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NIMH Data Archive
NDA ABCD CCF OAI NIAAADA AMP SCZ HEAL

Service Utilization and Resources Monthly Form for Schizophrenia

2,797 Shared Subjects

Service Utilization and Resources Monthly Form for Schizophrenia
Clinical Assessments
Questionnaire
05/08/2014
surf01
05/08/2014
View Change History
01
Definition
Submission Template
Query Element Name Data Type Size Required Description Value Range Notes Aliases
subjectkey GUID Required The NDAR Global Unique Identifier (GUID) for research subject NDAR*
src_subject_id String 20 Required Subject ID how it's defined in lab/project CATIEID, bid
interview_date Date Required Date on which the interview/genetic test/sampling/imaging/biospecimen was completed. MM/DD/YYYY
interview_age Integer Required Age in months at the time of the interview/test/sampling/imaging. 0::1440 Age is rounded to chronological month. If the research participant is 15-days-old at time of interview, the appropriate value would be 0 months. If the participant is 16-days-old, the value would be 1 month. dema1
sex String 20 Required Sex of subject at birth M;F; O; NR M = Male; F = Female; O=Other; NR = Not reported dema2, gender
Query visitid Integer Recommended MetaTrial Visit ID System variable: unique code for each type of visit -use to merge files
Query visit String 60 Recommended Visit name
Query truncvis Integer Recommended Truncated Visit Number Created variable: provides a numeric visit number for all visits, including unscheduled and end of phase
Query phase_ct String 20 Recommended Current Phase. Phase patient was in at the time of the assessment Phase 4 refers to the follow-up phase. Pre-Rand; Phase 1/1A; Phase 2; Phase 3; Phase 4; Phase 1B; Open-Choice Phase; Screening; Phase 1
Query visday Integer Recommended Number of days from study baseline to date of visit
protocol String 50 Recommended Protocol [Study] name
Query surfm1 Integer Recommended 1. Is todays visit intended as a psychoeducational session? 0;1 0=No; 1=Yes
Query surfm1a Integer Recommended 1a. If yes, is the session for 1;2 1 = Patient only; 2 = Patient and family
Query inpat1 Integer Recommended 2. Were you hospitalized for at least one night for any of the following reasons during the last month? 0;1 0=No; 1=Yes
Query inpat1a Integer Recommended 2a. If yes, check all that apply: Inpatient care 0;1 0=No; 1=Yes
Query inpat1b Integer Recommended b. If yes, check all that apply: Surgical problem 0;1 0=No; 1=Yes surfm01b
Query inpat1c Integer Recommended c. If yes, check all that apply: Psychiatric problem 0;1 0=No; 1=Yes surfm01c
Query inpat1d Integer Recommended d. If yes, check all that apply: Substance abuse problem 0;1 0=No; 1=Yes surfm01d
Query servcode Integer Recommended Service code (reason for admission) 1::5 1 = Medical - e.g., neurological; 2 = Surgical; 3 = Psychiatric - non-substance abuse; 4 = Drug Abuse - not alcohol; 5 = Alcohol Abuse
Query hosptype Integer Recommended 3b. Hospital Type 1::6 1 = State and county mental hospital; 2 = Private psychiatric hospital; 3 = Non-federal general hospital; 4 = VA; 5 = Multi-service community mental health; 6 = Substance abuse/detox facility
Query night Integer Recommended 3c. Total Number of Nights in Past Month
Query scode Integer Recommended 3d. Total Number of Admissions Past Mont
Query surfm31 Integer Recommended 4. In the past month did you spend any nights in a nursing home for any reason (physical or emotional)? 0;1 0=No; 1=Yes
Query night2 Integer Recommended 5a. Number of Nights in Nursing home srf5
Query nurlevel Integer Recommended 5b. Level of Nursing Home Care 1;2 1 = Skilled; 2 = Intermediate
Query surfm41 Integer Recommended 6.In the past month did you spend any nights in a structured residence for any reason (physical or emotional)? 0;1 0=No; 1=Yes
Query night3 Integer Recommended 7a. Number of Nights in Structured residence
Query levelc Integer Recommended 7b. Level of Care 1::4 1 = Halfway house; 2 = Board & Care; 3 = Supervised Apartment; 4=respite care
Query surfm51 Integer Recommended 8. In the last month, did you see a doctor or any other health care professional for an emotional or psychiatric problem? 0;1 0=No; 1=Yes srf6
