- Title
- FoRSE Admit Survey
- instrumentId
- SH63
- Description
- Instructions
Questions
Q1: What is the highest level of care this client is admitting into?
Critical Item
A valid answer must be supplied for this question or the entire survey will be rejected.
"Not Answered" is NOT allowed.
| Question Number |
Q1 |
| Allow 'Not Answered'? |
No |
| Question Type |
pick_one |
Answer Options pick_one
| Value |
Text |
| 1 |
Inpatient Hospital or Medical Detox |
| 2 |
Residential |
| 3 |
Partial Hospitalization |
| 4 |
Intensive Outpatient |
| 5 |
Outpatient |
| 6 |
Sober Living/Recovery Residence |
| 7 |
Recovery Support (e.g., recovery coaching) |
| 8 |
Other type of program |
Q2: What was the client's employment status at the time of admission?
| Question Number |
Q2 |
| Allow 'Not Answered'? |
Yes |
| Question Type |
pick_one |
Answer Options pick_one
| Value |
Text |
| 1 |
Full Time |
| 2 |
Part Time |
| 3 |
Student |
| 4 |
Unemployed - seeking employment |
| 5 |
Unemployed - not seeking employment (retired, on disability, other source of income, in controlled environment) |
| Not Answered |
Not Answered |
Q3: Housing status at the time of admission?
| Question Number |
Q3 |
| Allow 'Not Answered'? |
Yes |
| Question Type |
pick_one |
Answer Options pick_one
| Value |
Text |
| 1 |
Homeless/unstable housing - (shelter, street, outdoors, temporarily staying with friends) |
| 2 |
Institution/controlled environment - (hospital, nursing home, jail/prison, residential treatment) |
| 3 |
Stable housing - (Own or rent apartment, room or house, stable housing with friends/family, dormitory or college residence, sober living home, other) |
| Not Answered |
Not Answered |
Q4: Days of substance use in the 30 days prior to admission?
| Question Number |
Q4 |
| Allow 'Not Answered'? |
Yes |
| Question Type |
info |
Q4a: Alcohol
| Question Number |
Q4a |
| Allow 'Not Answered'? |
Yes |
| Question Type |
input_box |
| Answer Type |
number |
| Maximum Characters |
2 |
| Min |
0.00 |
| Max |
30.00 |
Q4b: Cannabis
| Question Number |
Q4b |
| Allow 'Not Answered'? |
Yes |
| Question Type |
input_box |
| Answer Type |
number |
| Maximum Characters |
2 |
| Min |
0.00 |
| Max |
30.00 |
Q4c: Hallucinogens
| Question Number |
Q4c |
| Allow 'Not Answered'? |
Yes |
| Question Type |
input_box |
| Answer Type |
number |
| Maximum Characters |
2 |
| Min |
0.00 |
| Max |
30.00 |
Q4d: Inhalants
| Question Number |
Q4d |
| Allow 'Not Answered'? |
Yes |
| Question Type |
input_box |
| Answer Type |
number |
| Maximum Characters |
2 |
| Min |
0.00 |
| Max |
30.00 |
Q4e: Opioids
| Question Number |
Q4e |
| Allow 'Not Answered'? |
Yes |
| Question Type |
input_box |
| Answer Type |
number |
| Maximum Characters |
2 |
| Min |
0.00 |
| Max |
30.00 |
Q4f: Sedatives, hypnotics, or anxiolytics
| Question Number |
Q4f |
| Allow 'Not Answered'? |
Yes |
| Question Type |
input_box |
| Answer Type |
number |
| Maximum Characters |
2 |
| Min |
0.00 |
| Max |
30.00 |
Q4g: Stimulants
| Question Number |
Q4g |
| Allow 'Not Answered'? |
Yes |
| Question Type |
input_box |
| Answer Type |
number |
| Maximum Characters |
2 |
| Min |
0.00 |
| Max |
30.00 |
Q4h: Tobacco
| Question Number |
Q4h |
| Allow 'Not Answered'? |
Yes |
| Question Type |
input_box |
| Answer Type |
number |
| Maximum Characters |
2 |
| Min |
0.00 |
| Max |
30.00 |
Q4i: Other (or unknown) substance
| Question Number |
Q4i |
| Allow 'Not Answered'? |
Yes |
| Question Type |
input_box |
| Answer Type |
number |
| Maximum Characters |
2 |
| Min |
0.00 |
| Max |
30.00 |
Q5: History of IV drug use?
