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ADOLESCENT SPNS PROJECT
RESIDENTIAL FORM INSTRUCTIONS
Use a black writing instrument (pen or pencil) to complete this form. Answer questions by either filling in a circle, or writing a number or letter in a square box. If the answer goes in a square box, you must use a CAPITAL LETTER or number that does not touch the side of the box. Print only one letter or number in each box. Make the letter or number look like those in the boxes on the Instructions form. If they do not, the computer cannot read your answers. If the letters or numbers that you print touch the sides of the boxes, or if you do not clearly print the information, the computer will "kick out" the form and we will need to return it to you to be completed correctly. If the question asks the answer to be filled in a circle, make sure that the circle is completely darkened.
Specific Parts of the Residential Form
SPNS SITE. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form. If it has not been already entered on the form, check with your project to find out your site code and enter it in the boxes. Site codes are 2 or 3 letters.
PROVIDER. Enter the code for the service provider agency doing the activity. The provider codes are on a separate sheet. Provider codes are 2 or 3 letters.
STAFF CODE. Enter the staff member code or codes for each of the staff providing services. The staff codes are on a separate sheet. If there is a combination of 2 or more staff members providing the service, the staff codes for combinations of staff should be used. Staff codes are 3 numbers.
SERVICE DATE. Enter the numbers representing today's date (the date of the service) 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, "94" for 1994). Make sure that if a month or day is less than 10, you place a "0" before the number.
CLIENT CODE. If your site is using the unique identifier proposed by The Measurement Group, print the first and last initials of the person you have contacted in the first two boxes. If he or she does not want to tell you his/her initials, leave these boxes blank. Leave the rest of the boxes for "CLIENT CODE" blank.
If your site is not using the unique identifier proposed by The Measurement Group, use the boxes next to "CLIENT CODE" to enter the unique identifier your site is using. See specific instructions for your site.
GENDER. Darken the circle next to "Male" or "Female" to indicate the person's gender.
CLIENT BIRTHDATE/AGE. 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. If you do not know the person’s birthdate, fill in his/her age in the boxes labeled "Month/Age" and leave the "Day" and "Year" boxes blank. Estimate the age if the person does not tell you him or herself.
TYPE OF SESSION AND SERVICES. For the items listed under "TYPE OF SESSION AND SERVICES," darken the circle next to all of the items that describe the services that the person received today. Also, if there are boxes labeled "Minutes Today" to the right of an item, enter the number of minutes that the service lasted in these boxes. If the service lasted less than one hundred minutes, you would enter "0" before the number of minutes. For example, if the activity lasted 25 minutes, you would enter "025"; if it lasted 5 minutes, you would enter "005." Note that for medical services "units" are used instead of "minutes." A unit is one instance of service, such as one physical exam or one medical appointment. For example, if the person was given a medical physical examination, you would darken the circle labeled "Medical--physical exam" and if this was the only medical service this person received on this day, you would enter "01" in the boxes labeled "TOTAL UNITS OF MEDICAL SERVICES TODAY." If services were given that are not listed here, write in a short description of the services in the boxes under "Other Services." Write the first service in the boxes labeled "#1" and if there was a second service given that is not listed here, write it in the boxes labeled "#2." Make sure you fill in the number of minutes that these services lasted in the appropriate boxes. These should reflect the totals for the day.
Medical--physical exam. Darken this circle if the person was given a physical exam, including exams for general health care or HIV-specific.
Medical--emergency. Darken this circle if the person had a medical emergency, including visits to an emergency room or urgent care clinic.
Medical--walk-in. Darken this circle if the person had an unscheduled medical visit to a clinic or medical office.
Medical--appt. Darken this circle if the person had a scheduled medical appointment.
Medical--lab (not HIV). Darken this circle if the person had general lab work done (not specifically HIV-related).
Family Planning. Darken this circle if the person received advice and services related to contraception/birth control, and related family planning issues.
Sub Abuse/Ment Health Screen. Darken this circle if the person received screening for substance abuse and/or mental health issues needing further attention.
TOTAL UNITS OF MEDICAL SERVICES TODAY. Enter the total number of units of medical services that the person received on this day.
HIV Risk Assessment. Darken this circle if the person received assessment of their risk level for HIV infection.