Query typecode Integer Recommended 9a. Type Code for places from which patient may have received services 1::16 1 = Community mental health center; 2 = Psychiatric clinic or private psychiatry; 3 = Family service or child guidance center 4 = Private Mental Health Professional; 5 = Alcohol or drug counseling center; 6 = Self-help group - e.g. AA CA NA; 7 = Day hospital or day treatment center; 8 = VA clinic; 9 = Vocational rehabilitation; 10 = Psychosocial rehabilitation program; 11 = Case Management-PACT; 12 = Other; 13 = Psychiatric contacts associated with; 14 = Clinical contacts associated with the; 15 = Study related psycho-educational visi 16 = Supportive employment
Query numvisit Integer Recommended Number of Visits
Query avgmin Float Recommended 9c. Average Minutes per Visit
Query surfm10 Integer Recommended 10. In the past month, have you been to see a doctor or any other health care professional for any physical problems on an outpatient basis? 0;1 0=No; 1=Yes surfm21
Query surfm10a Integer Recommended If YES, in which of the following settings did you have at least one outpatient visit for a physical or medical problem during the past month? Private medical doctor
Query surfm10b Integer Recommended If YES, in which of the following settings did you have at least one outpatient visit for a physical or medical problem during the past month? Private health care practitioner (non-M.D)
Query surfm10c Integer Recommended If YES, in which of the following settings did you have at least one outpatient visit for a physical or medical problem during the past month? Outpatient clinic
Query surfm10d Integer Recommended If YES, in which of the following settings did you have at least one outpatient visit for a physical or medical problem during the past month? Day surgery
Query surfm10e Integer Recommended If YES, in which of the following settings did you have at least one outpatient visit for a physical or medical problem during the past month? Community Health Center
Query srfm10fa Integer Recommended If YES, in which of the following settings did you have at least one outpatient visit for a physical or medical problem during the past month? Other
Query surfm10g Integer Recommended If YES, in which of the following settings did you have at least one outpatient visit for a physical or medical problem during the past month? Emergency room (medical)
Query surfm10h Integer Recommended If YES, in which of the following settings did you have at least one outpatient visit for a physical or medical problem during the past month? Emergency room (psychiatric)
Query fseqno Integer Recommended Sequence Number 0::999 The FSEQNO variable in the ADJ form has a special interpretation compared to other forms. For example, ADJ FSEQNO of '1' can be thought of as being '001', FSEQNO of '2' can be thought of as being '002', and FSEQNO of '3' can be thought of as being '003'. The first digit of FSEQNO relates to the corresponding ENF sequence number at that visit and the third digit relates to the specific adjudicator who completed the adjudication form.
Query srfa1 Integer Recommended First, I want to ask you about times during the past month when you were an inpatient in a hospital, do not include nursing homes or halfway house stays. Were you hospitalized for at least one night during the last month for any of the following reasons: medical or surgical problem, or a psychiatric or substance abuse problem. 0;1 0=No; 1=Yes
Query srfa2a1 Integer Recommended 1st event Reason 0;1;2;3;4;5 0=No further events; 1=Medical problem (e.g. neurological); 2=Surgical problem; 3=Psychiatric (non-substance abuse); 4=Drug Abuse (not alcohol); 5=Alcohol abuse
Query srfa2a2 Integer Recommended 1st event Number of nights 0::50
Query srfa2a3 Integer Recommended 1st event Provider Type 1;2;3;4;5;6 1=State or county mental hospital; 2=Private psychiatric hospital; 3=Non-federal general hospital; 4=VA; 5=Multi-service community mental health center; 6=Substance abuse (detox facility)
Query srfa2b1 Integer Recommended 2nd event Reason 0;1;2;3;4;5 0=No further events; 1=Medical problem (e.g. neurological); 2=Surgical problem; 3=Psychiatric (non-substance abuse); 4=Drug Abuse (not alcohol); 5=Alcohol abuse
Query srfa2b2 Integer Recommended 2nd event Number of nights 0::50
Query srfa2b3 Integer Recommended 2nd event Provider type 1;2;3;4;5;6 1=State or county mental hospital; 2=Private psychiatric hospital; 3=Non-federal general hospital; 4=VA; 5=Multi-service community mental health center; 6=Substance abuse (detox facility)
Query srfa2c1 Integer Recommended 3rd event Reason 0;1;2;3;4;5 0=No further events; 1=Medical problem (e.g. neurological); 2=Surgical problem; 3=Psychiatric (non-substance abuse); 4=Drug Abuse (not alcohol); 5=Alcohol abuse
