Instructions: Module 1 - TheMeasurementGroup.com

Staff Code. Each staff member should be assigned a unique number code (up to 3 digits). Make sure than each new staff member has a unique code. Do not reassign any staff codes that have been previously assigned. Enter the 3-digit code for the person who provided the services. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is "003."

Intake/Service Date. Enter the numbers representing today's date (the date of the activity) in these boxes. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "95" for 1995). Make sure that, if a month or day is less than 10, you place a "0" before the number.

Client Birthdate. Where the boxes specify, enter the numbers representing the person's birth date. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the birth year (for example, "70" for 1970). Make sure that if a month or day is less than 10, you place a "0" before the number. If the person does not want to tell you his/her birth date, leave these boxes blank.

ID Letters/ID Numbers. These boxes are provided for entering the unique identifier your site is using to track client information. The four boxes on the left are to be used for letters, while the ten boxes on the right are reserved for numbers. You may use letters, numbers, or a combination of letters and numbers, for identification purposes. If you use a combination of letters and numbers, however, please use the letters first in your alphanumeric sequence (for example, if your unique identifier is MD-1479, the letters "M" and "D" would be entered in the first two of the four boxes reserved for letters and the numbers "1", "4", "7", and "9" would be entered into the first four of the ten boxes reserved for numbers). If you are unsure about a client’s unique identifier, check with your project director.

This module is intended to be administered as a semi-structured interview. A semi-structured interview is one in which you are guided by question formats. However, you need not use the question format in a verbatim or absolutely standardized fashion, only as a guide to elicit a valid response. You should use your best judgment in using a combination of direct observation, informal conversation, and direct questions in eliciting responses. For the following items, you may refer to the Suggested Question Card for question formats.

1. Client Gender. Use your observations to determine if client is male or female. If the client is biologically male, darken the circle next to "Male." If the client is biologically female, darken the circle next to "Female." Ask him or her if necessary.

Transgender. Say to the client: "Do you identify yourself as transgender?" If the client identifies him/herself as a gender different from his/her biological gender, darken the circle next to "Transgender."

2. Children. Ask for the Number of Children he or she has and enter the number in the boxes provided. "Children" refers to the biological and legally adopted children of the client who are under the age of 18. For example, if the person has 3 children, write "0" in the first box and then a "3" in the other. Then ask "How many children are living with you?" and fill in the boxes labeled Children Living With You. These children refer to children under the age of 18 who reside in the same household as the client. They need not be the client’s own children. Finally, ask "How many of your children need care while you get services?" and fill in the boxes labeled Children Needing Care While You Get Services. This item refers to the number of children under the age of 18 who would need child care services while the client in getting services, care, or treatment from the project.

3. Primary Ethnic/Cultural/Racial Background. Ask the client what his/her primary ethnic background is. If the client gives a non-specific response, probe him/her until a response corresponding to a two-digit code is given. If the client cannot specify subcategories of ethnic/cultural/racial background, use the broader categories ("10" = Caucasian, "20" = African-American/Black (non-Hispanic), "30" = Hispanic, "40" = Asian/Pacific Islander, "50" = American Indian, Aleutian, Native Alaskan or Eskimo). Mark "99" if the ethnic/cultural/racial background is unknown.

4. Multi-Racial. Say to the client: "Are you multi-racial?" Darken either the "Yes," "No," or "Do Not Know" circle to indicate if the client identifies him/herself as multi-racial. If the client responds yes, ask: "What is your secondary ethnic background?" Enter the two-digit code for the second race or ethnicity in the boxes provided. Use the same codes as those listed under "Primary Ethnic/Cultural/Racial Background."

5. Payer Insurance. (All that apply) Say to the client: "What kind of health insurance do you have?" Probe client until he/she provides a specific response that can be coded. Darken the circle(s) of the choices which indicate the client’s insurance coverage status.

Type of Insurance Payer	Working Definition
Private, 3rd party health insurance (include HMO)	Private (non-governmental), fee-for-service payer such as Blue Shield, Cigna, and Prudential. Includes Health Maintenance Organizations (HMO) such as Kaiser.
Medicaid (fee for service)	Public (governmentally administrated) fee-for-service payer for those who qualify.
Other public insurance / Medicare	Other public (governmentally administrated) insurance program, including Medicare.
Medicaid managed care	The managed care system of Medicaid
Other insurance (e.g., incarcerated)	Other types of insurance; for example, if the client is incarcerated
Self-pay	Insurance that the client purchases individually, as opposed to his/her employer paying for it.
None	No insurance.
Unknown	The client does not know the type of insurance payer he/she has.

6. Pregnant. Say to the client, "Are you currently pregnant?" Darken only one circle among the choices provided. Do not ask male clients.

7. Highest Grade Completed. Say to the client: "What is the highest grade you have completed?" Indicate the highest grade completed by the client by entering a number in the boxes provided. For example, if the person completed 8th grade, write "0" in the first box and then an "8" in the other. Then ask: "Do you have a GED?" If the client has a GED, indicate that by darkening the circle provided. Finally, ask the client: "Are you currently in school?" If the client is currently in school, darken the circle provided.

