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