CSAT GPRA K¬v‡q›U djvdj †¯^”Qvaxb Kg©m~wP¸‡jvi Rb¨ c`‡¶cmg~n (cwigvwR©Z 06/01/2012)

dig Aby‡gvw`Z
OMB bs: 0930-0208
†gqv‡`vËx‡Y©i ZvwiL 01/31/2016
CSAT GPRA K¬v‡q›U djvdj
†¯^”Qvaxb Kg©m~wP¸‡jvi Rb¨ c`‡¶cmg~n
(cwigvwR©Z 06/01/2012)
hw` me¸‡jv AvB‡Ug †Kv‡bv K¬v‡q›U/AskMªnYKvix‡K wR‡Ám Kiv nq, Zvn‡j GB Z_¨ msMª‡ni Rb¨ RbM‡Yi
cªwZ‡e`‡bi ¸i“fvi wn‡m‡e cªwZwU Rev‡ei Rb¨ M‡o 30 wgwbU K‡i mgq jvM‡e e‡j Abygvb Kiv n‡q‡Q, Gi g‡a¨ Aš—
fz©³ i‡q‡Q wb‡`©kbv ch©v‡jvPbv, we`¨gvb Z_¨fvÛvi AbymÜvb, cª‡qvRbxq Z_¨ÑDcvË msMªn I i¶Yv‡e¶Y, Ges
msM„nxZ Z_¨ m¤ú~Y© Kiv I ch©v‡jvPbvi Rb¨ e¨wqZ mgq; hw` †cªvfvBWviiv Zv‡`i Pjgvb K¬v‡q›U/AskMªnYKvix
Bb‡UK ev d‡jvAv‡ci Ask wn‡m‡e GB Z‡_¨i A‡bKLvwb BwZg‡a¨B msMªn K‡i _v‡K Zvn‡j Zvi Dci wfwË K‡i, mgq
Kg jvM‡e| GB AvbygvwbK ¸i“fvi m¤ú‡K© A_ev Z_¨ msMªn m¤úwK©Z Ab¨ †h †Kv‡bv wel‡q GB wVKvbvq gZvgZ
cvVvb: SAMHSA Reports Clearance Officer, Room 7-1044, 1 Choke Cherry Road, Rockville, MD 20857. eZ©gv‡b ˆea
†Kv‡bv OMB K‡›U«vj b¤¦i cª`k©b bv Ki‡j †Kv‡bv G‡RwÝ cwiPvjbv ev c„ô‡cvlKZv bvI Ki‡Z cv‡i, Ges †Kv‡bv e¨w³
Z_¨ msMª‡ni Aby‡iv‡a mvov †`qvi Rb¨ eva¨ bq| GB cª‡R‡±i Rb¨ K‡›U«vj b¤¦i n‡”Q 0930-0208.
SAIS_GPRA_Client_Outcome_Instrument
v4.6
A.
†iKW© e¨e¯’vcbv
K¬v‡q›U ID
|____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
K¬v‡q‡›Ui aib:
wPwKrmvaxb K¬v‡q›U
wbivgqiZ K¬v‡q›U
K›U«v±/Mª¨v›U ID
|____|____|____|____|____|____|____|____|____|____|
mv¶vrKv‡ii aib [ïaygvÎ GKwU ai‡b †Mvj`vM w`b|]
Bb‡UK [mv¶vrKv‡ii Zvwi‡L P‡j hvb|]
6 gv‡mi d‡jvAvc → → → Avcwb wK †Kv‡bv d‡jvAvc mv¶vrKvi cwiPvjbv K‡i‡Qb?
[hw` bv nq, mivmwi †mKkb IцZ P‡j hvb|]
3 gv‡mi d‡jvAvc [ïaygvÎ wK‡kviÑwK‡kvix‡`i †cvU©‡dvwjI] →
Avcwb wK †Kv‡bv d‡jvAvc mv¶vrKvi cwiPvjbv K‡i‡Qb?
[hw` bv nq, mivmwi †mKkb IцZ P‡j hvb|]
nu¨v
nu¨v
bv
bv
wWmPvR© → → → Avcwb wK †Kv‡bv wWmPvR© mv¶vrKvi cwiPvjbv K‡i‡Qb? _______________
[hw` bv nq, mivmwi †mKkb JцZ P‡j hvb|]
mv¶vrKv‡ii ZvwiL
nu¨v
|____|____| / |____|____| / |____|____|____|____|
gvm
w`b
eQi
[d‡jvAvc Ges wWmPvR© mv¶vrKvi: †mKkb BцZ P‡j hvb|]
1.
Avcbvi K¬v‡q›U‡K wK hyMcrfv‡e gvbwmK ¯^v¯’¨ Ges gv`K`ªe¨ e¨enviRwbZ e¨vwa‡Z †fvMvi Rb¨ Avcbvi
Kg©m~wP‡Z Aš—f©z³ Kiv n‡q‡Q?
nu¨v
bv
1a.
[1a.ev` w`‡q GwM‡q hvb]
[hw` nu¨v nq] K¬v‡q›U wK gvbwmK ¯^v¯’¨ Ges gv`K`ªe¨ e¨enviRwbZ e¨vwa‡Z GKmv‡_ †fvMvi
welqwU aiv c‡o‡Q?
nu¨v
bv
[SBIRT Pj‡Q| Ab¨ mevB †mKkb A ÒcwiKwíZ cwi‡levmg~nÓ†Z P‡j hvb|]
SAIS_GPRA_Client_Outcome_Instrument
1
v4.6
GB †mKkbwU ïaygvÎ SBIRT gÄzwimg~‡ni Rb¨ [AvB‡Ug 2, 2a, I 3 - ïaygvÎ Bb‡UK/†emjvBbÑG D‡j­L Kiv
n‡q‡Q]|
2.
Avcbvi SBIRT-Gi Rb¨ K¬v‡q›U †Kgb w¯Œb K‡i‡Qb?
†b‡MwUf
c‡RwUf
2a.
Zvi w¯Œwbs †¯‹vi KZ wQj?
AUDIT
= |____|____|
CAGE
= |____|____|
DAST
= |____|____|
DAST-10
= |____|____|
NIAAA MvBW
= |____|____|
ASSIST/A¨vj‡Kvnj mve‡¯‹vi = ________________ |____|____|
Ab¨vb¨ (D‡j­L Ki“b)
= |____|____|
______________________________________
______________________________________
______________________________________
3.
wZwb wK SBIRT Kg©m~wP‡Z Zvi AskMªnY Ae¨vnZ ivL‡Z B”QzK wQ‡jb?
nu¨v
bv
SAIS_GPRA_Client_Outcome_Instrument
2
v4.6
A.