8. Sources Of Income. Say to the client, "What are your sources of income?" You may need to rephrase the question, such as, "Do you get money from any of these sources?" Then read the entire list and darken as many circles as necessary to indicate the client’s sources of income. Use the boxes labeled Other to write in sources of income not described by the circles.

Source of Income	Working Definition
AFDC	Aid to Families with Dependent Children
Employer Benefits	Health insurance or other fringe benefits that are attached to the client’s job
General Relief	General Relief
Private Insurance	Private disability or other supplemental insurance that the client obtains by him/herself
Social Security	Social Security
SSI	Supplemental Security Income
State Disability	Disability insurance obtained from the state
Wages / Salary	Income from salary or wages from client’s job
None	No source of income

9. Self-Identified Sexual Orientation. Say to the client: "What is your sexual orientation?" If the client does not understand the question or does not respond, read the list of options provided and ask the client to choose one. Indicate his or her choice by darkening the appropriate circle. You may need to paraphrase the question to ask it in a sensitive and appropriate manner.

10. Marital Status. Say to the client: "What is your marital status?" Read the list of options provided and ask the client to choose one. Indicate his or her choice by darkening the appropriate circle. Use the boxes labeled Other to write in marital status not described by the circles.

Marital Status	Working Definition
Single	Never married, not living with someone who is a partner or spouse
Married	Married
Common Law	The client considers himself or herself to be married, and is living together as married even if not legally married. This definition may differ from the legal definition of "common law".
Live with same sex partner	Living with a partner of the same sex
Live with opposite sex partner	Living with a partner of the opposite sex
Separated	Married but separated from spouse
Divorced	Married in the past but now divorced from spouse
Widowed	Spouse has died
Other	Other marital status not coded elsewhere
DK / Refused	Don’t know marital status or refused to answer

11. Other Categories. Do not read this question to the client. Your project may designate questions to be coded using the boxes or circles in this section.

12. Primary Health Care Source. Say to the client: "Where do you go to get medical care?" Read the list of options provided and ask the client to choose one. If client does not understand the list of options, probe with: "Do you go to a doctor at a doctor’s office? Do you go to an HMO such as Kaiser?" Continue probing until client gives a specific response. Indicate his or her choice by darkening the appropriate circle. Use the boxes labeled Other to write in health care sources not described by the circles.

Primary Health Care Source	Working Definition
Solo / group practice, not HMO	A private physician or a group of physicians who practice together. Does not include health maintenance organizations (HMO).
HMO	Health maintenance organization, such as Kaiser.
Publicly-funded community health center	A community-based clinic or health center that receives public funds.
Hospital outpatient clinic/dept	A unit or department based in a hospital. Does not include hospitals that are health maintenance organizations (HMO) such as Kaiser.
Emergency room	A unit or department with a hospital that handles emergencies or crises.
VA / military hospital or outpatient dept.	An outpatient clinic, department, or hospital for veterans or military personnel administered by the Veterans’ Administration (VA).
Other public clinic or department	Other clinic or department that receives public funds not coded elsewhere.
Other	Other primary health care sources not coded elsewhere.
None	No primary source of health care.
Unknown	Client does not know his/her primary source of health care.

13. Employment Status. Say to the client: "Are you working full-time? Part-time?" Continue reading the list of options provided and ask the client to choose one. Indicate his or her choice by darkening the appropriate circle. Use the boxes labeled Other to write in employment status not described by the circles.

14. Housing Status. Say to the client: "Where are you living now?" Read the list of options provided and ask the client to choose one. Indicate his or her choice by darkening the appropriate circle.

Housing Status	Working Definition
Your house / apt.	The client lives in a house or apartment that he/she considers home. The client need not own the house or apartment.
Someone else’s house / apt.	The client lives in a house or apartment that is primarily someone else’s home. The client considers the house or apartment someone else’s home and not his/her own home.
Transitional housing	The client lives in temporary housing that is considered transitional, such as a shelter.
On the street	The client does not live in a house, apartment, or any housed facility. The client stays on the street.
Institution £ 30 days	The client is staying at an institution for 30 days or less. Institutions may include jail, prison, or treatment facilities.
Institution > 30 days	The client is staying at an institution for more than 30 days. Institutions may include jail, prison, or treatment facilities.

15. Primary Language. Say to the client: "What is the primary language that you use?" Probe client with the list of options until client responds yes. Darken the circle of the choice that indicates the client’s primary language. Choose only one. Use the boxes labeled Other to write in languages not indicated on the form.

16. Years Resided (Optional). Say to the client: "How long have you lived in the area where you now live?" Indicate the length of time that client has lived in the catchment area (the geographical area served by your program). For example, if the person has resided in the catchment area for 4 years, write a "0" in the first box and then a "4" in the other. If the client has resided in the catchment area for less than 1 year, fill in the bubble marked "less than 1 year." If the client has moved recently, determine whether his/her previous home was in the same catchment area.