Query srfa2c2 Integer Recommended 3rd event Number of nights 0::50
Query srfa2c3 Integer Recommended 3rd event provider type 1;2;3;4;5;6 1=State or county mental hospital; 2=Private psychiatric hospital; 3=Non-federal general hospital; 4=VA; 5=Multi-service community mental health center; 6=Substance abuse (detox facility)
Query srfa2d1 Integer Recommended 4th event Reason 0;1;2;3;4;5 1st event; 0=No further events; 1=Medical problem (e.g. neurological); 2=Surgical problem; 3=Psychiatric (non-substance abuse); 4=Drug Abuse (not alcohol); 5=Alcohol abuse
Query srfa2d2 Integer Recommended 4th event number of nights 0::50
Query srfa2d3 Integer Recommended 4th event provider type 1;2;3;4;5;6 1=State or county mental hospital; 2=Private psychiatric hospital; 3=Non-federal general hospital; 4=VA; 5=Multi-service community mental health center; 6=Substance abuse (detox facility)
Query srfa2e1 Integer Recommended 5th event Reason 0;1;2;3;4;5 0=No further events; 1=Medical problem (e.g. neurological); 2=Surgical problem; 3=Psychiatric (non-substance abuse); 4=Drug Abuse (not alcohol); 5=Alcohol abuse
Query srfa2e2 Integer Recommended 5th event number of nights 0::50
Query srfa2e3 Integer Recommended 5th event provider type 1;2;3;4;5;6 1=State or county mental hospital; 2=Private psychiatric hospital; 3=Non-federal general hospital; 4=VA; 5=Multi-service community mental health center; 6=Substance abuse (detox facility)
Query srfa3 Integer Recommended In the past month did you spend any nights in a nursing home for any reason, (Physical or emotional)? 0;1 0=No; 1=Yes
Query srfa3a1 Integer Recommended Number of nights 00::50 Nursing home #1
Query srfa3a2 Integer Recommended Level of care 1;2 Nursing home #1; 1=Skilled; 2=Intermediate
Query srfa3b1 Integer Recommended Number of nights 00::50 Nursing home #2
Query srfa3b2 Integer Recommended Level of care 1;2 Nursing home #2; 1=Skilled; 2=Intermediate
Query srfa3c1 Integer Recommended Number of nights 00::50 Nursing home #3
Query srfa3cb Integer Recommended Level of care 1;2 Nursing home #3; 1=Skilled; 2=Intermediate
Query srfa4 Integer Recommended In the past month did you spend any nights in a structured residence or halfway house for any reason (physical or emotional)? 0;1 0=No; 1=Yes
Query srfa4a1 Integer Recommended Number of nights 00::50 Residence #1
Query srfa4a2 Integer Recommended Level of care 1;2;3 Residence #1; 1=Halfway House; 2=Board &Care; 3= Supervised apartment
Query srfa4b1 Integer Recommended Number of nights 00::50 Residence #2
Query srfa4b2 Integer Recommended Level of care 1;2;3 Residence#2; 1=Halfway House; 2=Board &Care; 3= Supervised apartment
Query srfa4c1 Integer Recommended Number of nights 00::50 Residence#3
Query srfa4c2 Integer Recommended Level of care 1;2;3 Residence#3; 1=Halfway House; 2=Board &Care; 3= Supervised apartment
Query srfa5 Integer Recommended Next, I want to ask you about outpatient visits for help with drug or alcohol abuse, emotional or psychiatric problems. In the last month, did you see a doctor or any other health care professional for an emotional or psychiatric problem? This should include visits for problems related to alcohol or drug use. 0;1 0=No; 1=Yes
Query srfa5a1 Integer Recommended Services. Commnity Mental Health Clinic Services 0;1 0=No; 1=Yes surfm17e
Query srfa5a2 Integer Recommended Number of visits 0::50 Commnity Mental Health Clinic Services srfa7
Query srfa5a3 Integer Recommended average minutes/visit 000::999 Commnity Mental Health Clinic Services
Query srfa5b1 Integer Recommended Services. Psychiatric Clinic 0;1 0=No; 1=Yes surfm17f
Query srfa5b2 Integer Recommended number of visits 0::100; -99 Psychiatric Clinic; -99=NK srfa8
Query srfa5b3 Integer Recommended average minutes/visit 000::999; -99 Psychiatric Clinic; -99=NK
Query srfa5c1 Integer Recommended Services. Family Service or Guardian Agency 0;1 0=No; 1=Yes surfm17g
Query srfa5c2 Integer Recommended number of visits 0::50 Family Service or Guardian Agency srfa9
Query srfa5c3 Integer Recommended average minutes/visit 000::999 Family Service or Guardian Agency
Query srfa5d1 Integer Recommended services. Private Mental Health Professional 0;1 0=No; 1=Yes surfm17h
Query srfa5d2 Integer Recommended number of visits 0::50 Private Mental Health Professional (psychiatrist, social worker, psychologist, visiting nurse,etc...) srfa10, surfm21b
Query srfa5d3 Integer Recommended average minutes/visit 000::999 Private Mental Health Professional (psychiatrist, social worker, psychologist, visiting nurse,etc...)