| Question Number |
Q5 |
| Allow 'Not Answered'? |
Yes |
| Question Type |
pick_one |
Answer Options pick_one
| Value |
Text |
| 1 |
No |
| 2 |
Yes |
| Not Answered |
Not Answered |
Q6: Number of the past alcohol/drug overdoses?
| Question Number |
Q6 |
| Allow 'Not Answered'? |
Yes |
| Question Type |
input_box |
| Answer Type |
number |
| Maximum Characters |
3 |
Q7: Number of previous SUD treatments (Including outpatient, residential, and detox episodes)
| Question Number |
Q7 |
| Allow 'Not Answered'? |
Yes |
| Question Type |
input_box |
| Answer Type |
number |
| Maximum Characters |
3 |
Q8: Is the client readmitting within 90 days of a prior episode within this organization?
| 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 |
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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},
{
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"date_created": "2023-12-30 12:55:29"
},
{
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"answer_order": 3,
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},
{
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"answer_order": 4,
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"date_created": "2023-12-30 12:55:29"
},
{
"answer_text": "Unemployed - not seeking employment (retired, on disability, other source of income, in controlled environment)",
"answer_order": 5,
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"answer_value": "5.00",
"answer_status": "ACTIVE",
"date_created": "2023-12-30 12:55:29"
},
{
"answer_severity": null,
"answer_value": null,
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"answer_status": "ACTIVE"
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{
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"date_created": "2023-12-30 12:55:58",
"qNum": "Q3",
"answer_options": [
{
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"answer_order": 1,
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"date_created": "2023-12-30 12:55:29"
},
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"answer_severity": null,
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"date_created": "2023-12-30 12:55:29"
},
{
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"answer_order": 3,
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"date_created": "2023-12-30 12:55:29"
},
{
"answer_severity": null,
"answer_value": null,
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{
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"instrumentId": "SH63",
"include_in_export": "y",
"allow_NotAnswered": "y",
"question_status": "ACTIVE",
"question_text": "Days of substance use in the 30 days prior to admission?",
"question_order": 4,
"question_type": "info",
"textbox_max_chars": null,
"textbox_input_type": null,
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"date_created": "2023-12-30 12:55:58",
"qNum": "Q4",
"answer_options": []
},
{
"assign_qnum": "y",
"instrumentId": "SH63",
"include_in_export": "y",
"allow_NotAnswered": "y",
"question_status": "ACTIVE",
"question_text": "Alcohol",
"question_order": 5,
"question_type": "input_box",
"textbox_max_chars": 2,
"textbox_input_type": "number",
"textbox_min_value": "0.00",
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"date_created": "2023-12-30 12:55:58",
"qNum": "Q4a",
"answer_options": []
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{
"assign_qnum": "y",
"instrumentId": "SH63",
"include_in_export": "y",
"allow_NotAnswered": "y",
"question_status": "ACTIVE",
"question_text": "Cannabis",
"question_order": 6,
"question_type": "input_box",
"textbox_max_chars": 2,
"textbox_input_type": "number",
"textbox_min_value": "0.00",
