- Title
- FoRSE Outcomes Survey
- instrumentId
- FVBJ
- Description
- Instructions
Questions
Q1: Over the last 30 days, have you used any of the following services?
| Question Number |
Q1 |
| Allow 'Not Answered'? |
Yes |
| Question Type |
pick_multiple |
Answer Options pick_multiple
| Value |
Text |
| 1 |
None |
| 2 |
Detox |
| 3 |
Residential |
| 4 |
Partial Hospitalization (≥ 20 hrs of services weekly) |
| 5 |
Intensive Outpatient (9-20 hrs of services weekly) |
| 6 |
Outpatient (< 9 hrs of services weekly) |
| 7 |
Sober Living/Recovery Residence |
| 8 |
Recovery Support (e.g., recovery coaching) |
| Not Answered |
Not Answered |
Q2: Over the last 30 days, how many recovery support meetings (e.g., AA, NA, or other peer support groups) have you attended?
| Question Number |
Q2 |
| Allow 'Not Answered'? |
Yes |
| Question Type |
input_box |
| Answer Type |
number |
| Maximum Characters |
3 |
| Min |
0.00 |
| Max |
100.00 |
Q3: Over the last 30 days, how many total days have you used alcohol and/or drugs?
| Question Number |
Q3 |
| Allow 'Not Answered'? |
Yes |
| Question Type |
input_box |
| Answer Type |
number |
| Maximum Characters |
3 |
| Min |
0.00 |
| Max |
30.00 |
Q4: Which of the following medications are you currently taking in support of your recovery? (select all that apply)
| Question Number |
Q4 |
| Allow 'Not Answered'? |
Yes |
| Question Type |
pick_multiple |
Answer Options pick_multiple
| Value |
Text |
| 1 |
None |
| 2 |
Acamprosate/Campral |
| 3 |
Buprenorphine (Subutex/Suboxone Film) |
| 4 |
Buprenorphine (Sublocade injection) |
| 5 |
Disulfiram/Antabuse |
| 6 |
Naltrexone (ReVia Pill) |
| 7 |
Naltrexone (Vivitrol Injection) |
| 8 |
Methadone |
| 9 |
Medications for co-occurring disorder (e.g., anxiety or depression) |
| 10 |
Medication not listed |
| 11 |
Other |
| Not Answered |
Not Answered |
Q5: Over the last 30 days, how many days did you visit the hospital or ER, related to your substance use or recovery?
| Question Number |
Q5 |
| Allow 'Not Answered'? |
Yes |
| Question Type |
input_box |
| Answer Type |
number |
| Maximum Characters |
3 |
| Min |
0.00 |
| Max |
30.00 |
Q6: Over the last 30 days, how many incidents have you had with law enforcement?
| Question Number |
Q6 |
| Allow 'Not Answered'? |
Yes |
| Question Type |
input_box |
| Answer Type |
number |
| Maximum Characters |
3 |
| Min |
0.00 |
| Max |
30.00 |
Q7: What is your current employment status?
| Question Number |
Q7 |
| Allow 'Not Answered'? |
Yes |
| Question Type |
pick_one |
Answer Options pick_one
| Value |
Text |
| 1 |
Full-time |
| 2 |
Part-time |
| 3 |
Unemployed - seeking employment |
| 4 |
Unemployed - not seeking employment (retired, on disability, other source of income, etc...) |
| Not Answered |
Not Answered |
Q8: Have you experienced a relapse since discharging from treatment?
| Question Number |
Q8 |
| Allow 'Not Answered'? |
Yes |
| Question Type |
pick_one |
Answer Options pick_one
| Value |
Text |
| 1 |
No |
| 2 |
Yes |
| Not Answered |
Not Answered |
Q9: How would you rate your quality of life?
| Question Number |
Q9 |
| Allow 'Not Answered'? |
Yes |
| Question Type |
pick_one |
Answer Options pick_one
| Value |
Text |
| 1 |
Very poor |
| 2 |
Poor |
| 3 |
Neither poor nor good |
| 4 |
Good |
| 5 |
Very good |
| Not Answered |
Not Answered |
Q10: How frequently are you using nicotine (smoking, vaping, or dipping)?
| Question Number |
Q10 |
| Allow 'Not Answered'? |
Yes |
| Question Type |
pick_one |
Answer Options pick_one
| Value |
Text |
| 1 |
Daily |
| 2 |
Weekly |
| 3 |
Less than weekly |
| 4 |
Not at all |
| Not Answered |
Not Answered |
Scoring
The scoring details below are for information only. The scoring for this survey happens on our side. Please do not provide survey scores.
JSON Instrument Definition for developers
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{
"answer_text": "Good",
"answer_order": 4,
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"answer_status": "ACTIVE",
"date_created": "2023-12-30 12:55:29"
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{
"answer_text": "Very good",
"answer_order": 5,
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"answer_status": "ACTIVE",
"date_created": "2023-12-30 12:55:29"
},
{
"answer_severity": null,
"answer_value": null,
"answer_text": "Not Answered",
"answer_status": "ACTIVE"
}
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"question_text": "How frequently are you using nicotine (smoking, vaping, or dipping)?",
"question_order": 11,
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"qNum": "Q10",
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"date_created": "2023-12-30 12:55:29"
},
{
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"answer_status": "ACTIVE",
"date_created": "2023-12-30 12:55:29"
},
{
"answer_text": "Less than weekly",
"answer_order": 4,
"answer_severity": null,
"answer_value": "3.00",
"answer_status": "ACTIVE",
"date_created": "2023-12-30 12:55:29"
},
{
"answer_text": "Not at all",
"answer_order": 5,
"answer_severity": null,
"answer_value": "4.00",
"answer_status": "ACTIVE",
"date_created": "2023-12-30 12:55:29"
},
{
"answer_severity": null,
"answer_value": null,
"answer_text": "Not Answered",
"answer_status": "ACTIVE"
}
]
}
]
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Example Push for developers
URL Endpoint:
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Complete Post
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