Query srfa5e1 Integer Recommended services. Alcohol or Drug Counseling 0;1 0=No; 1=Yes surfm17i
Query srfa5e2 Integer Recommended number of visits 0::50 Alcohol or Drug Counseling srfa11
Query srfa5e3 Integer Recommended average minutes/visit 000::999 Alcohol or Drug Counseling
Query srfa5f1 Integer Recommended services. Self-Help Group 0;1 0=No; 1=Yes surfm17j
Query srfa5f2 Integer Recommended number of visits 0::60 Self-Help Group (AA, NA, Peer Support) srfa12
Query srfa5f3 Integer Recommended Self-Help Group (AA, NA, Peer Support) average minutes/visit 000::999 Self-Help Group (AA, NA, Peer Support)
Query srfa5g1 Integer Recommended Services. Day Hospital/Day Treatment Center 0;1 0=No; 1=Yes surfm17k
Query srfa5g2 Integer Recommended number of visits 0::50 Day Hospital/Day Treatment Center srfa13
Query srfa5g3 Integer Recommended average number of minutes 000::999 Day Hospital/Day Treatment Center
Query srfa5h1 Integer Recommended services. VA Clinic 0;1 0=No; 1=Yes surfm17l
Query srfa5h2 Integer Recommended number of visits 0::50 VA Clinic srfa14
Query srfa5h3 Integer Recommended average minutes/visit 000::999 VA Clinic
Query srfa5i1 Integer Recommended services. Vocational Rehabilitation 0;1 0=No; 1=Yes surfm17m
Query srfa5i2 Integer Recommended number of visits 0::50 Vocational Rehabilitation srfa15
Query srfa5i3 Integer Recommended average minutes/visit 000::999 Vocational Rehabilitation
Query srfa5j1 Integer Recommended services. Psychosocial Rehabilitation Program 0;1 0=No; 1=Yes surfm17n
Query srfa5j2 Integer Recommended number of visits 0::50 Psychosocial Rehabilitation Program srfa16
Query srfa5j3 Integer Recommended average minutes/visit 000::999 Psychosocial Rehabilitation Program
Query srfa5k1 Integer Recommended services. Supportive employment 0;1 0=No; 1=Yes surfm17b
Query srfa5k2 Integer Recommended number of visits 0::50 Supportive employment
Query srfa5k3 Integer Recommended average minutes/visit 000::999 Supportive employment
Query srfa5l1 Integer Recommended services. Case Management/PACT 0;1 0=No; 1=Yes surfm17a
Query srfa5l2 Integer Recommended number of visits 0::50 Case Management/PACT (note: If included in previous categories do not double count) srfa17
Query srfa5l3 Integer Recommended average minutes/visit 000::999 Case Management/PACT (note: If included in previous categories do not double count)
Query srfa5m1 Integer Recommended services. Clinical contacts with study psychiatrists 0;1 0=No; 1=Yes surfm17c
Query srfa5m2 Integer Recommended number of visits 0::50 Clinical contacts with study psychiatrists
Query srfa5m3 Integer Recommended average minutes/visit 000::999 Clinical contacts with study psychiatrists
Query srfa5n1 Integer Recommended services. Clinical contacts with study research staff for non-study clinical care 0;1 0=No; 1=Yes surfm17d
Query srfa5n2 Integer Recommended number of visits 0::50 Clinical contacts with study research staff for non-study clinical care
Query srfa5n3 Integer Recommended average minutes/visit 000::999 Clinical contacts with study research staff for non-study clinical care
Query srfa5o1 Integer Recommended Services 0;1 0=No; 1=Yes
Query srfa5o2 Integer Recommended number of visits 0::100; -99 Other services; -99=NK srfa18
Query srfa5o3 Integer Recommended average minutes/visit 000::999; -99 Other services; -99=NK
Query srfa6a Integer Recommended PrivateMedicalDoctor number of visits 0::50 srfa20
Query srfa6b Integer Recommended Private Health Care Practitioner (Non-M.D.) number of visits 0::50 srfa21
Query srfa6c Integer Recommended OutpatientClinic number of visits 0::50 srfa22, surfm21c
Query srfa6d Integer Recommended Day surgery number of visits 0::50 srfa23, surfm21d
Query srfa6e Integer Recommended Community Health Center number of visits 0::50 srfa24, surfm21e
Query srfa6f Integer Recommended Other number of visits 0::50 srfa25
Query srfa6g Integer Recommended Emergency Room (Medical) number of visits 0::200 srfa26, surfm21f
Query srfa6h Integer Recommended Emergency Room (Psychiatric) number of visits 0::50 srfa27, surfm21g
version_form String 121 Recommended Form used/assessment name vers
Query daysrz Integer Recommended days since randomization srfa0b