"textbox_max_value": "30.00",
"date_created": "2023-12-30 12:55:58",
"qNum": "Q4b",
"answer_options": []
},
{
"assign_qnum": "y",
"instrumentId": "SH63",
"include_in_export": "y",
"allow_NotAnswered": "y",
"question_status": "ACTIVE",
"question_text": "Hallucinogens",
"question_order": 7,
"question_type": "input_box",
"textbox_max_chars": 2,
"textbox_input_type": "number",
"textbox_min_value": "0.00",
"textbox_max_value": "30.00",
"date_created": "2023-12-30 12:55:58",
"qNum": "Q4c",
"answer_options": []
},
{
"assign_qnum": "y",
"instrumentId": "SH63",
"include_in_export": "y",
"allow_NotAnswered": "y",
"question_status": "ACTIVE",
"question_text": "Inhalants",
"question_order": 8,
"question_type": "input_box",
"textbox_max_chars": 2,
"textbox_input_type": "number",
"textbox_min_value": "0.00",
"textbox_max_value": "30.00",
"date_created": "2023-12-30 12:55:58",
"qNum": "Q4d",
"answer_options": []
},
{
"assign_qnum": "y",
"instrumentId": "SH63",
"include_in_export": "y",
"allow_NotAnswered": "y",
"question_status": "ACTIVE",
"question_text": "Opioids",
"question_order": 9,
"question_type": "input_box",
"textbox_max_chars": 2,
"textbox_input_type": "number",
"textbox_min_value": "0.00",
"textbox_max_value": "30.00",
"date_created": "2023-12-30 12:55:58",
"qNum": "Q4e",
"answer_options": []
},
{
"assign_qnum": "y",
"instrumentId": "SH63",
"include_in_export": "y",
"allow_NotAnswered": "y",
"question_status": "ACTIVE",
"question_text": "Sedatives, hypnotics, or anxiolytics",
"question_order": 10,
"question_type": "input_box",
"textbox_max_chars": 2,
"textbox_input_type": "number",
"textbox_min_value": "0.00",
"textbox_max_value": "30.00",
"date_created": "2023-12-30 12:55:58",
"qNum": "Q4f",
"answer_options": []
},
{
"assign_qnum": "y",
"instrumentId": "SH63",
"include_in_export": "y",
"allow_NotAnswered": "y",
"question_status": "ACTIVE",
"question_text": "Stimulants",
"question_order": 11,
"question_type": "input_box",
"textbox_max_chars": 2,
"textbox_input_type": "number",
"textbox_min_value": "0.00",
"textbox_max_value": "30.00",
"date_created": "2023-12-30 12:55:58",
"qNum": "Q4g",
"answer_options": []
},
{
"assign_qnum": "y",
"instrumentId": "SH63",
"include_in_export": "y",
"allow_NotAnswered": "y",
"question_status": "ACTIVE",
"question_text": "Tobacco",
"question_order": 12,
"question_type": "input_box",
"textbox_max_chars": 2,
"textbox_input_type": "number",
"textbox_min_value": "0.00",
"textbox_max_value": "30.00",
"date_created": "2023-12-30 12:55:58",
"qNum": "Q4h",
"answer_options": []
},
{
"assign_qnum": "y",
"instrumentId": "SH63",
"include_in_export": "y",
"allow_NotAnswered": "y",
"question_status": "ACTIVE",
"question_text": "Other (or unknown) substance",
"question_order": 13,
"question_type": "input_box",
"textbox_max_chars": 2,
"textbox_input_type": "number",
"textbox_min_value": "0.00",
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"date_created": "2023-12-30 12:55:58",
"qNum": "Q4i",
"answer_options": []
},
{
"assign_qnum": "y",
"instrumentId": "SH63",
"include_in_export": "y",
"allow_NotAnswered": "y",
"question_status": "ACTIVE",
"question_text": "History of IV drug use?",
"question_order": 14,
"question_type": "pick_one",
"textbox_max_chars": null,
"textbox_input_type": null,
"textbox_min_value": null,
"textbox_max_value": null,
"date_created": "2023-12-30 12:55:58",
"qNum": "Q5",
"answer_options": [
{
"answer_text": "No",
"answer_order": 1,
"answer_severity": null,
"answer_value": "1.00",
"answer_status": "ACTIVE",
"date_created": "2023-12-30 12:55:29"
},
{
"answer_text": "Yes",
"answer_order": 2,
"answer_severity": null,
"answer_value": "2.00",
"answer_status": "ACTIVE",