†iKW© e¨e¯’vcbv Ñ cwiKwíZ cwi‡levmg~n [ïaygvÎ Bb‡UK/†emjvB‡b K¬v‡q›U m¤ú‡K© Kg©m~wPi
Kg©x‡`i Øviv wi‡cvU©K…Z]
K¬v‡q‡›Ui wPwKrmv/Av‡ivM¨jv‡fi mg‡q Avcwb
K¬v‡q›U‡K †h me cwi‡lev¸‡jv †`qvi cwiKíbv Ki‡Qb
†m¸‡jv wPwýZ Ki“b| [cªwZwUi Rb¨ nu¨v n‡j Ônu¨vÕ †Z
A_ev bv n‡j ÔbvÕ †Z †Mvj`vM w`b|]
wPwKrmvi aib
nu¨v bv
[Kgc‡¶ GKwU aib wbe©vPb Ki“b|]
1. †Km e¨e¯’vcbv
nu¨v bv
2. w`evKvjxb wPwKrmv
nu¨v bv
3. fwZ© nIqv †ivMx/nvmcvZvj (gv`Kvkw³
wbivgq e¨ZxZ)
nu¨v bv
4. ewnwe©fvMxq †ivMx
nu¨v bv
5. AvDUwiP
nu¨v bv
6. wbweo ewnwe©fvMxq †ivMx
nu¨v bv
7. †g_v‡Wvb
nu¨v bv
8. AvevwmK/cybe©vmb
nu¨v bv
9. gv`Kvkw³ wbivgq (ïaygvÎ GKwU wbe©vPb
Ki“b)
A. nvmcvZv‡j fwZ© nIqv †ivMx
nu¨v bv
B. wd« ÷¨vwÛs AvevwmK
nu¨v bv
C. ewnwe©fvMxq †ivMx‡`i gv`Kvkw³
wbivgq
nu¨v bv
10. cieZ©x cwiPh©v
nu¨v bv
11. wbivg‡q mnvqZv
nu¨v bv
12. Ab¨vb¨ (D‡j­L Ki“b) _______________ nu¨v bv
[Kgc‡¶ GKwU cwi‡lev wbe©vPb Ki“b|]
wPwKrmv †mev
[SBIRT gÄzwi: 1 †_‡K 4 Gi g‡a¨ GKwU
wPwKrmv †mevq Avcbv‡K Aek¨B Ônu¨vÕ †Z
†Mvj`vM w`‡Z n‡e|]
1. w¯Œwbs
2. msw¶ß n¯—‡¶c
3. msw¶ß wPwKrmv
4. wPwKrmvi Rb¨ †idvi Kiv
5. g~j¨vqb
6. wPwKrmv/wbivg‡qi cwiKíbv
7. e¨w³MZ civgk© †mev
8. `jMZ civgk© †mev
9. cvwievwiK/ˆeevwnK civgk©
10. hyMcr wPwKrmv/
wbivgq †mev
11. IlyawfwËK n¯—‡¶c
12. HIV/GBWm m¤úwK©Z civgk©
13. Ab¨vb¨ wPwKrmv †mev
(D‡j­L Ki“b) ______________________
SAIS_GPRA_Client_Outcome_Instrument
nu¨v bv
nu¨v
nu¨v
nu¨v
nu¨v
nu¨v
nu¨v
nu¨v
nu¨v
nu¨v
bv
bv
bv
bv
bv
bv
bv
bv
bv
nu¨v bv
nu¨v bv
nu¨v bv
nu¨v bv
3
†Km e¨e¯’vcbv cwi‡lev
nu¨v
1. cvwievwiK cwi‡lev (we‡q msµvš— wk¶v,
wcZ…Z¡/gvZ…Z¡, wkï Dbœqb cwi‡lev
mn)
nu¨v
2. wkï cwiPh©v
nu¨v
3. Kg©ms¯’vb msµvš— †mev
A. cªvKÑKg©ms¯’vb
nu¨v
B. Kg©ms¯’vb msµvš— †KvwPs
nu¨v
4. e¨w³MZ cwi‡levi mgš^q
nu¨v
5. cwienb
nu¨v
6. HIV/GBWm welqK cwi‡lev
nu¨v
7. mnvqZvg~jK µvwš—Kvjxb gv`KÑgy³
Avevmb †mev
nu¨v
8. Ab¨vb¨ †Km e¨e¯’vcbv cwi‡lev
(D‡j­L Ki“b) _____________________ nu¨v
bv
wPwKrmv †mev
1. wPwKrmv cwiPh©v
2. A¨vj‡Kvnj/gv`K cix¶v
3. HIV/GBWm wPwKrmv mnvqZv I cix¶v
4. Ab¨vb¨ wPwKrmv †mev
(D‡j­L Ki“b) _____________________
nu¨v
nu¨v
nu¨v
nu¨v
bv
bv
bv
bv
cwiPh©v cieZ©x †mev
1. Ae¨vnZ cwiPh©v
2. cybivq wjß nIqv cªwZ‡iva
3. wbivg‡qi †KvwPs
4. AvZ¥-mvnvh¨ I mnvqZv `j
5. Ava¨vwZ¥K mnvqZv
6. Ab¨vb¨ cwiPh©v cieZ©x †mev
(D‡j­L Ki“b) _____________________
nu¨v
nu¨v
nu¨v
nu¨v
nu¨v
nu¨v
wk¶v cwi‡lev
1. gv`‡Ki Ace¨envi m¤úwK©Z wk¶v
2. HIV/GBWm m¤úwK©Z wk¶v
3. Ab¨vb¨ wk¶v cwi‡lev
(D‡j­L Ki“b) _____________________
nu¨v bv
nu¨v bv
nu¨v bv
m½xiÑØvivÑm½xi wbivgq mnvqZv cwi‡lev
1. m½x‡`i †KvwPs ev civgk©
2. evm¯’vb mnvqZv
3. A¨vj‡KvnjÑ I gv`KÑgy³ mvgvwRK
Kvh©µg
4. Z_¨ I mycvwik
5. m½xiÑØvivÑm½xi Ab¨vb¨ wbivgq
mnvqZv †mev
(D‡j­L Ki“b) _____________________
nu¨v bv
nu¨v bv
nu¨v bv
bv
bv
bv
bv
bv
bv
bv
bv
bv
nu¨v bv
bv
bv
bv
bv
bv
bv
nu¨v bv
nu¨v bv
nu¨v bv
nu¨v bv
nu¨v bv
v4.6
A.
†iKW© e¨e¯’vcbv Ñ RbmsL¨vZvwË¡K [ïaygvÎ Bb‡UK/†emjvB‡b wRÁvmv Kivi Rb¨]
1. Avcwb †Kvb wj‡½i?
cyi“l
gwnjv
U«v݇RÛvi
Ab¨vb¨ (D‡j­L Ki“b) _______________________________
DËi w`‡Z Abxnv
2.
Avcwb wK wn¯úvwbK ev j¨vwU‡bv?
nu¨v
bv
DËi w`‡Z Abxnv
[hw` nu¨v nq] Avcwb wb‡R‡K †Kvb RvwZMZ `‡ji Aš—fz³ e‡j we‡ePbv K‡ib? AbyMªn K‡i wb‡Pi
cªwZwUi Rb¨ nu¨v ev bv DËi w`b| Avcwb GKwUi †ewk Dˇi nu¨v ej‡Z cv‡ib|
ga¨ Av‡gwiKvb
wKDevb
WwgwbKvb
†gw·Kvb
cy‡q‡Z©vwiKvb
`w¶Y Av‡gwiKvb
Ab¨vb¨
3.
nu¨v bv DËi w`‡Z Abxnv
nu¨v bv DËi w`‡Z Abxnv
nu¨v bv DËi w`‡Z Abxnv
nu¨v bv DËi w`‡Z Abxnv
nu¨v bv DËi w`‡Z Abxnv
nu¨v bv DËi w`‡Z Abxnv
nu¨v bv DËi w`‡Z Abxnv
nu¨v bv DËi w`‡Z Abxnv [hw` nu¨v nq, wb‡P mywbw`©ófv‡e D‡j­L Ki“b|]
(D‡j­L Ki“b) _________________________________ _________________________
Avcwb †Kvb RvwZi? AbyMªn K‡i wb‡Pi cªwZwUi Rb¨ nu¨v ev bv DËi w`b| Avcwb GKwUi †ewk Dˇi
nu¨v ej‡Z cv‡ib|
nu¨v bv
K…òv½ ev Avwd«Kvb Av‡gwiKvb
nu¨v bv
Gkxq
nu¨v bv
nvIqvB ev Ab¨ cªkvš— gnvmvMixq Øx‡ci Awaevmx
Avjv¯‹vi Avw`evmx
nu¨v bv
†k¦Zv½
nu¨v bv
Av‡gwiKvb BwÛqvb
nu¨v bv
4.
DËi w`‡Z Abxnv
DËi w`‡Z Abxnv
DËi w`‡Z Abxnv
nu¨v ____________________________________ bv
DËi w`‡Z Abxnv
DËi w`‡Z Abxnv
DËi w`‡Z Abxnv
Avcbvi Rb¥w`b K‡e?*
|____|____| / |____|____| / [*wm‡÷g ïaygvÎ gvm I eQi msi¶Y Ki‡e|
gvm
w`b
†MvcbxqZv i¶vi Rb¨ w`‡bi Z_¨ msi¶Y Kiv n‡e bv|]
|____|____|____|____|
eQi
DËi w`‡Z Abxnv
SAIS_GPRA_Client_Outcome_Instrument
4
v4.6
mvgwiK cwievi I wb‡qvwRZKiY
5.
Avcwb wK KL‡bv mk¯¿ evwnbx, wiRvf©, ev b¨vkbvj MvW© evwnbx‡Z KvR K‡i‡Qb? [hw` K‡i _v‡Kb]
mk¯¿ evwnbx, wiRvf©, ev b¨vkbvj MvW© evwnbxi †Kvb As‡k KvR K‡i‡Qb?
bv
nu¨v, mk¯¿ evwnbx‡Z
nu¨v, wiRvf© evwnbx‡Z
nu¨v, b¨vkbvj MvW© evwnbx‡Z
DËi w`‡Z Abxnv
Rvwb bv
[hw` bv, DËi w`‡Z Abxnv, ev Rvwb bv nq, Zvn‡j mivmwi cªkœ A6 G P‡j hvb|]
5a.