Query srfa19 Integer Recommended Clinical visits associated with project (*) 0::50 Do not include clinical visits exclusively for research data collection. This category includes both physician and non-physician visits for clinical care.
Query srf1 Integer Recommended Medical problem: number of nights 0::50
srf1a String 30 Recommended Medical problem: Provider Type S-Legitimately skipped
Query srf2 Integer Recommended Surgical problem: Number of nights 0::50
srf2a String 30 Recommended Surgical problem: Provider Typer S-Legitimately skipped
Query srf3 Integer Recommended Psychiatric problem: Number of nights 0::50
srf3a String 50 Recommended Psychiatric problem: Provider Type S-Legitimately skipped
Query srf4 Integer Recommended Substance abuse problem: Number of nights 0::50
srf4a String 30 Recommended Substance abuse problem: Provider Type S-Legitimately skipped
Query surfm01 Integer Recommended Was [patient] hospitalized for at least one night for any of the following reasons during the last month? 0;1 0=No; 1=Yes
Query surfm01a Integer Recommended Medical Problem 1; 0 1=Yes; 0=No
Query copyid Integer Recommended Copy ID for multi-copy forms The case report form used to create this file is a multi- copy form, meaning more than one copy of it can be completed at any one visit. For example, a patient with three adverse events to report at a single visit would have 3 copies of the form at that visit, one for each adverse event. The data file will have three unique records for this patient at this visit. COPYID identifies the order in which the forms were completed at a visit.
Query surfm12 Integer Recommended In the last month, did [patient] receive special help, services, or equipment related to Alzheimer's Disease or its effect? 0;1 0=No; 1=Yes
Query surfm12a Integer Recommended Social day care / adult day care? 1; 0 In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
Query surfm12b Integer Recommended In home respite care 1; 0 In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
Query surfm12c Integer Recommended Case Management 1; 0 In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
Query surfm12d Integer Recommended Congregate Meals 1; 0 In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
Query surfm12e Integer Recommended Home delivered meals 1; 0 In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
Query surfm12f Integer Recommended Visiting nurses services 1; 0 In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
Query surfm12g Integer Recommended Physical therapy 1; 0 In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
Query surfm12h Integer Recommended Speech/occupational therapy 1; 0 In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
Query surfm12i Integer Recommended Homemaker/ housekeeping services 1; 0 In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
Query surfm12j Integer Recommended Live-in Caregiver Services 1; 0 In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
Query surfm12k Integer Recommended Companion services 1; 0 In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
Query surfm12l Integer Recommended Client education training services 1; 0 In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
Query surfm12m Integer Recommended Client support group 1; 0 In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
Query surfm12n Integer Recommended Transportation services: ambulance 1; 0 In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
Query surfm12o Integer Recommended Transportation services to health services (taxi, escort, but not family) 1; 0 In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
Query surfm12p Integer Recommended Delivery of adaptive or assistive equipment or medical supplies 1; 0 In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
Query surfm12q Integer Recommended Clinical contacts associated with research staff of this project 1; 0 In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
Query surfm12r Integer Recommended Psychiatric contacts associated with study medication (Physician related visits) 1; 0 In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