17. Incarcerated/Jail. Say to the client: "Are you currently in jail or in prison?" If the client is currently incarcerated or in jail, indicate by darkening the circle provided.

18. Zip Code (Optional). Say to the client: "What is the zip code where you live?" Fill in the boxes provided with the client’s zip code number.

19. Purpose Of Contact. Do not read this question to the client. Darken the circle of the choice that most appropriately defines the purpose of your contact with the client. Choose only one. Use the boxes labeled Other to write in purposes not indicated on the form.

20. Referral Source (Optional). Say to the client: "Who referred you to us?" Indicate the referral source from which the client came by filling in the appropriate box(es) with one of the following letters:

Referral Source	Working Definition
Case Manager	Provides a range of client-centered services that links clients and other family members with health care, psychosocial services, and other services to ensure timely, coordinated access to appropriate services. Includes on-going assessment of the needs of clients and family members.
Corrections / Parole	Someone who works within the corrections system, such as a parole or probation officer.
Emergency Room	Unit of a hospital handling emergencies or crises.
Family Members / Friends	Family members or friends of client.
Food / Drop-In Center	An informal setting providing support in which clients can have informal social contact and receive basic necessities such as food or clothing.
HIV Testing Site	A site that provides the test to detect the presence of HIV antibodies.
Hospital	A centralized setting that provides primary, specialized, and emergency medical services and care.
Mental Health Agency	Agency that provides mental health services, including individual and group counseling/therapy, psychiatric evaluations, and other services.
Substance Abuse Agency	Agency that provides treatment and counseling/therapy related to substance abuse problems.
Other Medical Services Unit	Unit providing medical services not coded elsewhere.
Outreach	Service which seeks potential clients out in the community who are in need of care or services.
Private / Primary Care Physician	A physician providing office-based, long-term medical services focusing on the prevention of illness and the ongoing management of chronic conditions and acute health problems.
Public Health Agency	Agency that provides public health services such as education and prevention at a regional level (i.e. city, county).
Self	The client him- or herself.
Self-Help Group	A support group focusing on a topic of concern to members of that group. Includes 12-Step groups such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), or Cocaine Anonymous (CA).
Shelter / Housing	Services to obtain short-term (less than one-month stay) or long-term housing.
Social Service Agency	Agency that provides social services such as public assistance or vocational training.
STD Clinic	Medical unit that provides treatment for sexually transmitted diseases.
Other	Other referral sources not coded elsewhere.

21. Behaviors (Optional) Determine if the client has engaged in the behaviors indicated. The response options are:

Information on behaviors may best be gathered through direct observation. If you have direct knowledge of the client’s behaviors, you may not want to use the question format. Additionally, an informal conversation may yield more accurate information than questions in the format outlined below, so you should use your best judgment in obtaining valid and accurate information for this section. If you wish to use the direct question format, start by asking the client if he/she ever engaged in the behavior. If no, then skip to the next item. If yes, ask if he/she engaged in the behavior in the last 30 days. If yes, ask if he/she engaged in the behavior in the last 24 hours. Below are examples of questions.

2. Inferred alcohol problem (For this item, use your professional judgment to determine if the client has an alcohol problem, or pose the question directly to the client.)

Behavior	Working Definition
Cigarette Smoker (1/2 pack or more a day)	If client smokes 1/2 pack or more (10 or more) tobacco cigarettes daily, on the average.
Inferred Alcohol Problem	If service provider infers an alcohol problem based on clinical judgment, or if client reports an alcohol problem.
Heroin Use	If client uses heroin (china white, smack).
Crack Use	If client uses crack cocaine (rock).
Other Illicit Drug Use	If client uses other illegal, non-prescribed, drugs (forms of cocaine other than crack, methamphetamines, PCP, hallucinogens, etc.)
Injection Drug Use	If client injects drugs intravenously or intramuscularly (skin popping).
Needle Sharing	If client shares needles with others in the course of injecting drugs.
CJS Involved	If client is involved with any aspect of the criminal justice system (including arrests, convictions, incarcerations, probation, etc.).
Sex Work / Survival Sex	If client engages in the exchange of sex for money, drugs, a place to stay, or other goods.
STD (not HIV)	If client has a sexually transmitted disease other than HIV, such as gonorrhea, chlamydia, syphilis, herpes, etc.
Sex With Males	If client has sex, including oral, anal, or vaginal sex, with males.
Unprotected Sex With Males	If client has sex with males without using a condom or other latex protection, such as dental dams.
Sex With Females	If client has sex, including oral, anal, or vaginal sex, with females.
Unprotected Sex with Females	If client has sex with females without using a condom or other latex protection, such as dental dams.
Sex with IDU	If client has sex with someone who has injected drugs or is currently injecting drugs.
Sex with HIV+ Person	If client has sex with someone who is known to have tested HIV positive.