HIV Pre-Test Counseling. Darken this circle if the person received counseling prior to taking an HIV test.
HIV Test. Darken this circle if the person took an HIV test.
HIV Post-Test Counseling. Darken this circle if the person received counseling after taking an HIV test; may or may not be when the person receives the test results.
HIV Prevention. Darken this circle if the person took part in activities designed to reduce the risk of HIV infection.
Other Prevention. Darken this circle if the person took part in activities designed to reduce the risk of other risky behaviors or to prevent related problems such as substance abuse, violence, other health problems, etc.
PREVENTION SERVICES. Enter the total number of minutes of prevention services that the person received on this day.
Individual Counseling/Therapy. Darken this circle if the person received individual (one-on-one) counseling or therapy from a psychologist, social worker, counselor, or other service provider.
Crisis Intervention. Darken this circle if the person received intervention for acute crisis; may be provided by a psychologist, social worker, counselor, or other service provider.
INDIVIDUAL THERAPY/COUNSELING. Enter the total number of minutes of individual therapy or counseling that the person received on this day.
Group Counseling/Therapy. Darken this circle if the person received group counseling or therapy from a psychologist, social worker, counselor, or other service provider.
Family/Couple Counsel/Therapy. Darken this circle if the person received counseling or therapy with family members or a partner. Services provided by a psychologist, social worker, counselor, or other service provider.
GROUP/FAMILY THERAPY/COUNSELING. Enter the total number of minutes of group and/or family therapy or counseling that the person received on this day.
AA/NA/CA. Darken this circle if the person attended these specific 12-step groups.
Peer Support Grp. Darken this circle if the person attended self-help groups that are conducted by and for youth.
Other 12-Step Group. Darken this circle if the person attended other 12-step groups (Not AA/NA/CA).
HIV Support Group. Darken this circle if the person attended self-help groups concerned with issues related to HIV.
12-STEP AND OTHER SUPPORT GROUPS. Enter the total number of minutes of support groups that the person attended on this day.
Info & Referral. Darken this circle if the person was provided with information, education, and referrals for a variety of problems.
Practical Support. Darken this circle if the person received help with daily life tasks like grocery shopping, meal preparation, running errands, etc.
Case Review. Darken this circle if the person met with a case manager or other program staff to discuss the client's progress.
Minutes Today. Enter the total number of minutes the person spent in activities related to Info & Referral, Practical Support, and Case Review on this day.
Recreation. Darken this circle if the person participated in activities such as sports, parties, outings, etc. Enter the total number of minutes for the day.
House Duties/Life Skills. Darken this circle if the person participated in house duties or other activities that train them for life outside of treatment. Enter the total number of minutes for the day.
School. Darken this circle if the person attended school. Enter the total number of minutes for the day.
Vocational Educ. Darken this circle if the person received vocational education or training. Enter the total number of minutes for the day.
"Alternate" Therapy. Darken this circle if the person received alternative therapy including herbals, acupuncture, Chinese medicine, etc. Enter the total number of minutes for the day.
Milieu Therapy. Darken this circle if the client attended house meetings, morning meetings, etc. where the entire community met together. Enter the total number of minutes for the day.
Topics Discussed. For the items listed under "Topics Discussed," darken the circle next to all of the topics that were discussed with the person during the session. For example, if you discussed HIV Risk Factors with the person, you would darken the circle labeled "HIV Risk Factors." If you discussed a topic that is not listed here, write in a short description of the topic in the boxes labeled "Other #1." If you discussed a second topic that is not listed here, write in the description of the topic in the boxes labeled "#2," and if a third topic was discussed that is not listed here, write in the description in the boxes labeled "#3."
HIV Risk Factors. Darken this circle if the topics discussed related to HIV risk factors, including but not limited to sexual behaviors, injection and other drug use, blood sharing, and other factors that increase a person's risk for HIV.
"Safer" Sex. Darken this circle if the topics discussed related to "safer sex" and ways to reduce risk through using latex protection and less risky sexual behaviors.
HIV Testing. Darken this circle if the topics discussed related to getting HIV testing, what the test means, pre- and post-test counseling, implications of getting tested, and other related topics.