Query surfm13 Integer Recommended Type Code 1::18 1=Social day care adult day care; 2=In home respite care; 3=Case management; 4=Congregate meals 5=Home delivered meals; 6=Visiting nurses services; 7=Physical therapy; 8=Speech/occupational therapy; 9=Homemaker/Housekeeping services; 10=Live-in caregiver services; 11=Companion services; 12=Client education training services; 13=Client support group; 14=Transportation services: ambulance; 15=Transportation servic+D1es to health ser; 16=Delivery of adaptive or assistive equ; 17=Clinical contacts associated with res; 18=Psychiatric contacts associated with
Query surfm13a Integer Recommended Number of Visits 1::31 surfm14
Query surfm13b Integer Recommended Average Minutes per Visit 0::999 surfm15
Query surfm16 Integer Recommended In the last month, did [patient] see a doctor or any other health care professional for an emotional or psychiatric problem? 0;1 0=No; 1=Yes
Query surfm16a Integer Recommended Number of visits in the past month 1::31
Query surfm18 Integer Recommended Type Code 1;2;3;4;5;6;7;8;9;10;11;12;13;14 1 = Case management/PACT; 2=Supportive employment; 3=Psychiatric contacts associated with s; 4=Clinical contacts associated with rese; 5=Community mental health center; 6=Psychiatric clinic or Private Psychiat; 7=Family service or child guidance agenc; 8=Private mental health professional [a; 9=Alcohol or drug counseling; 10=Self-help group [e.g., AA, CA, NA]; 11=Day Hospital/Day Treatment Center; 12=VA Clinic; 13=Vocational rehabilitation; 14=Psychosocial rehabilitation program
Query surfm18a Integer Recommended Number of Visits: 1::31 surfm19
Query surfm18b Integer Recommended Average minutes per visit 0::999 surfm20
Query surfm21a Integer Recommended Private medical doctor 0::99
Query monthsbl Float Recommended Actual number of months from Baseline
Query days_baseline Integer Recommended Days since baseline
Query surm005b Integer Recommended Nursing home provider 1::7 1 = State and county mental hospital; 2 = Private psychiatric hospital; 3 = Non-federal general hospital; 4 = VA; 5 = Multi-service community mental health; 6 = Substance abuse/detox facility; 7=none of the above
Query surm006b Integer Recommended Halfway house or staffed residence provider 1::7 1 = State and county mental hospital; 2 = Private psychiatric hospital; 3 = Non-federal general hospital; VA = VA; 5 = Multi-service community mental health; 6 = Substance abuse/detox facility; 7=none of the above
Query surm007 Integer Recommended Emergency Room (past 30 days), Medical reason 0;1 0=No; 1=Yes
Query surm007b Integer Recommended Emergency Room (past 30 days), Medical reason; average duration, minutes
Query surm008 Integer Recommended Emergency Room (Psychiatric/Substance Use Reason)
Query surm008b Integer Recommended Emergency Room (Psychiatric/Substance Use Reason), average duration, minutes
Query surm009 Integer Recommended Who do you live with? Where do you usually sleep at night? 1::7 1=Living alone � independent living situation; 2=Supported living arrangement � may include other residents, some supervision but not daily on site management; 3=Structured environment � e.g., board and care, group home, halfway house; VA=Family of origin � e.g., parents, grandparents, siblings or other relative; 5=Family of orientation � e.g., spouse, children; 6=Homeless shelter or on the street; 7=Other living situation
currestx String 100 Recommended Other living situation, describe
Query studntyn Integer Recommended Is the client currently a student 0;1 0=No; 1=Yes
Query surm011 Integer Recommended If yes- Are you full-time or Part-time 1;2 1=Fulltime; 2= part-time
Query surm012 Integer Recommended What is the type of school or classes you are attending 1::5 1 =High school - include both for HS diploma and GED; 2 College or University - that offers Bachelors or advanced degree; 3= Community College - that offers Associate degree; VA =Vocational or Technical School - that offers Certificates such as culinary arts. such as automotive, electrical, plumbing, computer. IT (Information Technology) cosmetology; 5= Other school that offers a Certificate or skill training
surm012a String 100 Recommended Other school that offers a Certificate or skill training (specify)
Query surm013 Integer Recommended If yes - How many days per week are you scheduled to go to classes
Query dworked Integer Recommended How many days in the past month have you actually worked for pay?
