f10b     in your life?                                                        Number    1    0. No
                                                                                                        1. Yes
                    Have you had any serious problems getting along with your:

          f13a      Mother; in your lifetime?                                            Number     1
          f14a      Father; in your lifetime?                                            Number     1
          f15a      Brothers/Sisters; in your lifetime?                                  Number     1
          f16a      Sexual partners/spouse; in your lifetime?                            Number     1
          f17a      Children; in your lifetime?                                          Number     1
          f18a      Other significant family; in your lifetime?                          Number     1
          f19a      Close friends; in your lifetime                                      Number     1
          f20a      Neighbors; in your lifetime                                          Number     1
          f21a      Co-Workers; in your lifetime                                         Number     1

                    Have you had any serious problems getting along with your:

          f13b      Mother: in the past 30 days?                                         Number     2
          f14b      Father; in the past 30 days                                          Number     2
          f15b      Brothers/Sisters; in the past 30 days                                Number     2
          f16b      Sexual partners/spouse; in the past 30 days                          Number     2
          f17b      Children; in the past 30 days                                        Number     2
          f18b      Other significant family; in the past 30 days                        Number     2
          f19b      Close friends; in the past 30 days                                   Number     2
          f20b      Neighbors; in the past 30 days                                       Number     2
          f21b      Co-Workers; in the past 30 days                                      Number     2
           f22      In the past 30 days, how many days have you had serious conflicts    Number     2
                    with your family? [If None enter "0"]
          f11       How troubled or bothered have you been in the past 30 days by        Number     1   1. Not at all
                    family problems?                                                                    2. Slightly
                                                                                                        3. Moderately
                                                                                                        4. Considerably
                                                                                                        5. Extremely
          f12       How important to you NOW is treatment or counseling for family       Number     1   1. Not at all
                    problems?                                                                           2. Slightly
                                                                                                        3. Moderately
                                                                                                        4. Considerably
                                                                                                        5. Extremely
                                    End of Family Social Relationship




                                                                         Page 33
TEDS   Field Name                          Questions & Description                         Data Type Width            Value and Label
                                                                      Psychiatric Status

                    In your lifetime, how many times have you been treated for
                    any psychological or emotional problems (do not include
                    treatment for alcohol or other drug problems):
          p1a       Treated in a hospital or inpatient setting?                            Number     2
          p1b       Treated in an Out patient/Private patient setting (where you did not   Number
                    spend the night)
 G        p14       In the past 30 days, how many nights have you spent in the             Number     2
                    hospital because of psychological or emotional problems? [If None
                    enter "0"]
                    In the past 30 days, how many times were you treated for
                    psychological or emotional problems:
          p15        in an emergency room? [If None enter "0"]                             Number     2
          p16       as an outpatient? (In a doctor or clinic office)                       Number
                    [If none enter "0"]
          p2        Do you receive a pension for psychiatric disability?                   Number     1      0. No
                                                                                                             1. Yes
                    Have you experienced serious depression for two weeks or
                    more at a time (feeling badly depressed, sad, hopeless,
                    uninterested in things) that was not related to your drug or
                    alcohol use:

          p3a       in the past 30 days?                                                   Number     1      0. No
                                                                                                             1. Yes
          p3b       in your life?                                                          Number     1      0. No
                                                                                                             1. Yes

                    Have you experienced serious tension or anxiety (feeling
                    uptight, unreasonably worried, inability to feel relaxed) while
                    you were not under effects of alcohol or another drug:

          p4a       in the past 30 days?                                                   Number     1      0. No
                                                                                                             1. Yes
          p4b       in your life?                                                          Number     1      0. No
                                                                                                             1. Yes

                    Have you experienced hallucinations (saw things or heard
                    voices that were not there) when you were not under the
                    influence of alcohol or another drug:
          p5a       in the past 30 days?                                                   Number     1      0. No
                                                                                                             1. Yes
          p5b       in your life?                                                          Number     1      0. No
                                                                                                             1. Yes
                                                                           Page 34
TEDS   Field Name                      Questions & Description                         Data Type Width                     Value and Label