Avcwb wK eZ©gv‡b mk¯¿ evwnbx, wiRvf©, ev b¨vkbvj MvW© evwnbx‡Z mwµqfv‡e `vwqZ¡ cvjb
K‡i‡Qb? [hw` K‡i _v‡Kb] †Kvb †¶‡Î, mk¯¿ evwnbx, wiRvf©, bvwK b¨vkbvj MvW© evwnbx?
bv, mk¯¿ evwnbx, wiRvf© ev b¨vkbvj MvW© evwnbx †_‡K wew”Qbœ ev Aemicªvß
nu¨v, mk¯¿ evwnbx‡Z
nu¨v, wiRvf© evwnbx‡Z
nu¨v, b¨vkbvj MvW© evwnbx‡Z
DËi w`‡Z Abxnv
Rvwb bv
5b.
Avcbv‡K wK KL‡bv hyׇ¶‡Î wb‡qvwRZ Kiv n‡qwQj? [cª‡hvR¨ me¸‡jv‡Z wUKwPý w`b|]
KL‡bvB wb‡qvwRZ Kiv nqwb
BivK ev AvdMvwb¯—vb (†hgb, OEF/OIF/OND)
cvim¨ DcmvMi (Acv‡ikb †WRvU© wkì/†WRvU© ÷g©)
wf‡qZbvg/`w¶Yc~e© Gwkqv
†Kvwiqv
wØZxq wek¦hy×
Dc‡i D‡j­L Kiv nqwb Ggb GKwU hyׇ¶‡Î wb‡qvwRZ Kiv n‡qwQj (†hgb, emwbqv/†mvgvwjqv)
DËi w`‡Z Abxnv
Rvwb bv
[SBIRT MªvnK: †h me K¬v‡q›U †b‡MwUf wn‡m‡e w¯Œwbs n‡q‡Qb, Zv‡`i Rb¨ AvB‡Ug A6, A6a †_‡K A6d ch©š—
mivmwi ev` w`‡q GwM‡q hvb]
SAIS_GPRA_Client_Outcome_Instrument
5
v4.6
6.
Avcbvi cwiev‡ii †KD ev Avcbvi Nwbô †KD wK mk¯¿ evwnbx, wiRvf© ev b¨vkbvj MvW© evwnbx‡Z
mwµqfv‡e Kg©iZ Av‡Qb, A_ev mk¯¿ evwnbx, wiRvf© ev b¨vkbvj MvW© evwnbx †_‡K wew”Qbœ ev
Aemicªvß n‡q‡Qb?
bv
nu¨v, †KejgvÎ GKRb
nu¨v, GKvwaK
DËi w`‡Z Abxnv
Rvwb bv
[hw` bv, DËi w`‡Z Abxnv, ev Rvwb bv nq, Zvn‡j mivmwi †mKkb B †Z P‡j hvb|]
[hw` nu¨v nq, 6 Rb ch©š— e¨w³i Rb¨ DËi w`b] Avcbvi mv‡_ †mB e¨w³i (mvwf©m †g¤¦vi) m¤úK© Kx? [Kjv‡gi
wk‡ivbv‡g m¤úK© wjLyb]
1 = gv
2 = evev
3 = fvB
4 = †evb
5 = ¯^vgx/¯¿x 6 = cvU©bvi
7 = mš—vb
8 = Ab¨vb¨ (D‡j­L Ki“b) ___________________
mvwf©m †g¤¦vi wK wb‡Pi
†Kv‡bvwUi m¤§zLxb
n‡qwQ‡jb? [cª‡hvR¨
me¸‡jvi Rb¨ h_vh_ Dˇii
Kjv‡g wUKwPý w`b]
6a. mk¯¿ Acv‡ik‡b
mnvqZv Kivi Rb¨
wb‡qvwRZ Kiv
n‡qwQj wK (†hgb,
Biv‡K ev
AvdMvwb¯—v‡b)?
6b. mk¯¿ Acv‡ik‡b
kvixwiKfv‡e AvnZ
n‡qwQ‡jb?
_________
(m¤úK©)
1.
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
_________
(m¤úK©)
2.
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
_________
(m¤úK©)
3.
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
_________
(m¤úK©)
4.
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
_________
(m¤úK©)
5.
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
_________
(m¤úK©)
6.
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
 nu¨v
6c. hy‡×i Pv‡ci j¶Y¸‡jv
 bv
†`Lv w`‡qwQj/
 DËi w`‡Z
wb‡qvwRZ nIqvi ci
Abxnv
gvwb‡q wb‡Z mgm¨v
 Rvwb bv
n‡qwQj, hvi g‡a¨
i‡q‡Q PTSD,
welbœZv, ev
AvZ¥nZ¨vi wPš—v?
 nu¨v
6d. gviv wM‡q‡Qb ev
 bv
wbnZ n‡q‡Qb?
 DËi w`‡Z
Abxnv
 Rvwb bv
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
 nu¨v
 bv
 DËi w`‡Z
Abxnv
 Rvwb bv
SAIS_GPRA_Client_Outcome_Instrument
6
v4.6
gv`K I A¨vj‡Kvnj e¨envi
B.
w`‡bi
msL¨v
1. MZ 30 w`‡b, Avcwb wb‡P Dwj­wLZ¸‡jv KZ w`b e¨envi K‡i‡Qb:
a. †h †Kv‡bv A¨vj‡Kvnj [hw` k~b¨ nq, Zvn‡j mivmwi AvB‡Ug
B1cцZ P‡j hvb|]
b1. †bkv Kivi Rb¨ A¨vj‡Kvnj (GK ˆeV‡K 5+ wW«sK)
b2. †bkvi Rb¨ A¨vj‡Kvnj (GK ˆeV‡K 4wU ev Zvi Kg wW«sK I
†bkv †eva Kiv)
c. A‰ea gv`K [hw` B1a A_ev B1c = 0, DËi w`‡Z Abxnv (RF), ev
Rvwb bv (DK) nq Zvn‡j mivmwi AvB‡Ug B2цZ P‡j hvb|]
d. A¨vj‡Kvnj Ges gv`K DfqB (GKB w`‡b)
DËi w`‡Z
Abxnv (RF)
Rvwb bv
(DK)
|____|____|
|____|____|
|____|____|
|____|____|
|____|____|
cª‡qvM c‡_i aib:
1. gy‡L 2. bv‡K 3. a~gcvb 4. wkivc‡_ bq Ggb Bb‡RKkb 5. wkiv
c‡_
*mvaviY cª‡qvM c_ D‡j­L Ki“b| GKwUi †ewk cª‡qvM c‡_i Rb¨,
me‡P‡q ¸i“ZiwU D‡j­L Ki“b| cª‡qvM c_¸‡jv ZvwjKvfz³ Kiv n‡q‡Q
me‡P‡q Kg ¸i“Zi (1) †_‡K me‡P‡q †ewk ¸i“Zi (5) wn‡m‡e|
2. MZ 30 w`‡b, Avcwb wb‡P Dwj­wLZ¸‡jv KZ w`b e¨envi K‡i‡Qb:
[B2a †_‡K B2i ch©š— †Kv‡bv AvB‡U‡gi gvb 0ÑGi †P‡q eo n‡j,
B1cÑGi gvb Aek¨B 0ÑGi †P‡q eo n‡e|]
w`‡bi
msL¨v
RFDK
cª‡qvM
c_*
RF DK
a. †Kv‡KBb/µ¨vK
|____|____|
|____|
b. gvwiRyqvbv/nvwkk (cU, R‡q›U, e­v›U, µwbK, DBW, †gwi,
†Rb)
|____|____|
|____|
1. †n‡ivBb (¯§¨vK, GBP, RvsK, ¯‹¨vM)
|____|____|
|____|
2. giwdb
|____|____|
|____|
3. wWjyqvwWW
|____|____|
|____|
4. †W‡gij
|____|____|
|____|
5. cvi‡Kv‡mU
|____|____|
|____|
6. Wvifb
|____|____|
|____|
7. †Kv‡WBb
|____|____|
|____|
8. UvB‡jbj 2, 3, 4
|____|____|
|____|
9. Aw·KbwUb/Aw·‡KvWb
|____|____|
|____|
d. †cªmwµckbwenxb †g_v‡Wvb
|____|____|
|____|
e. `„wóåg m„wóKvix/Db¥v`RbK, PCP (A¨v‡Äj Wv÷, I‡Rvb,
Iq¨vK, i‡KU dz‡qj) MDMA (G·U¨vwm, XTC, G·, GWvg), LSD
(GwmW, eygvm©, B‡q‡jv mvbkvBb), gvki“g ev †gmKvwjb
|____|____|
|____|
†g_vg‡dUvwgb ev Ab¨ A¨vwçUvwgb (†g_, Avcvi, w¯úW,
AvBm, PK, wµ÷vj, M-vm, dvqvi, µ¨vsK)
|____|____|
|____|
c. Avwdg:
f.
