Instructions: Module 4A - TheMeasurementGroup.com

Citation: Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1997). Module 4A: Services Needed and Received Form. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

This form is intended to be used in the interview format. It is not intended for the client to fill out by himself or herself.

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. 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. Only darken one circle for each question unless the instructions specifically tell you to darken as many as apply for that question.

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 the unique identifier for this client, check with your project director.

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 in the table below. Site codes are 3 letters.

Site Code	ORGANIZATION
AHF	AIDS Healthcare Foundation
DCW	Center for Women Policy Studies
CCY	Cook County Hospital
EBO	East Boston Neighborhood Health Center
EMY	Emory University
HAI	Haitian Community AIDS Outreach Project
HFY	Health Initiatives for Youth
IND	Indiana Community AIDS Action Network
IAC	Interamerican College of Physicians and Surgeons
HOP	Johns Hopkins University
LAR	Larkin Youth Center
VER	Medical Center Hospital of Vermont
MIC	Michigan Protection and Advocacy
MDH	Missouri Department of Health
COL	Mountain-Plains AETC
NYS	New York State Dept. of Health
OTR	OUTREACH, Inc.
PRO	PROTOTYPES
SNY	Research Foundation of SUNY
FOR	The Fortune Society
MSP	University of Mississippi Medical Center
REN	University of Nevada School of Medicine
WAS	University of Washington Center for AIDS and STD
TEX	University of Texas Health Science Center
VNA	Visiting Nurse Association of LA
STL	Washington University School of Medicine
WBI	Well-Being Institute

Sub-Provider. This field may be used to designate specific sites or providers within your project. If appropriate, enter the code of the service provider agency doing the activity. Provider codes can be up to three letters.

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, "96" for 1996). Make sure that if a month or day is less than 10, you place a "0" before the number.

Staff Code. Each staff member should be assigned a unique number code (up to 3 digits). Make sure that 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.

For services 1 through 21 listed in the column labeled "Services" in Module 4A, ask the client if he/she needed and/or received the service in the last six months and record the client's response in the manner described below.

For each service, darken the circle in the column labeled "Needed in Last Six Months?" next to "No" if the client did not need the service. Darken the circle next to "Yes" if the client needed the service. Darken the circle next to "DK" if the client does not know. Darken the circle next to "Ref." If the client refuses to answer.

For each service, darken the circle in the column labeled "Received in Last Six Months?" next to "No" if the client did not receive the service. Darken the circle next to "Yes" if the client received the service. Darken the circle next to "DK" if the client does not know. Darken the circle next to "Ref." if the client refuses to answer.

Service	Definition
Drug detoxification or maintenance.	This category includes services provided by a facility or program that helps individuals detoxify from substance abuse. The program may use either a medical model or social model detoxification approach. Maintenance programs such as methadone maintenance may also be included in this service category.
Residential drug treatment.	This category includes services provided by a facility or program that provides residential ("live-in") substance abuse treatment or counseling. Included in this category are programs that run the spectrum from very structured therapeutic communities to less structured "sober living" or "drug-free" living environments.
Outpatient or day treatment for substance abuse.	This category includes services provided by a facility or program that provides outpatient or day treatment substance abuse treatment or counseling. Day treatment programs usually require a substantial commitment of time on the part of the client and are characterized by a very structured therapeutic approach which includes an array of professional interventions. Outpatient treatment, on the other hand, may only require a minimal regular commitment of time on the part of the client such an hour a week an counseling may be conducted by either a professional therapist or a paraprofessional counselor.
Housing or shelter.	An agency or facility that provides short and/or long-term housing or assistance in locating and obtaining suitable, on-going, or transitional shelter. These agencies may be government supported such as public housing authorities or private non-profit organizations providing immediate shelter such as the Red Cross or church-affiliated organizations.
Food or other basic needs.	Food, clothing, blankets or other basic needs that are provided by an agency, facility, or program. This category includes government supported programs such as the Food Stamp program as well as non-profit private programs such as food share programs run by community-based organizations.
Dental services.	Routine or other treatment by a dentist such as dental examinations or filling of cavities.
Scheduled outpatient medical services.	This category includes medical services provided on an appointment basis in an outpatient setting such as a doctor’s office or community clinic. Services may include routine physical examinations or services required in the treatment of a specific illness or condition.
Emergency room services	This category includes medical services provided in a hospital or emergency care setting. Such services are usually required because of the sudden onset of an illness or because of an injury-related accident. A client may, however, have received medical treatment in an emergency room setting for routine medical care.
Inpatient medical services.	Medical services provided in a residential ("sleep-in") setting such as a hospital, convalescent home, or physical rehabilitation center.
HIV-related medical services.	Medical services that are related specifically to HIV infection such as the diagnostic monitoring of T-cell count, treatment and/or prophylactic intervention for pneumonia, and the use of immune system enhancing chemotherapy.
HIV-related self-care services.	Social and/or educational services designed to assist an HIV infected individual in taking care of him/herself. Such services may include stress management or assertiveness training, education regarding nutrition and exercise, and/or training is working collaboratively with medical and other caregivers.
HIV-related home care services.	This category includes medical and social services provided in the client’s home. Such services may include medical treatment, physical therapy, and/or assistance in housekeeping, shopping and food preparation.
HIV-related hospice.	This category includes services provided in an agency, facility, or program where individuals who are infected with HIV get residential ("live-in") medical and other care on a long term basis. Hospices usually provide supportive care in a homelike setting designed for the terminally ill.
Mental health services (inpatient or outpatient).	Outpatient and/or inpatient mental health services include individual and group counseling/therapy, psychiatric evaluations, crisis intervention, psychosocial assessment, and other services.
Self-help group.	This category includes support groups focusing on a topic of concern to members of that group. These include 12-Step groups such as Alcoholics Anonymous (AA), or Narcotics Anonymous (NA) as well as support groups that focus on specific health conditions such as herpes or Kaposi’s sarcoma.
Family counseling.	Therapy and counseling services provided to a family to resolve problems or conflicts among family members. Examples of such services include parent training, assertiveness training, or values and role clarification counseling.
Pharmacy.	Prescription medication services given by a doctor, hospital, or pharmacy.
Vocational training.	Services provided by an agency or individual targeting information related to obtaining education, instructional assistance, and/or training to obtain employment. Such services may be provided by government supported programs, local schools and colleges, and/or community-based programs.
Case management.	This category includes a range of client-centered services that link clients and other family members with health care, psychosocial care, and other social services to ensure timely, coordinated access to appropriate assistance. Case management includes on-going assessment of the needs of clients and family members.
HIV testing for partner or friend.	Testing for a friend or sex partner to detect the presence of HIV antibodies. Such services may include pre and post-test counseling and/or support for the client as well as the partner/friend.
Prenatal/pregnancy care.	Medical services or other care related to pregnancy. Such services may include diagnostic medical examinations, substance use education and counseling, and/or education regarding nutrition.