                    Have you had a period in which you have experienced trouble
                    understanding, concentrating, or remembering while you
                    were not under the influence of alcohol or another drug:

          p6a       in the past 30 days?                                               Number     1      1. Yes    0. No
          p6b       in your life?                                                      Number     1      1. Yes    0. No
                    Have you had a period of time in which you have experienced
                    trouble controlling violent behavior (or losing control), rage,
                    or violence:
          p7a       in the past 30 days?                                               Number     1      0. No
                                                                                                         1. Yes
          p7b       in your life?                                                      Number     1      0. No
                                                                                                         1. Yes
                    Have you had a period of time in which you have experienced
                    serious thoughts of suicide (seriously considered a plan for
                    taking your life):
          p8a       in the past 30 days?                                               Number     1      1. Yes   0. No
          p8b       in your life?                                                      Number     1      1. Yes   0. No

                    Have you attempted suicide:
          p9a       in the past 30 days?                                               Number     1      1. Yes   0. No
          p9b       in your life?                                                      Number     1      1. Yes   0. No

                    Have you been prescribed medication for any psychological or
                    emotional problems for at least 2 weeks or more (even if you
                    did not actually take it):
         p10a       in the past 30 days?                                               Number     1      1. Yes   0. No
         p10b       in your life?                                                      Number     1      1. Yes   0. No
          p11       In the past 30 days, how many DAYS have you experienced these      Number     2
                    psychological or emotional problems?
          p12       In the past 30 days, how much have you been troubled or            Number     1      1. Not at all
                    bothered by these psychological or emotional problems?                               2. Slightly
                                                                                                         3. Moderately
                                                                                                         4. Considerably
                                                                                                         5. Extremely
          p13       How important to you NOW is treatment for these psychological or   Number            1. Not at all
                    emotional problems?                                                                  2. Slightly
                                                                                                         3. Moderately
                                                                                                         4. Considerably
                                                                                                         5. Extremely
                                       End of Psychiatric Status



                                                                         Page 35
TEDS   Field Name                        Questions & Description                         Data Type Width                         Value and Label
                                     Health Risk Behavior

          h1        In the past 6 months, how many TIMES have you shared needles         Number     3
                    with other people?
          h2        In the past 6 months, with how many                                  Number     3
                    different PEOPLE have you shared needles?
          h3        Which statement best describes the way you cleaned your needles      Number     1      1. I have NEVER used needles
                    during the past 6 months?                                                              2. I have NOT used needles in the past 6 months
                                                                                                           3. I used a new needle EACH TIME I injected drugs in the past
                                                                                                           6 months
                                                                                                           4. I always cleaned my needle with BLEACH just BEFORE I
                                                                                                           injected drugs in the past 6 months
                                                                                                           5. I SOMETIMES cleaned my needles with BLEACH before I
                                                                                                           injected drugs in the past 6 months
                                                                                                           6. I NEVER cleaned my needles with BLEACH when I injected
                                                                                                           drugs in the past 6 months
          h4a       In the past 6 months, with how many different PEOPLE have you        Number     3
                    had sex? (sex includes vaginal intercourse, anal intercourse and
                    oral sex)
          h4b       How many of these people were the same sex as you?                   Number     3
          h5        In the past 6 months, how much of the time did you use condoms       Number     1      1. No Sex in the past 6 months
                    when you had sex ( sex = vaginal intercourse, anal intercourse and                     2. None of the time
                    oral sex)                                                                              3. Less than half the time
                                                                                                           4. About half the time
                                                                                                           5. Most of the time
                                                                                                           6. All of the time
          h6a       Have you ever been tested for HIV?                                   Number     1      0. No
                                                                                                           1. Yes
          h6b       If yes, did you get your result?                                     Number     1      0. No/Never
                                                                                                           1. Yes with all tests
                                                                                                           2. Yes with some of the tests
          h7a       Have you ever been tested for Hepatitis?                             Number     1      0. No
                                                                                                           1. Yes
          h7b       If yes, did you get your results?                                    Number            0. No/Never
                                                                                                           1. Yes with all tests
                                                                                                           2. Yes with some of the tests
                                       End of Health Risk Behavior