SAIS_GPRA_Client_Outcome_Instrument
7
‘
v4.6
gv`K I A¨vj‡Kvnj e¨envi (µgkt)
B.
cª‡qvM c‡_i aib:
1. gy‡L 2. bv‡K 3. a~gcvb 4. wkivc‡_ bq Ggb Bb‡RKkb 5. wkiv c‡_
*mvaviY cª‡qvM c_ D‡j­L Ki“b| GKwUi †ewk cª‡qvM c‡_i Rb¨,
me‡P‡q ¸i“ZiwU D‡j­L Ki“b| cª‡qvM c_¸‡jv ZvwjKvfz³ Kiv n‡q‡Q
me‡P‡q Kg ¸i“Zi (1) †_‡K me‡P‡q †ewk ¸i“Zi (5) wn‡m‡e|
2. MZ 30 w`‡b, Avcwb wb‡P Dwj­wLZ¸‡jv KZ w`b e¨envi K‡i‡Qb:
[B2a †_‡K B2i ch©š— †Kv‡bv AvB‡U‡gi gvb 0ÑGi †P‡q eo n‡j,
B1cÑGi gvb Aek¨B 0ÑGi †P‡q eo n‡e|]
w`‡bi
msL¨v
g. 1. †eb‡RvWvqv‡Rwcb: Wvqv‡Rcvg (f¨vwjqvg);
Avjcªv‡Rvjvg (R¨vbv·); U«vqv‡Rvjvg (n¨vjwmqb); Ges
GmUv‡mvjvg (†cªvmg I †ivwncbjÑGQvovI i“wdm, †ivP, I
†Kvc bv‡gI cwiwPZ)
cª‡qvM
c_*
RF DK
|____|____|
|____|
2. evwe©Pz‡iU: †g‡dvevwe©Uvj (†gevKvU); Ges
†c‡›Uvevwe©Uvj †mvwWqvg (†bgweDUvj)
|____|____|
|____|
3. †cªmwµckbÑwenxb GHB (wMªfvm& ewWwj nvg©;
wjKzBW G·U¨vwm; I RwR©qv †nvg eq bv‡g cwiwPZ)
|____|____|
|____|
4. †KUvwgb (†¯úkvj K ev wfUvwgb K bv‡g cwiwPZ)
|____|____|
|____|
5. Ab¨vb¨ cªkvwš—`vqK, D‡ËRbv cªkgbKvix, wb`ªvKviK ev
m‡¤§vnbx gv`K
|____|____|
|____|
|____|____|
|____|
|____|____|
|____|
h. wbtk¦v‡mi mv‡_ M„nxZ (ccvi, mœ¨vcvi, ivk, ûB‡cU)
i.
RFDK
Ab¨vb¨ A‰ea gv`K (D‡j­L Ki“b) ______________________
3. MZ 30 w`‡b, Avcwb wK Bb‡RKk‡bi gva¨‡g gv`K wb‡q‡Qb? [hw` B2a †_‡K B2i ch©š— Mªn‡Yi c_ = 4 ev 5 nq,
Zvn‡j, Aek¨B B3 = nu¨v n‡e|]
nu¨v
bv
DËi w`‡Z Abxnv
Rvwb bv
[hw` bv, DËi w`‡Z Abxnv, A_ev Rvwb bv nq, Zvn‡j mivmwi †mKkb CцZ P‡j hvb|]
4. MZ 30 w`‡b, Avcwb KZ Nb Nb Ab¨ Kv‡iv e¨envi Kiv wmwiÄ/muyB, KzKvi, Zzjv ev cvwb e¨envi K‡i‡Qb?
me mgq
A‡a©‡Ki †ewk mgq
A‡a©K mgq
A‡a©‡Ki Kg mgq
KL‡bvB bq
DËi w`‡Z Abxnv
Rvwb bv
SAIS_GPRA_Client_Outcome_Instrument
8
v4.6
C.
cwievi I emev‡mi Ae¯’v
1. MZ 30 w`‡b, Avcwb †ewkifvM mgq †Kv_vq emevm K‡i‡Qb? [K¬v‡q›U‡`i‡K Dˇii Ackb¸‡jv c‡o †kvbv‡eb bv|]
Avkªq (wbivc` Avkªq [†md †n‡fb], µvwš—Kvjxb Avkªq †K›`ª [U«¨vbwRkbvj wjwfs †m›Uvi, wUGjwm], Kg
Pvwn`vhy³ ¯’vcbv, wi‡mckb †m›Uvi, Ab¨vb¨ A¯’vqx w`ev ev mvܨKvjxb †K›`ª)
iv¯—v/AvDU‡Wvi (dzUcvZ, `iRvi mvg‡b, cvK©, miKvwi ev cwiZ¨³ feb)
cªwZôvb (nvmcvZvj, bvwm©s †nvg, †Rj/KvivMvi)
evmvq: [hw` evmvq nq, Zvn‡j h_vh_ Dcwefv‡M wUKwPý w`b:]
wbR¯^/fvov A¨vcvU©‡g›U, i“g, ev evwo
Ab¨ Kv‡iv A¨vcvU©‡g›U, i“g, ev evwo
W‡g©Uwi/K‡j‡Ri nj
nvdI‡q nvDm
AvevwmK wPwKrmv
Ab¨vb¨ ai‡bi AvevwmK (D‡j­L Ki“b) _____________________________________________________
DËi w`‡Z Abxnv
Rvwb bv
2.
MZ 30 w`‡b, Avcbvi A¨vj‡Kvnj ev Ab¨vb¨ gv`K e¨envi Kivi Kvi‡Y Avcbvi Rb¨ wewfbœ welq¸‡jv KZUv
cxov`vqK wQj? [hw` B1a A_ev B1c > 0 nq, Zvn‡j C2 = Òcª‡hvR¨ bqÓ n‡Z cv‡i bv|]
G‡Kev‡iB bq
wKQzUv
D‡j­L‡hvM¨fv‡e
AZ¨š—
cª‡hvR¨ bq [ïaygvÎ B1a Ges B1c = 0 n‡j e¨envi Ki“b|]
DËi w`‡Z Abxnv
Rvwb bv
3.
MZ 30 w`‡b, Avcbvi A¨vj‡Kvnj ev Ab¨vb¨ gv`K e¨envi Kivi Kvi‡Y Avcbv‡K wK ¸i“Z¡c~Y© KvRKg©
Kwg‡q †dj‡Z ev †Q‡o w`‡Z n‡q‡Q? [hw` B1a A_ev B1c > 0 nq, Zvn‡j C3 = Òcª‡hvR¨ bqÓ n‡Z cv‡i bv|]
G‡Kev‡iB bq
wKQzUv
D‡j­L‡hvM¨fv‡e
AZ¨š—
cª‡hvR¨ bq [ïaygvÎ B1a Ges B1c = 0 n‡j e¨envi Ki“b|]
DËi w`‡Z Abxnv
Rvwb bv
SAIS_GPRA_Client_Outcome_Instrument
9
v4.6
C.
cwievi I emev‡mi Ae¯’v (µgkt)
4.
MZ 30 w`‡b, Avcbvi A¨vj‡Kvnj ev Ab¨vb¨ gv`K e¨envi Kivi Kvi‡Y Avcbvi wK Av‡eM m¤úwK©Z mgm¨v
n‡q‡Q? [hw` B1a A_ev B1c > 0 nq, Zvn‡j C4 = Òcª‡hvR¨ bqÓ n‡Z cv‡i bv|]
G‡Kev‡iB bq
wKQzUv
D‡j­L‡hvM¨fv‡e
AZ¨š—
cª‡hvR¨ bq [ïaygvÎ B1a Ges B1c = 0 n‡j e¨envi Ki“b|]
DËi w`‡Z Abxnv
Rvwb bv
5.
[cyi“l bv n‡j] Avcwb wK eZ©gv‡b Mf©eZx?
nu¨v
bv
DËi w`‡Z Abxnv
Rvwb bv
6.
Avcbvi wK †Q‡j‡g‡q Av‡Q?
nu¨v
bv
DËi w`‡Z Abxnv
Rvwb bv
[hw` bv, DËi w`‡Z Abxnv, A_ev Rvwb bv nq, Zvn‡j mivmwi †mKkb DцZ P‡j hvb|]
a.