Query hworked Integer Recommended About how many hours a week do/did you usually work? 999 = Missing
Query earnweek Integer Recommended About how much did you earn per week? (round to dollars, no cents)
Query surfq2 Integer Recommended IB. In addition to the above earnings, during the past month, have you done any casual employment or day jobs, such as yard work or babysitting over a few days for which you got paid? 0;1 0 = No; 1 = Yes
Query surfq2a Integer Recommended About how much did you earn doing day jobs in the past month? (round to dollars, no cents)
Query surfq3 Integer Recommended During the past month, have you done any kind of volunteer work (such as working at a hospital or a school)? 0;1 0 = No; 1 = Yes
Query surfq3a Integer Recommended About how many days did you do volunteer work?
Query surfq3b Integer Recommended On a day that you did volunteer work, about how many hours per day did you do volunteer work?
Query surm019 Integer Recommended During the last 30 days, have you been looking for work 0;1 0=No; 1=Yes
Query surm041 Integer Recommended In the past 30 days, how many visits did you attend at these programs for an emotionalor psychiatric problem, or for an alcohol or drug problem? Psychiatrist 0;1 0=No; 1=Yes
Query surm041a Integer Recommended Psychiatrist. Number of outpatient visits of this type
Query surm041b Integer Recommended Psychiatrist. Average duration of this type of visit, minutes
Query surm042 Integer Recommended In the past 30 days, how many visits did you attend at these programs for an emotionalor psychiatric problem, or for an alcohol or drug problem? Nurse Practitioner 0;1 0=No; 1=Yes
Query surm042a Integer Recommended Nurse Practitioner. Number of outpatient visits of this type
Query surm042b Integer Recommended Nurse Practitioner. Average duration of this type of visit, minutes
Query surm043 Integer Recommended Were you asked to record your symptoms and side effects before you met with your psychiatrist or nurse practitioner 0::3 2=No; 1=Yes; 3= DK; 0=Not prescribed any psychiatric medication
Query surm044c Integer Recommended get a job in the community or furthering your education. How many visits were in community (non-clinic) settings?
Query surm045 Integer Recommended Has your family met with a mental health provider to help them understand and address your situation? 0;1 0=No; 1=Yes
Query outpprof Integer Recommended Outpatient Mental Health treatment: Professional treatment: Number of visits
Query surm045b Integer Recommended mental health provider. Average duration of this type of visit, minutes
Query surm046 Integer Recommended Have you had individual sessions with a mental health provider that help you work on your goals and look positively towards the future?
Query surm046a Integer Recommended individual sessions with a mental health provider. Number of outpatient visits of this type
Query surm046b Integer Recommended individual sessions with a mental health provider. Average duration of this type of visit, minutes
Query surm048c Integer Recommended Case Management. How many visits were in community (non-clinic) settings?
Query surm049 Integer Recommended Peer support/counseling dont include Alcoholics Anonymous(AA) or Narcotics Anonymous (NA) 0;1 0=No; 1=Yes
Query surm049a Integer Recommended Peer Support. Number of outpatient visits of this type
Query surm049b Integer Recommended Peer Support. Average duration of this type of visit, minutes
Query surm052 Integer Recommended Club House 0;1 0=No; 1=Yes
Query surm052a Integer Recommended Club House. Number of days you visited a club house
q14_4_s13 String 100 Recommended Other service: Other Specify
Query surm059 Integer Recommended In the past 30 days, how many visits did you attend at these clinics for medical problems? Private Medical Doctor 0;1 0=No; 1=Yes
Query surm060 Integer Recommended In the past 30 days, how many visits did you attend at these clinics for medical problems? Private Health Care Practitioner (Non-M.D.) 0;1 0=No; 1=Yes
Query surm061 Integer Recommended In the past 30 days, how many visits did you attend at these clinics for medical problems? Outpatient Clinic 0;1 0=No; 1=Yes
Query surm062 Integer Recommended In the past 30 days, how many visits did you attend at these clinics for medical problems? Day/Outpatient surgery 0;1 0=No; 1=Yes
Query surm063 Integer Recommended In the past 30 days, how many visits did you attend at these clinics for medical problems? Community Health Center 0;1 0=No; 1=Yes
