"Rsa-R Provider Version Survey Template"

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Code:_____
RSA-R
Provider Version
Please circle the number below which reflects how accurately the following statements describe the activities,
values, policies, and practices of this program.
1
2
3
4
5
Strongly Disagree
Strongly Agree
N/A= Not Applicable
D/K= Don’t Know
1. Staff make a concerted effort to welcome people in recovery and help them
1
2
3
4
5
N/A
D/K
to feel comfortable in this program.
2. This program/agency offers an inviting and dignified physical environment
1
2
3
4
5
N/A
D/K
(e.g., the lobby, waiting rooms, etc.).
3. Staff encourage program participants to have hope and high expectations for
1
2
3
4
5
N/A
D/K
their recovery.
4. Program participants can change their clinician or case manager if they wish.
1
2
3
4
5
N/A
D/K
5. Program participants can easily access their treatment records if they wish.
1
2
3
4
5
N/A
D/K
6. Staff do not use threats, bribes, or other forms of pressure to influence the
1
2
3
4
5
N/A
D/K
behavior of program participants.
7. Staff believe in the ability of program participants to recover.
1
2
3
4
5
N/A
D/K
8. Staff believe that program participants have the ability to manage their own
1
2
3
4
5
N/A
D/K
symptoms.
9. Staff believe that program participants can make their own life choices
regarding things such as where to live, when to work, whom to be friends with,
1
2
3
4
5
N/A
D/K
etc.
10. Staff listen to and respect the decisions that program participants make
1
2
3
4
5
N/A
D/K
about their treatment and care.
11. Staff regularly ask program participants about their interests and the things
1
2
3
4
5
N/A
D/K
they would like to do in the community.
12. Staff encourage program participants to take risks and try new things.
1
2
3
4
5
N/A
D/K
13. This program offers specific services that fit each participant’s unique
1
2
3
4
5
N/A
D/K
culture and life experiences.
14. Staff offer participants opportunities to discuss their spiritual needs and
1
2
3
4
5
N/A
D/K
interests when they wish.
15. Staff offer participants opportunities to discuss their sexual needs and
1
2
3
4
5
N/A
D/K
interests when they wish.
16. Staff help program participants to develop and plan for life goals beyond
managing symptoms or staying stable (e.g., employment, education, physical
1
2
3
4
5
N/A
D/K
fitness, connecting with family and friends, hobbies).
17. Staff routinely assist program participants with getting jobs.
1
2
3
4
5
N/A
D/K
O’Connell, Tondora, Kidd, Stayner, Hawkins, and Davidson (2007)
Code:_____
RSA-R
Provider Version
Please circle the number below which reflects how accurately the following statements describe the activities,
values, policies, and practices of this program.
1
2
3
4
5
Strongly Disagree
Strongly Agree
N/A= Not Applicable
D/K= Don’t Know
1. Staff make a concerted effort to welcome people in recovery and help them
1
2
3
4
5
N/A
D/K
to feel comfortable in this program.
2. This program/agency offers an inviting and dignified physical environment
1
2
3
4
5
N/A
D/K
(e.g., the lobby, waiting rooms, etc.).
3. Staff encourage program participants to have hope and high expectations for
1
2
3
4
5
N/A
D/K
their recovery.
4. Program participants can change their clinician or case manager if they wish.
1
2
3
4
5
N/A
D/K
5. Program participants can easily access their treatment records if they wish.
1
2
3
4
5
N/A
D/K
6. Staff do not use threats, bribes, or other forms of pressure to influence the
1
2
3
4
5
N/A
D/K
behavior of program participants.
7. Staff believe in the ability of program participants to recover.
1
2
3
4
5
N/A
D/K
8. Staff believe that program participants have the ability to manage their own
1
2
3
4
5
N/A
D/K
symptoms.
9. Staff believe that program participants can make their own life choices
regarding things such as where to live, when to work, whom to be friends with,
1
2
3
4
5
N/A
D/K
etc.
10. Staff listen to and respect the decisions that program participants make
1
2
3
4
5
N/A
D/K
about their treatment and care.
11. Staff regularly ask program participants about their interests and the things
1
2
3
4
5
N/A
D/K
they would like to do in the community.
12. Staff encourage program participants to take risks and try new things.
1
2
3
4
5
N/A
D/K
13. This program offers specific services that fit each participant’s unique
1
2
3
4
5
N/A
D/K
culture and life experiences.
14. Staff offer participants opportunities to discuss their spiritual needs and
1
2
3
4
5
N/A
D/K
interests when they wish.
15. Staff offer participants opportunities to discuss their sexual needs and
1
2
3
4
5
N/A
D/K
interests when they wish.
16. Staff help program participants to develop and plan for life goals beyond
managing symptoms or staying stable (e.g., employment, education, physical
1
2
3
4
5
N/A
D/K
fitness, connecting with family and friends, hobbies).
17. Staff routinely assist program participants with getting jobs.
1
2
3
4
5
N/A
D/K
O’Connell, Tondora, Kidd, Stayner, Hawkins, and Davidson (2007)
Code:_____
18. Staff actively help program participants to get involved in non-mental
health/addiction related activities, such as church groups, adult education,
1
2
3
4
5
N/A
D/K
sports, or hobbies.
19. Staff work hard to help program participants to include people who are
important to them in their recovery/treatment planning (such as family, friends,
1
2
3
4
5
N/A
D/K
clergy, or an employer).
20. Staff actively introduce program participants to persons in recovery who
1
2
3
4
5
N/A
D/K
can serve as role models or mentors.
21. Staff actively connect program participants with self-help, peer support, or
1
2
3
4
5
N/A
D/K
consumer advocacy groups and programs.
22. Staff actively help people find ways to give back to their community (i.e.,
1
2
3
4
5
N/A
D/K
volunteering, community services, neighborhood watch/cleanup).
23. People in recovery are encouraged to help staff with the development of
1
2
3
4
5
N/A
D/K
new groups, programs, or services.
24. People in recovery are encouraged to be involved in the evaluation of this
1
2
3
4
5
N/A
D/K
agency’s programs, services, and service providers.
25. People in recovery are encouraged to attend agency advisory boards and
1
2
3
4
5
N/A
D/K
management meetings.
26. Staff talk with program participants about what it takes to complete or exit
1
2
3
4
5
N/A
D/K
the program.
27. Progress made towards an individual’s own personal goals is tracked
1
2
3
4
5
N/A
D/K
regularly.
28. The primary role of agency staff is to assist a person with fulfilling his/her
1
2
3
4
5
N/A
D/K
own goals and aspirations.
29. Persons in recovery are involved with facilitating staff trainings and
1
2
3
4
5
N/A
D/K
education at this program.
30. Staff at this program regularly attend trainings on cultural competency.
1
2
3
4
5
N/A
D/K
31. Staff are knowledgeable about special interest groups and activities in the
1
2
3
4
5
N/A
D/K
community.
32. Agency staff are diverse in terms of culture, ethnicity, lifestyle, and
1
2
3
4
5
N/A
D/K
interests.
O’Connell, Tondora, Kidd, Stayner, Hawkins, and Davidson (2007)
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