Avcbvi KqwU †Q‡j‡g‡q Av‡Q? [hw` C6 = nu¨v nq, Zvn‡j C6a Gi gvb Aek¨B 0ÑGi †P‡q eo n‡e|]
|____|____|
b.
DËi w`‡Z Abxnv
Rvwb bv
Av`vj‡Zi †Kv‡bv wkï myi¶v Av‡`‡ki Kvi‡Y Avcbvi †Kv‡bv †Q‡j‡g‡q wK Ab¨ Kv‡iv mv‡_ emevm
Ki‡Q?
nu¨v
bv
DËi w`‡Z Abxnv
Rvwb bv
[hw` bv, DËi w`‡Z Abxnv, A_ev Rvwb bv nq, Zvn‡j mivmwi AvB‡Ug C6d-†Z P‡j hvb|]
c.
[hw` nu¨v nq] Av`vj‡Zi wkï myi¶v Av‡`‡ki Kvi‡Y Avcbvi KqwU †Q‡j‡g‡q Ab¨ Kv‡iv mv‡_
emevm Ki‡Q? [C6cÑGi gvb C6aÑGi gv‡bi †P‡q eo n‡Z cvi‡e bv|]
|____|____|
d.
DËi w`‡Z Abxnv
Rvwb bv
Avcbvi KqwU †Q‡j‡g‡qi Rb¨ Avcwb wcZ…‡Z¡i/gvZ…‡Z¡i AwaKvi nvwi‡q‡Qb? [K¬v‡q‡›Ui
wcZ…‡Z¡i/gvZ…‡Z¡i AwaKvi †K‡o †bIqv n‡q‡Q|] [AvB‡Ug C6dÑGi gvb C6aÑGi gv‡bi †P‡q eo n‡Z
cvi‡e bv|]
|____|____|
DËi w`‡Z Abxnv
SAIS_GPRA_Client_Outcome_Instrument
Rvwb bv
10
v4.6
D.
wk¶v, Kg©ms¯’vb, I Avq
1.
Avcwb wK eZ©gv‡b †Kv‡bv ¯‹zj ev Kg©ms¯’vb cªwk¶Y Kg©m~wP‡Z fwZ© n‡q Av‡Qb? [hw` fwZ©
_v‡Kb] GUv wK c~Y©Kvjxb bvwK LÛKvjxb? [hw` K¬v‡q›U Kvivi“× _v‡Kb Zvn‡j D1ÑGi Rb¨ †KvW Ki“b
ÒfwZ© n‡q †bBÓ|]
fwZ© n‡q †bB
fwZ© n‡q Av‡Qb, c~Y©Kvjxb
fwZ© n‡q Av‡Qb, LÛKvjxb
Ab¨vb¨ (D‡j­L Ki“b) _______________________________
DËi w`‡Z Abxnv
Rvwb bv
2.
Avcwb †Kv‡bv wWMªx †c‡q _v‡Kb ev bv _v‡Kb, Avcwb m‡e©v”P †Kvb ch©v‡qi wk¶v m¤úbœ K‡i‡Qb?
KL‡bv ¯‹z‡j cwowb
1g †MªW
2q †MªW
3q †MªW
4_© †MªW
5g †MªW
6ô †MªW
7g †MªW
8g †MªW
9g †MªW
10g †MªW
11Zg †MªW
12Zg †MªW/nvB ¯‹zj wW‡c­vgv/mggvb
K‡jR ev BDwbfvwm©wU/1g eQi m¤úbœ
K‡jR ev BDwbfvwm©wU/2q eQi m¤úbœ/mswk­ó wWMªx (AA, AS)
K‡jR ev BDwbfvwm©wU/3q eQi m¤úbœ
mœvZK wWMªx (BA, BS) ev D”PZi
nvB ¯‹z‡ji c‡i e„wËg~jK/KvwiMwi Kg©m~wP‡Z AskMªnY wKš‘ †Kv‡bv e„wËg~jK/KvwiMwi
wW‡c­vgv †bB
 nvB ¯‹z‡ji c‡i e„wËg~jK/KvwiMwi wW‡c­vgv
 DËi w`‡Z Abxnv
 Rvwb bv

















3.
Avcwb wK eZ©gv‡b Kg©iZ? [MZ mßv‡ni †ewkifvM As‡ki Dci g‡bv‡hvM †`qvi gva¨‡g cwi®‹vi Ki“b †h,
K¬v‡q›U G‡Kev‡iB KvR K‡iwQ‡jb wKbv A_ev Zvi wbqwgZ PvKwi wQj wKbv hv †_‡K wZwb QzwU‡Z wQ‡jb|]
[hw` K¬v‡q›U D1ÑGi Dˇi e‡jb ÒfwZ© n‡q Av‡Qb, c~Y©KvjxbÓ Ges D3ÑGi Dˇi e‡jb Òc~Y©Kvjxb
PvKwiÓ, Zvn‡j GB welqwU e¨vL¨v Ki‡Z ejyb| hw` K¬v‡q›U Kvivi“× _v‡Kb Ges KvivMv‡ii evB‡i Zvi †Kv‡bv
KvR bv _v‡K, Zvn‡j D3ÑGi Rb¨ †KvW Ki“b Ò†eKvi, KvR LyuR‡Qb bvÓ|]
 c~Y©Kvjxb PvKwiiZ (cªwZ mßv‡n 35+ N›Uv, A_ev KiwQ‡jb)
 LÛKvjxb PvKwiiZ
 †eKvi, KvR LyuR‡Qb
 †eKvi, cªwZeÜx
 †eKvi, †¯^”Qv‡mevg~jK KvR
 †eKvi, Aemicªvß
 †eKvi, KvR LyuR‡Qb bv
 Ab¨vb¨ (D‡j­L Ki“b) _____________________________________
 DËi w`‡Z Abxnv
 Rvwb bv
SAIS_GPRA_Client_Outcome_Instrument
11
v4.6
D.
wk¶v, Kg©ms¯’vb, I Avq (µgkt)
4.
MZ 30 w`‡b Avcwb wb‡P Dwj­wLZ iƒ‡c cªvq Kx cwigvY A_© †c‡q‡Qb (KiÑc~e© e¨w³MZ Avq)...
[hw` D3 =ÒPvKwiiZÓ bv nq Ges D4aÑGi gvb k~‡b¨i †P‡q eo nq, Zvn‡j wRÁvmv Ki“b| hw` D3 = Ò†eKvi, KvR
LyuR‡QbÓ nq Ges D4b = 0 nq, Zvn‡j wRÁvmv Ki“b| hw` D3 = Ò†eKvi, AemicªvßÓ nq Ges D4c = 0 nq, Zvn‡j
wRÁvmv Ki“b| hw` D3 = Ò†eKvi, cªwZeÜxÓ nq Ges D4d = 0 nq, Zvn‡j wRÁvmv Ki“b|]
RF
a.
b.
c.
d.
e.
f.
g.
†eZb
miKvwi mnvqZv
Aemi fvZv
cªwZeÜxZ¡
A‰ea Avq
cwievi Ges/A_ev eÜz
Ab¨vb¨ (D‡j­L Ki“b)
__________________
$ |__|__|__| , |__|__|__|
$ |__|__|__| , |__|__|__|
$ |__|__|__| , |__|__|__|
$ |__|__|__| , |__|__|__|
$ |__|__|__| , |__|__|__|
$ |__|__|__| , |__|__|__|
$ |__|__|__| , |__|__|__|
E.
Aciva Ges Aciv‡ai wePv‡ii Ae¯’v
1.
MZ 30 w`‡b, Avcwb KZevi †Mªßvi n‡q‡Qb?
|____|____| evi
DK
DËi w`‡Z Abxnv
Rvwb bv
[hw` GKeviI †Mªßvi bv nb, Zvn‡j mivmwi AvB‡Ug E3цZ P‡j hvb|]
2.
MZ 30 w`‡b, Avcwb gv`KÑmswk­ó Kvi‡Y KZevi †Mªßvi n‡q‡Qb? [E2ÑGi gvb E1ÑGi †P‡q eo n‡Z cvi‡e
bv|]
|____|____| evi
3.
DËi w`‡Z Abxnv
Rvwb bv
MZ 30 w`‡b, Avcwb KZevi Aciva K‡i‡Qb? [KZ w`b A‰ea gv`K MªnY K‡i‡Qb Zv c„ôv 7ÑGi AvB‡Ug
B1cцZ †`Lyb| GLv‡b E4ÑGi DËi B1cÑGi msL¨vi mgvb ev Zvi‡P‡q eo n‡e KviY A‰ea gv`K e¨envi Kiv GKUv
Aciva|]
|____|____|____| evi
5.