Query surm064 Integer Recommended In the past 30 days, how many visits did you attend at these clinics for medical problems? Other 0;1 0=No; 1=Yes
Query surm064b Integer Recommended Other. Average duration of this type of visit, minutes
surm064c String 100 Recommended Other, specify
Query surm065 Integer Recommended In the past 30 days how many days have you used tobacco, number of days
Query surm071 Integer Recommended INPATIENT CARE. Since our last assessment. Psychiatric program 0;1 0=No; 1=Yes
Query surm071a Integer Recommended INPATIENT CARE. Since our last assessment. Psychiatric program. Total Number of ADDITIONAL nights
Query surm071b Integer Recommended INPATIENT CARE. Since our last assessment. Psychiatric program. Provider 1::7 1 = State and county mental hospital; 2 = Private psychiatric hospital; 3 = Non-federal general hospital; 4 = VA; 5 = Multi-service community mental health; 6 = Substance abuse/detox facility; 7=none of the above
Query surm072 Integer Recommended INPATIENT CARE. Since our last assessment. Medical Surgical program 0;1 0=No; 1=Yes
Query surm072a Integer Recommended INPATIENT CARE. Since our last assessment. Medical Surgical program. Total Number of ADDITIONAL nights
Query surm072b Integer Recommended INPATIENT CARE. Since our last assessment. Medical Surgical program Provider 1::7 1 = State and county mental hospital; 2 = Private psychiatric hospital; 3 = Non-federal general hospital; 4 = VA; 5 = Multi-service community mental health; 6 = Substance abuse/detox facility; 7=none of the above
Query surm073 Integer Recommended INPATIENT CARE. Since our last assessment. Emergency Room Psychiatric/Substance use Reason 0;1 0=No; 1=Yes
Query surm073a Integer Recommended INPATIENT CARE. Since our last assessment. Emergency Room Psychiatric/Substance use Reason Total Number of ADDITIONAL visits
Query surm073b Integer Recommended INPATIENT CARE. Since our last assessment. Emergency Room Psychiatric/Substance use Reason Provider 1::7 1 = State and county mental hospital; 2 = Private psychiatric hospital; 3 = Non-federal general hospital; 4 = VA; 5 = Multi-service community mental health; 6 = Substance abuse/detox facility; 7=none of the above
Query surm074 Integer Recommended INPATIENT CARE. Since our last assessment. Emergency Room Medical/Surgical Reason 0;1 0=No; 1=Yes
Query surm074a Integer Recommended INPATIENT CARE. Since our last assessment. Emergency Room Medical/Surgical Reason Total Number of ADDITIONAL visits
Query surm074b Integer Recommended INPATIENT CARE. Since our last assessment. Emergency Room Medical/Surgical Reason Provider 1::7 1 = State and county mental hospital; 2 = Private psychiatric hospital; 3 = Non-federal general hospital; 4 = VA; 5 = Multi-service community mental health; 6 = Substance abuse/detox facility; 7=none of the above
Query gap_days Integer Recommended NUMBER OF DAYS GREATER THAN or LESS THAN 30 between data collection
Query wrkfrpay Integer Recommended Work for Pay? 0;1;9;777 0=No; 1=Yes; 9=NK; 777=Not applicable
Data Structure

This page displays the data structure defined for the measure identified in the title and structure short name. The table below displays a list of data elements in this structure (also called variables) and the following information:

  • Element Name: This is the standard element name
  • Data Type: Which type of data this element is, e.g. String, Float, File location.
  • Size: If applicable, the character limit of this element
  • Required: This column displays whether the element is Required for valid submissions, Recommended for valid submissions, Conditional on other elements, or Optional
  • Description: A basic description
  • Value Range: Which values can appear validly in this element (case sensitive for strings)
  • Notes: Expanded description or notes on coding of values
  • Aliases: A list of currently supported Aliases (alternate element names)
  • For valid elements with shared data, on the far left is a Filter button you can use to view a summary of shared data for that element and apply a query filter to your Cart based on selected value ranges

At the top of this page you can also:

  • Use the search bar to filter the elements displayed. This will not filter on the Size of Required columns
  • Download a copy of this definition in CSV format
  • Download a blank CSV submission template prepopulated with the correct structure header rows ready to fill with subject records and upload

Please email the The NDA Help Desk with any questions.

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