                                                                          Page 36
TEDS   Field Name                         Questions & Description                         Data Type Width                        Value and Label
                                      Interviewer Severity Rating

        empsrate    How would interviewer rate the patient's need for employement         Number     5      0, 1. No. Treatment Necessary
                    conseling? (Numeric filed, value 1 through 9)                                           2, 3. Slightly
                                                                                                            4, 5. Moderately
                                                                                                            6, 7. Considerably
                                                                                                            8, 9. Extremely
        medsrate    How would interviewer rate the patient's need for medical             Number            0, 1. No. Treatment Necessary
                    treatment? (Numeric filed, value 1 through 9)                                           2, 3. Slightly
                                                                                                            4, 5. Moderately
                                                                                                            6, 7. Considerably
                                                                                                            8, 9. Extremely
        alcsrate    How would interviewer rate the patient's need for alcohol abuse       Number            0, 1. No. Treatment Necessary
                    treatment? (Numeric filed, value 1 through 9)                                           2, 3. Slightly
                                                                                                            4, 5. Moderately
                                                                                                            6, 7. Considerably
                                                                                                            8, 9. Extremely
        drgsrate    How would interviewer rate the patient's need for drug abuse          Number            0, 1. No. Treatment Necessary
                    treatment? (Numeric filed, value 1 through 9)                                           2, 3. Slightly
                                                                                                            4, 5. Moderately
                                                                                                            6, 7. Considerably
                                                                                                            8, 9. Extremely
        legalrat    How would interviewer rate the patient's need for legal services or   Number            0, 1. No. Treatment Necessary
                    counseling? (Numeric filed, value 1 through 9)                                          2, 3. Slightly
                                                                                                            4, 5. Moderately
                                                                                                            6, 7. Considerably
                                                                                                            8, 9. Extremely
        famsrate    How would interviewer rate the patient's need for family and/or       Number            0, 1. No. Treatment Necessary
                    social counseling?                                                                      2, 3. Slightly
                                                                                                            4, 5. Moderately
                                                                                                            6, 7. Considerably
                                                                                                            8, 9. Extremely
        psysrate    How would interviewer rate the patient's need for psychological       Number            0, 1. No. Treatment Necessary
                    and/or emotional counseling? (Numeric filed, value 1 through 9)                         2, 3. Slightly
                                                                                                            4, 5. Moderately
                                                                                                            6, 7. Considerably
                                                                                                            8, 9. Extremely
       Temp. var.   Is this client eligible to admit at this level of care?                                 1. Yes     0. NO
       Temp. var.   If yes, able to re-select level of care




                                                                              Page 37
TEDS   Field Name                          Questions & Description                        Data Type Width                            Value and Label
           aloc      If not, please re-select                                              Number    2       1. Standard/Traditional Outpatient
                                                                                                             2. Intensive Outpatient
                                                                                                             3. Partial Hospitalization
                                                                                                             4. Transitional Care/Extended Care
                                                                                                             5. Halfway House
                                                                                                             6. Long-Term Residential
                                                                                                             7. Short-Term Residential (Medically Monitored)
                                                                                                             8. Hospital-Based (acute) Residential
                                                                                                             9. Detox-Free-Standing Residential (Sub-Acute)
                                                                                                            10. Detox-Hospital Inpatient
                                                                                                            11. Detox-Outpatient (Non-Methadone)
                                                                                                            12. OPIOID Maintenance-Outpatient
                                                                                                            13. Detox-Methadone Outpatient
                                                                                                            14. Non-traditional program
                                                                                                            15. OPIOID Maintenance - Intensive Outpatient
       reftoagency   If no, Client is ineligible for this agency and refer to another       text     6

                                   End of Interviewer Severity Index (ASI)

                     Last Update: 07/02/2007 - Kyu Kyu Hlaing

                     609-292-1466 (V), 609-292-1045 (Fax)




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