HIV Services. Darken this circle if the topics discussed related to getting prevention, intervention, and/or treatment services for HIV for oneself or someone else.
Medical Services. Darken this circle if the topics discussed related to health and medical services in general, not necessarily specific to HIV or AIDS.
Public Assistance. Darken this circle if the topics discussed related to getting benefits the person may be eligible for, such as welfare, AFDC, food stamps, etc.
Alternate Therapy. Darken this circle if the topics discussed related to alternative therapies including herbals, acupuncture, Chinese medicine, etc.
Family Planning. Darken this circle if the topics discussed related to contraception/birth control advice and services, and related family planning issues.
Substance Abuse. Darken this circle if the topics discussed related to alcohol and other drug abuse, including but not limited to prevention, identification of abuse, intervention and treatment services, links between substance abuse and HIV, 12-step groups, and other related issues.
Emotional Problems. Darken this circle if you discussed mental or emotional problems.
"Hassles." Darken this circle if the topics discussed related to problems in general; not specifically identified in terms of the other categories listed. Includes relationship problems with family and peers.
Assertiveness. Darken this circle if the topics discussed related to assertiveness. May include learning to be more assertive.
Housing/Jobs. Darken this circle if the topics discussed related to obtaining housing or jobs. May include job skills, vocational training, etc.
Eating Disorder. Darken this circle if the topics discussed related to eating disorders such as anorexia, bulimia, etc.
Self Identity. Darken this circle if the topics discussed related to identity and sexual orientation.
Youth Empowerment. Darken this circle if the topics discussed related to teaching youth skills to negotiate the service system on their own. This is similar to advocacy, but in youth empowerment the youth learns how to advocate for him or herself.
Living with HIV. Darken this circle if the topics discussed related to living with HIV disease. Can refer to oneself or a family member or friend.
Health Status. Darken this circle if the topics discussed related to the respondent's health.
Dating/Sex. Darken this circle if the topics discussed related to dating, relationships, and sex.
Risk Reduction Barriers. Darken this circle if the topics discussed related to barriers to reducing one's risk of HIV. Includes reasons why it is hard for youth to change risky behaviors.
House Rules. Darken this circle if the topics discussed related to rules of behavior while staying at the program.
SERVICES PROVIDED TODAY BY. Darken the circle next to all of the people who provided services to this person during this session. For example, if a medical doctor examined or treated the person, you would darken the circle next to "Physician." If the service was provided by some other type of person, write a short description in the boxes indicated.
Physician. Darken this circle if the service was provided by a medical doctor. A physician's assistant (PA) should be marked under "Other."
Nurse. Darken this circle if the service was provided by a nurse (RN, LVN, etc.)
Psychiatrist. Darken this circle if the service was provided by a psychiatrist (a medical doctor specializing in psychiatry.)
Health Educator. Darken this circle if the service was provided by a staff member who provides information about health practices, nutrition, etc.
Case Manager. Darken this circle if the service was provided by a staff member who coordinates a number of services for a client. Case managers may also be social workers, but not necessarily.
Social Worker. Darken this circle if the service was provided by a social worker. Social workers provide mental health and social services. They usually have a Master's degree (MSW) and sometimes are licensed by the state (LSCW).
Teacher. Darken this circle if the service was provided by a school teacher.
Psychologist. Darken this circle if the service was provided by a psychologist. Psychologists provide mental health and some other social services. They usually have a doctorate (PhD, EdD, or PsyD) but often may have a Master's degree (MA or MS).
Other MH Worker. This refers to some other type of mental health care worker, such as a Marriage, Family and Child Counselor (MFCC).
Counselor. Darken this circle if the service was provided by a counselor. Counselors can be professionals or paraprofessionals who provide individual or group counseling.
Peer Counselor. Darken this circle if the service was provided by a counselor who is approximately the same age as the client.
Public Health Worker. Darken this circle if the service was provided by a public health worker. Public health workers may include Public Health Nurses and other service providers who work in a public health setting or for a public health department.
Outreach Worker. Darken this circle if the service was provided by an outreach worker. Outreach workers go into the community to raise awareness of problems and services.
© Copyright 1998-2005 by The Measurement Group LLC. All rights reserved.