Rvwb bv
MZ 30 w`‡b, Avcwb KZ ivZ nvR‡Z/KvivMv‡i wQ‡jb? [hw` E3ÑGi gvb 15ÑGi †P‡q eo nq, Zvn‡j Aek¨B C1
= cªwZôvb (nvRZ/KvivMvi) n‡e| hw` C1 = cªwZôvb (nvRZ/KvivMvi) nq, Zvn‡j E3ÑGi gvb Aek¨B 15 Gi mgvb ev
Zvi‡P‡q eo n‡e|]
|____|____| ivZ
4.
DËi w`‡Z Abxnv
DËi w`‡Z Abxnv
Rvwb bv
Avcwb wK eZ©gv‡b Awfhy³ nIqv, wePv‡ii m¤§zLxb nIqv, ev `Û cvIqvi Rb¨ A‡c¶v Ki‡Qb?
nu¨v
bv
DËi w`‡Z Abxnv
Rvwb bv
6.
Avcwb wK eZ©gv‡b c¨v‡iv‡j ev cª‡ek‡b Av‡Qb?
nu¨v
bv
DËi w`‡Z Abxnv
Rvwb bv
SAIS_GPRA_Client_Outcome_Instrument
12
v4.6
F.
gvbwmK I kvixwiK ¯^v‡¯’¨i mgm¨v Ges wPwKrmv/wbivgq
1.
GB gyû‡Z© Avcbvi mvwe©K ¯^v¯’¨‡K Avcwb Kxfv‡e g~j¨vqb Ki‡eb?
PgrKvi
Lye fv‡jv
fv‡jv
†gvUvgywU
Lvivc
DËi w`‡Z Abxnv
Rvwb bv
2.
MZ 30 w`‡b, Avcwb wK wb‡P Dwj­wLZ¸‡jv †c‡q‡Qb:
a.
wb‡P Dwj­wLZ¸‡jvi Rb¨ nvmcvZv‡j
fwZ© †_‡K wPwKrmv:
nu¨v
i.
ii.
b.
kvixwiK Amy¯’Zv
gvbwmK ev Av‡eMMZ mgm¨v
iii. A¨vj‡Kvnj ev gv`‡Ki Ace¨envi
_________ ivZ
wb‡P Dwj­wLZ¸‡jvi Rb¨ ewnwe©fvM
†_‡K wPwKrmv:
i.
kvixwiK Amy¯’Zv
[hw` nu¨v nq]
me wgwj‡q †gvU KZ
ivZ
_________ evi
ii.
gvbwmK ev Av‡eMMZ mgm¨v
_________ evi
nu¨v
c.
[hw` nu¨v nq]
me wgwj‡q †gvU KZ
ivZ
_________ ivZ
_________ ivZ
iii. A¨vj‡Kvnj ev gv`‡Ki Ace¨envi
_________ evi
wb‡P Dwj­wLZ¸‡jvi Rb¨ Ri“wi
wefv‡Mi wPwKrmv:
[hw` nu¨v nq]
me wgwj‡q †gvU KZ
ivZ
_________ evi
_________ evi
nu¨v
i.
ii.
kvixwiK Amy¯’Zv
gvbwmK ev Av‡eMMZ mgm¨v
iii. A¨vj‡Kvnj ev gv`‡Ki Ace¨envi
SAIS_GPRA_Client_Outcome_Instrument
bv
RF
DK
bv
RF
DK
bv
RF
DK
_________ evi
13
v4.6
F.
gvbwmK I kvixwiK ¯^v‡¯’¨i mgm¨v Ges wPwKrmv/wbivgq (µgkt)
3.
MZ 30 w`‡b, Avcwb wK †hŠbK‡g© RwoZ n‡q‡Qb?
nu¨v
bv → [mivmwi F4ÑG P‡j hvb|]
wRÁvmv Kivi Rb¨ Aby‡gvw`Z bq → [mivmwi F4ÑG P‡j hvb|]
DËi w`‡Z Abxnv → [mivmwi F4ÑG P‡j hvb|]
Rvwb bv → [mivmwi F4ÑG P‡j hvb|]
[hw` nu¨v nq] me wgwj‡q, KZ evi:
msmM©©
4.
a. Avcwb wK †hŠb msmM© (†hvwbc‡_, gy‡L, ev cvqyc‡_)
K‡i‡Qb?
|____|____|____|
b. Avcwb wK Aiw¶Z †hŠb msmM© K‡i‡Qb? [F3bÑGi gvb
F3aÑGi gv‡bi †P‡q eo n‡Z cvi‡e bv|] [hw` k~b¨ nq, Zvn‡j
F4ÑG P‡j hvb|]
|____|____|____|
c. Ggb GKRb e¨w³i mv‡_ Aiw¶Z †hŠb msmM© K‡i‡Qb hvi
eZ©gvb ev AZx‡Zi Ae¯’v n‡”Q: [F3c1 †_‡K F3c3 ch©š—
†KvbwUi gvb F3bÑGi gv‡bi †P‡q eo n‡Z cvi‡e bv|]
1. HIV c‡RwUf ev GBWm Av‡Q
|____|____|____|
2. Bb‡RKk‡bi gva¨‡g gv`K e¨enviKvix
|____|____|____|
3. wKQz wKQz gv`K MªnY K‡i †bkv K‡ib
|____|____|____|
RF
DK
Avcwb Kx KL‡bv HIVÑGi cix¶v Kwi‡q‡Qb?
nu¨v......................... [F4aцZ P‡j hvb|]
bv ............................ [mivmwi F5ÑG P‡j hvb|]
DËi w`‡Z Abxnv .... [mivmwi F5ÑG P‡j hvb|]
Rvwb bv ................. [mivmwi F5ÑG P‡j hvb|]
4a.
Avcwb wK Avcbvi HIV cix¶vi djvdj Rv‡bb?
nu¨v
bv
SAIS_GPRA_Client_Outcome_Instrument
14
v4.6
F.
gvbwmK I kvixwiK ¯^v‡¯’¨i mgm¨v Ges wPwKrmv/wbivgq (µgkt)
5.
MZ 30 w`‡b, Avcbvi A¨vj‡Kvnj ev gv`K e¨envi bv Kivi Kvi‡Y, Avcwb KZ w`b:
a.
gvivZ¥K welbœZvq fz‡M‡Qb
w`b
|____|____|
b.
gvivZ¥K `ywðš—v ev D‡ËRbvq fz‡M‡Qb
|____|____|
c.
`„wóweå‡g fz‡M‡Qb
|____|____|
d.
eyS‡Z, g‡bv‡hvM w`‡Z, ev g‡b ivL‡Z mgm¨vq c‡o‡Qb
|____|____|
e.
wnsmª AvPiY wbqš¿Y Ki‡Z Amyweavq c‡o‡Qb
|____|____|
f.
AvZ¥nZ¨vi †Póv K‡i‡Qb
|____|____|
g.
gvbwmK/Av‡eMMZ mgm¨vi Kvi‡Y Ily‡ai †cªmwµckb
†c‡q‡Qb
|____|____|
RF
DK
[hw` cªkœ 5ÑGi me¸‡jv AvB‡U‡gi Dˇi K¬v‡q›U k~b¨ w`b, RF ev DK wi‡cvU© K‡ib, Zvn‡j mivmwi AvB‡Ug
F7 G P‡j hvb|]
6.
MZ 30 w`‡b GB me gvbwmK ev Av‡eMMZ mgm¨vi Kvi‡Y Avcwb KZUv Amyweavq c‡owQ‡jb?
G‡Kev‡iB bq
wKQzUv
†gvUvgywU
D‡j­L‡hvM¨fv‡e
AZ¨š—
DËi w`‡Z Abxnv
Rvwb bv
mwnsmZv I gvbwmK AvNvZ
7.