"date_created": "2023-12-30 12:55:29"
},
{
"answer_severity": null,
"answer_value": null,
"answer_text": "Not Answered",
"answer_status": "ACTIVE"
}
]
},
{
"assign_qnum": "y",
"instrumentId": "SH63",
"include_in_export": "y",
"allow_NotAnswered": "y",
"question_status": "ACTIVE",
"question_text": "Number of the past alcohol\/drug overdoses?",
"question_order": 15,
"question_type": "input_box",
"textbox_max_chars": 3,
"textbox_input_type": "number",
"textbox_min_value": null,
"textbox_max_value": null,
"date_created": "2023-12-30 12:55:58",
"qNum": "Q6",
"answer_options": []
},
{
"assign_qnum": "y",
"instrumentId": "SH63",
"include_in_export": "y",
"allow_NotAnswered": "y",
"question_status": "ACTIVE",
"question_text": "Number of previous SUD treatments (Including outpatient, residential, and detox episodes)",
"question_order": 16,
"question_type": "input_box",
"textbox_max_chars": 3,
"textbox_input_type": "number",
"textbox_min_value": null,
"textbox_max_value": null,
"date_created": "2023-12-30 12:55:58",
"qNum": "Q7",
"answer_options": []
},
{
"assign_qnum": "y",
"instrumentId": "SH63",
"include_in_export": "y",
"allow_NotAnswered": "y",
"question_status": "ACTIVE",
"question_text": "Is the client readmitting within 90 days of a prior episode within this organization?",
"question_order": 17,
"question_type": "pick_one",
"textbox_max_chars": null,
"textbox_input_type": null,
"textbox_min_value": null,
"textbox_max_value": null,
"date_created": "2023-12-31 19:13:35",
"qNum": "Q8",
"answer_options": [
{
"answer_text": "No",
"answer_order": 1,
"answer_severity": null,
"answer_value": "1.00",
"answer_status": "ACTIVE",
"date_created": "2023-12-31 19:13:35"
},
{
"answer_text": "Yes",
"answer_order": 2,
"answer_severity": null,
"answer_value": "2.00",
"answer_status": "ACTIVE",
"date_created": "2023-12-31 19:13:35"
},
{
"answer_severity": null,
"answer_value": null,
"answer_text": "Not Answered",
"answer_status": "ACTIVE"
}
]
}
]
}
Example Push for developers
URL Endpoint:
https://naatpdata.com/v2/api/surveys.php
Authentication
$FACILITY_ID = '123DEMO'; Provided By Us
$SECRET_KEY = 'aaaaaabbbbbbbbccccccccdddddddeeeeeefffffgggggg'; Provided By Us
$API_DATE = gmdate( time() ); Current UNIX UTC time = 1720278392
$API_SIGNATURE = hash_hmac('sha256', $API_DATE . $FACILITY_ID, $SECRET_KEY); f949bd75e202a3428dc559e35ef3964a43a208885370dc44c45856f6c7bbe12c
Complete Post
{
"facilityId": "123DEMO",
"apiDate": "1720278392",
"apiSignature": "f949bd75e202a3428dc559e35ef3964a43a208885370dc44c45856f6c7bbe12c",
"surveys": [
{
"instrumentId": "SH63",
"sessionId": "123session",
"clientId": "123client",
"assignedToType": "Client",
"yearOfAdmit": "2023",
"yearCompleted": "2023",
"daysFromAdmit": -99,
"daysFromDischarge": 180,
"completedWhile": "postDischarge",
"answerStyle": "byText",
"Q1": "Outpatient",
"Q2": "Full Time",
"Q3": "Stable housing - (Own or rent apartment, room or house, stable housing with friends\/family, dormitory or college residence, sober living home, other)",
"Q4": "--INFO: No Answer Expected--",
"Q4a": 3,
"Q4b": 6,
"Q4c": 0,
"Q4d": 12,
"Q4e": 24,
"Q4f": 17,
"Q4g": 25,
"Q4h": 30,
"Q4i": 18,
"Q5": "No",
"Q6": 3,
"Q7": 79,
"Q8": "Not Answered"
},
{
"instrumentId": "SH63",
"sessionId": "123session",
"clientId": "123client",
"assignedToType": "Client",
"yearOfAdmit": "2023",
"yearCompleted": "2023",
"daysFromAdmit": 30,
"daysFromDischarge": -99,
"completedWhile": "inTreatment",
"answerStyle": "byValue",
"Q1": 3,
"Q2": "Not Answered",
"Q3": 3,
"Q4": "--INFO: No Answer Expected--",
"Q4a": 26,
"Q4b": 0,
"Q4c": 10,
"Q4d": 24,
"Q4e": 12,
"Q4f": 13,
"Q4g": 28,
"Q4h": 19,
"Q4i": 29,
"Q5": "Not Answered",
"Q6": 50,
"Q7": 74,
"Q8": 2
}
]
}