Avcwb Kx KL‡bv †Kv‡bv cwi‡e‡k mwnsmZv ev gvbwmK AvNv‡Zi m¤§zLxb n‡qwQ‡jb (Gi g‡a¨ i‡q‡Q
KwgDwbwU‡Z ev ¯‹z‡j mwnsmZv; cvwievwiK mwnsmZv; cwiev‡ii †fZ‡i ev evB‡i kvixwiK, gvbwmK, ev
†hŠb Ace¨envi/AvµgY; cªvK…wZK `y‡h©vM; mš¿vmev`; Ae‡njv; ev gvbwmK AvNvZRwbZ `ytL?)
nu¨v
bv [mivmwi AvB‡Ug F8 G P‡j hvb|]
DËi w`‡Z Abxnv
Rvwb bv
[hw` bv, DËi w`‡Z Abxnv, ev Rvwb bv nq, Zvn‡j AvB‡Ug mivmwi F8 G P‡j hvb|]
SAIS_GPRA_Client_Outcome_Instrument
15
v4.6
F.
gvbwmK I kvixwiK ¯^v‡¯’¨i mgm¨v Ges wPwKrmv/wbivgq (µgkt)
GB AwfÁZv¸‡jvi †Kv‡bvwU Kx GZUv fxwZKi, fqvbK, ev wech©qKi wQj †h, AZx‡Z Ges/A_ev eZ©gv‡b,
Avcwb:
7a.
GwU m¤ú‡K© `yt¯^cœ †`‡LwQ‡jb ev Avcwb hLb Pvbwb ZL‡bv GwU m¤ú‡K© wPš—v
K‡iwQ‡jb?
nu¨v
bv
DËi w`‡Z Abxnv
Rvwb bv
7b.
GwU m¤ú‡K© wPš—v bv Kivi Rb¨ K‡Vvifv‡e †Póv K‡iwQ‡jb A_ev Avcbv‡K Gi K_v g‡b Kwi‡q
†`q GB iKg cwiw¯’wZ Gov‡bvi Rb¨ cªej †Póv K‡iwQ‡jb?
nu¨v
bv
DËi w`‡Z Abxnv
Rvwb bv
7c.
µgvMZfv‡e mZK© wQ‡jb, ch©‡e¶Y KiwQ‡jb, ev mn‡RB Pg‡K DVwQ‡jb?
nu¨v
bv
DËi w`‡Z Abxnv
Rvwb bv
7d.
Ab¨ †jvKRb, Kg©KvÛ, ev Avcbvi Pvicvk †_‡K wew”Qbœ ev Abyf‚wZk~b¨ †eva KiwQ‡jb?
nu¨v
bv
DËi w`‡Z Abxnv
Rvwb bv
8.
MZ 30 w`‡b, Avcwb KZ Nb Nb AvNvZ, jvw_, ev Po †L‡q‡Qb, A_ev Ab¨ †Kv‡bvfv‡e kvixwiKfv‡e AvNvZ
†c‡q‡Qb?
KL‡bvB bq
K‡qK evi
K‡qK ev‡ii †P‡q †ewk
DËi w`‡Z Abxnv
Rvwb bv
SAIS_GPRA_Client_Outcome_Instrument
16
v4.6
G.
mvgvwRK †hvM‡hvM
1.
MZ 30 w`‡b, Avcwb wK wbivg‡qi Rb¨ Ggb †Kv‡bv †¯^”Qv‡mex ¯^q¤¢i †Mvôx‡Z AskMªnY K‡i‡Qb hv
†Kv‡bv ag©xq ev wek¦vmÑwfwËK msMV‡bi mv‡_ m¤ú„³ wQj bv? Ab¨ K_vq ejv hvq, Avcwb wK †Kv‡bv
Aцckv`vi, m½xÑcwiPvwjZ msMV‡b AskMªnY K‡i‡Qb hv Ggb gvbyl‡`i‡K mvnvh¨ Kivi Rb¨ wb‡ew`Z
hv‡`i gv`Kvmw³ mswk­ó mgm¨v Av‡Q, †hgb: A¨vj‡KvnwjKm& A¨v‡bvwbgvm, bvi‡KvwUKm&
A¨v‡bvwbgvm, A·‡dvW© nvDm, †mKzjvi AM©vbvB‡Rkb di meiv‡qwU, ev DB‡gb di meiv‡qwU,
BZ¨vw`?
nu¨v
[hw` nu¨v nq] D‡j­L Ki“b KZ evi |____|____|
bv
DËi w`‡Z Abxnv
Rvwb bv
2.
DËi w`‡Z Abxnv
Rvwb bv
MZ 30 w`‡b, Avcwb wK Dc‡i Dwj­wLZ msMVb¸‡jv Qvov Ab¨ †Kv‡bv msMV‡bi mfvq †hvM w`‡q‡Qb
hviv wbivg‡q mvnvh¨ K‡i?
nu¨v
[hw` nu¨v nq] D‡j­L Ki“b KZ evi |____|____|
bv
DËi w`‡Z Abxnv
Rvwb bv
4.
Rvwb bv
MZ 30 w`‡b, Avcwb wK †Kv‡bv ag©xq/wek¦vm wfwËK wbivgq ¯^q¤¢i †Mvôx‡Z AskMªnY K‡i‡Qb?
nu¨v
[hw` nu¨v nq] D‡j­L Ki“b KZ evi |____|____|
bv
DËi w`‡Z Abxnv
Rvwb bv
3.
DËi w`‡Z Abxnv
DËi w`‡Z Abxnv
Rvwb bv
MZ 30 w`‡b, Avcbvi cwiev‡ii †Kv‡bv m`m¨ Ges/A_ev eÜz‡`i mv‡_ wK Avcbvi †hvMv‡hvM n‡q‡Q hviv
Avcbvi wbivg‡q mnvqZv Ki‡Z Pvb?
nu¨v
bv
DËi w`‡Z Abxnv
Rvwb bv
5.
Avcwb mgm¨vq co‡j Kvi Kv‡Q hvb? [ïaygvÎ GKwU wbe©vPb Ki“b|]
Kv‡iv Kv‡Q bq
ag©xq †bZv
cwiev‡ii m`m¨
eÜz
DËi w`‡Z Abxnv
Rvwb bv
Ab¨vb¨ (D‡j­L Ki“b) _______________________________
SAIS_GPRA_Client_Outcome_Instrument
17
v4.6
I.
d‡jvAv‡ci Ae¯’v
[ïaygvÎ d‡jvAv‡ci mgq K¬v‡q›U m¤ú‡K© Kg©m~wPi Kg©x‡`i Øviv wi‡cvU©K…Z|]
1.
K¬v‡q‡›Ui d‡jvAv‡ci Ae¯’v Kx? [GwU GKwU Avek¨K AvB‡Ug: cª‡hvR¨ bq, DËi w`‡Z Abxnv, Rvwb bv, Ges
†bB, MªnY Kiv n‡e bv]
01 = wba©vwiZ mg‡qi Av‡M gviv †M‡Qb
11 = wba©vwiZ mg‡qi g‡a¨ mv¶vrKvi m¤úbœ K‡i‡Qb
12 = wba©vwiZ mg‡qi evB‡i mv¶vrKvi m¤úbœ K‡i‡Qb
21 = Ae¯’vb Rvbv †M‡Q, wKš‘ Abxnv cªKvk K‡i‡Qb, mywbw`©ó bq
22 = Ae¯’vb Rvbv †M‡Q, wKš‘ cªwZôv‡b cª‡e‡ki my‡hvM cvIqv hvqwb
23 = Ae¯’vb Rvbv †M‡Q, wKš‘ Ab¨ †Kv‡bv Kvi‡Y †`Lv Kivi my‡hvM cvIqv hvqwb
24 = Ae¯’vb Rvbv †M‡Q, wKš‘ cªKí †_‡K wb‡R‡K cªZ¨vnvi K‡i‡Qb
31 = Ae¯’vb Rvbv hvqwb, ¯’vb e`j K‡i‡Qb
32 = Ae¯’vb Rvbv hvqwb, Ab¨vb¨ (D‡j­L Ki“b) ________________________
2.
K¬v‡q›U wK GL‡bv Avcbvi Kg©m~wP †_‡K †mev cv‡”Qb?
nu¨v
bv
[hw` GUv GKUv d‡jvAvc mv¶vrKvi nq, Zvn‡j GLb eÜ Ki“b; mv¶vrKvi †kl n‡q‡Q|]
SAIS_GPRA_Client_Outcome_Instrument
18
v4.6
J.
wWmvPv‡R©i Ae¯’v
[ïaygvÎ wWmPv‡R©i mgq K¬v‡q›U m¤ú‡K© Kg©m~wPi Kg©x‡`i Øviv wi‡cvU©K…Z]
1.
K¬v‡q›U‡K K‡e wWmPvR© Kiv n‡q‡Q?
|____|____| / |____|____| / |____|____|____|____|
gvm
w`b
eQi
2.
K¬v‡q‡›Ui wWmPv‡R©i Ae¯’v Kx?
01 = m¤úbœ/DËxY©
02 = LvwiR
hw` K¬v‡q›U‡K LvwiR Kiv nq, Zvn‡j Lvwi‡Ri KviY Kx wQj? [GKwU DËi wbe©vPb Ki“b|]
01 = Kg©x‡`i civg‡k©i wei“‡× wbR B”Qvq P‡j †M‡Qb, m‡š—vlRbK AMªMwZ wQj
02 = Kg©x‡`i civg‡k©i wei“‡× wbR B”Qvq P‡j †M‡Qb, m‡š—vlRbK AMªMwZ QvovB
03 = AskMªnY bv Kivi Kvi‡Y B”Qvi wei“‡× LvwiR Kiv n‡q‡Q
04 = wbqgÑKvbyb f½ Kivi Kvi‡Y B”Qvi wei“‡× LvwiR Kiv n‡q‡Q
05 = Ab¨ †Kv‡bv Kg©m~wP ev Ab¨ cwi‡levi Rb¨ mycvwik Kiv n‡q‡Q, m‡š—vlRbK AMªMwZ wQj
06 = Ab¨ †Kv‡bv Kg©m~wP ev Ab¨ cwi‡levi Rb¨ mycvwik Kiv n‡q‡Q, m‡š—vlRbK AMªMwZ wQj bv
07 = wPwKrmv/wbqvgqKvjxb mg‡q K…Z Aciv‡ai Rb¨ Kvivi“× n‡q‡Qb, m‡š—vlRbK AMªMwZ wQj
08 = wPwKrmv/wbqvgqKvjxb mg‡q K…Z Aciv‡ai Rb¨ Kvivi“× n‡q‡Qb, m‡š—vlRbK AMªMwZ wQj
bv
09 = wPwKrmv/wbqvgq Kvh©µ‡g cª‡e‡ki Av‡M K…Z Aciv‡ai c‡ivqvbv ev Awf‡hv‡Mi Rb¨ Kvivi“×
n‡q‡Qb, m‡š—vlRbK AMªMwZ wQj
10 = wPwKrmv/wbqvgq Kvh©µ‡g cª‡e‡ki Av‡M K…Z Aciv‡ai c‡ivqvbv ev Awf‡hv‡Mi Rb¨ Kvivi“×
n‡q‡Qb, m‡š—vlRbK AMªMwZ wQj bv
11 = ¯^v¯’¨MZ Kvi‡Y Av‡iKwU cªwZôv‡b ¯’vbvš—i Kiv n‡q‡Q
12 = g„Z¨z
13 = Ab¨vb¨ (D‡j­L Ki“b) ______________________________
3.
Kg©m~wPwU wK GB K¬v‡q‡›Ui HIVÑGi cix¶v K‡i‡Q?
nu¨v
bv
4.
[mivmwi †mKkb KцZ P‡j hvb|]
[J4ÑG hvb|]
[hw` bv nq] Kg©m~wPwU wK GB K¬v‡q›U‡K GB cix¶vi Rb¨ civgk© w`‡q‡Q?
nu¨v
bv
SAIS_GPRA_Client_Outcome_Instrument
19
v4.6
K.
M„nxZ †mevmg~n
[ïaygvÎ wWmPv‡R©i mgq K¬v‡q›U m¤ú‡K© Kg©m~wPi Kg©x‡`i Øviv wi‡cvU©K…Z]
K¬v‡q‡›Ui wPwKrmv/Av‡ivM¨jv‡fi mg‡q
K¬v‡q›U‡K KZ w`b cwi‡lev †`qv n‡q‡Q Zv D‡j­L
Ki“b| [†Kv‡bv cwi‡lev †`qv bv n‡j k~b¨ wjLyb|
wPwKrmvi ai‡bi Rb¨ Avcbvi Kgc‡¶ GK w`b _vK‡Z
n‡e|]
wPwKrmvi aib
1. †Km e¨e¯’vcbv
2. w`evKvjxb wPwKrmv
3. fwZ© nIqv †ivMx/nvmcvZvj
(gv`Kvkw³ wbivgq e¨ZxZ)
4. ewnwe©fvMxq †ivMx
5. AvDUwiP
6. wbweo ewnwe©fvMxq †ivMx
7. †g_v‡Wvb
8. AvevwmK/cybe©vmb
9. gv`Kvkw³ wbivgq (ïay GKwU †e‡Q
wbb):
A. nvmcvZv‡j fwZ© nIqv †ivMx
B. wd« ÷¨vwÛs AvevwmK
C. ewnwe©fvMxq †ivMx‡`i gv`Kvkw³
wbivgq
10. cieZ©x cwiPh©v
11. wbivg‡q mnvqZv
12. Ab¨vb¨ (D‡j­L Ki“b) ____________
†Km e¨e¯’vcbv cwi‡lev
1. cvwievwiK †mev (we‡q msµvš—
wk¶v, wcZ…Z¡/gvZ…Z¡, wkï
Dbœqb †mev mn)
2. wkï cwiPh©v
3. Kg©ms¯’vb msµvš— †mev
A. cªvKÑKg©ms¯’vb
B. Kg©ms¯’vb msµvš— †KvwPs
4. e¨w³MZ cwi‡levi mgš^q
5. cwienb
6. HIV/GBWm welqK cwi‡lev
7. mnvqZvg~jK µvwš—Kvjxb
gv`KÑgy³ Avevmb †mev
8. Ab¨vb¨ †Km e¨e¯’vcbv cwi‡lev
(D‡j­L Ki“b) __________________
w`b
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
K¬v‡q‡›Ui wPwKrmv/Av‡ivM¨jv‡fi mg‡q
K¬v‡q›U‡K KqwU †mkb †`qv n‡q‡Q Zv D‡j­L
Ki“b| [†Kv‡bv cwi‡lev †`qv bv n‡j k~b¨ wjLyb|]
wPwKrmv †mev
†mkb
[SBIRT gÄzwi: 1 †_‡K 4 ch©š— GKwU wPwKrmv
†mevi Rb¨ Avcbvi Kgc‡¶ GKwU †mkb _vK‡Z n‡e|]
1. w¯Œwbs
|___|___|___|
2. msw¶ß n¯—‡¶c
|___|___|___|
3. msw¶ß wPwKrmv
|___|___|___|
4. wPwKrmvi Rb¨ †idvi Kiv
|___|___|___|
5. g~j¨vqb
|___|___|___|
6. wPwKrmv/wbivg‡qi cwiKíbv
|___|___|___|
7. e¨w³MZ civgk© †mev
|___|___|___|
8. `jMZ civgk© †mev
|___|___|___|
9. cvwievwiK/ˆeevwnK civgk©
|___|___|___|
10. hyMcr wPwKrmv/wbivgq †mev
|___|___|___|
11. IlyawfwËK n¯—‡¶c
|___|___|___|
12. HIV/GBWm m¤úwK©Z civgk©
|___|___|___|
13. Ab¨vb¨ wPwKrmv †mev
(D‡j­L Ki“b)___________________ |___|___|___|
SAIS_GPRA_Client_Outcome_Instrument
†mkb
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
wPwKrmv †mev
1. wPwKrmv cwiPh©v
2. A¨vj‡Kvnj/gv`K cix¶v
3. HIV/GBWm wPwKrmv mnvqZv I
cix¶v
4. Ab¨vb¨ wPwKrmv †mev
(D‡j­L Ki“b) __________________
†mkb
|___|___|___|
|___|___|___|
cwiPh©v cieZ©x †mev
1. Ae¨vnZ cwiPh©v
2. cybivq wjß nIqv cªwZ‡iva
3. wbivg‡qi †KvwPs
4. ¯^q¤¢i †Mvôx I mnvqZv `j
5. Ava¨vwZ¥K mnvqZv
6. Ab¨vb¨ cwiPh©v cieZ©x †mev
(D‡j­L Ki“b) __________________
†mkb
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
wk¶v cwi‡lev
†mkb
1. gv`‡Ki Ace¨envi m¤úwK©Z wk¶v
|___|___|___|
2. HIV/GBWm m¤úwK©Z wk¶v
|___|___|___|
3. Ab¨vb¨ wk¶v cwi‡lev
(D‡j­L Ki“b) __________________ |___|___|___|
m½xiÑØvivÑm½xi wbivgq mnvqZv
cwi‡lev
1. m½x‡`i †KvwPs ev civgk©
2. evm¯’vb mnvqZv
3. A¨vj‡KvnjÑ I gv`KÑgy³ mgvRKg©
4. Z_¨ I mycvwik
5. m½xiÑØvivÑm½xi Ab¨vb¨ wbivgq
mnvqZv †mev
(D‡j­L Ki“b) __________________
20
†mkb
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
v4.6