Are you looking for an easy way to gather feedback from your customers or employees? Are you wanting to learn more about what they are thinking and feeling? If so, then a questionnaire oms form may be the perfect solution. A questionnaire oms form allows your audience to answer questions in their own time and provides a quick, efficient way of gathering qualitative data. In this blog post, we’ll explore different types of questionnaires oms forms and discuss how they can help you get valuable insights from those around you. Keep reading to discover why this type of tool is becoming increasingly popular — and how it can benefit your company!
| Question | Answer |
|---|---|
| Form Name | Questionnaire Oms Form |
| Form Length | 11 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 2 min 45 sec |
| Other names | adult questionnaire get, adult questionnaire pdf, adult questionnaire search, add questionnaire for adults |
ADULT QUESTIONNAIRE
OUTCOMES MEASUREMENT SYSTEM (OMS)
[VERSION 3; DECEMBER 13, 2014]
Client Name: __________________________________________
Interviewer Name: __________________________________________
*Date of Current Interview: ____ / ____ / ________
MM DD YYYY
A companion OMS Interview Guide for this questionnaire is available at
www.maryland.valueoptions.com.
The symbol (Ψ) denotes a client opinion only question.
An asterisk (*) denotes a question that is mandatory for submission.
Underlined questions indicate that a definition is available for a term within the questionnaire. Click on the hyperlink that appears in order to access the definition.
12/13/14 |
1 |
LIVING SITUATION
I’m going to ask you some questions today about different areas of your life, such as your living situation and daily activities.
*1. Where are you living now? (see OMS Interview Guide for more specific definitions)
OIndependent (Private Residence, Boarding House/Rooming House)
OCommunity (Residential Rehabilitation Program, Group Home/Therapeutic Group Home, Halfway House, Recovery Residence, School or Dormitory, Foster Home, Crisis Residence)
OInstitutional (Assisted Living, Skilled Nursing Facility, Residential Treatment Center for Children, Hospital, Jail/Correctional Facility/Detention Center)
OHomeless (Homeless or Emergency Shelter)
OOther (specify) _______________________________________________
(INTERVIEWER: Read all the answer options to the client)
2.In general, how satisfied are you with where you currently live? Ψ
O Not at all O A little bit O Somewhat O Quite a bit O Very much
3.Have you been homeless at all in the past six months? (see OMS Interview Guide for definition of “homeless”)
O No O Yes
(continued on next page)
12/13/14 |
2 |
RECOVERY AND FUNCTIONING
Now I am going to read a series of statements. As I read each statement, please indicate how much you agree with it: Not at all, A little bit, Somewhat, Quite a bit, or Very much.
[CARD #1 with response options]
Please note that Questions |
Not at |
A little |
Somewhat |
Quite a |
Very |
||
all Ψ (Client Opinion Only) |
all |
bit |
bit |
much |
|||
|
|||||||
4. |
I am confident that I can make positive |
|
|
|
|
|
|
|
changes in my life. |
|
|
|
|
|
|
5. |
I am hopeful about the future. |
|
|
|
|
|
|
6. |
I believe I make good choices in my life. |
|
|
|
|
|
|
7. |
I am able to set my own goals in life. |
|
|
|
|
|
|
8. |
I feel accepted as who I am. |
|
|
|
|
|
|
9. |
I do things that are meaningful to me. |
|
|
|
|
|
|
10. I am able to take care of my needs. |
|
|
|
|
|
||
11. I am able to handle things when they go |
|
|
|
|
|
||
|
wrong. |
|
|
|
|
|
|
12. I am able to do things that I want to do. |
|
|
|
|
|
||
13. My symptoms bother me. (see OMS |
|
|
|
|
|
||
Interview Guide for definition of “symptoms”) |
|
|
|
|
|
||
1Items
(INTERVIEWER: Read all the answer options to the client)
14.Overall, how satisfied are you with your recovery? Ψ (description of “recovery” in italics below)
O Not at all O A little bit O Somewhat O Quite a bit O Very much
[“Recovery from Mental Disorders and/or Substance Use Disorders is a process of change through which individuals improve their health and wellness, live a
(U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2011)]
12/13/14 |
3 |
PSYCHIATRIC SYMPTOMS
For the next several questions, please tell me your answer based on the past MONTH.
INTERVIEWER: (do not read aloud) For items
(Questionnaire Items
During the PAST MONTH, how much difficulty did you have…
15.Managing your
O No difficulty O A little difficulty
O Moderate difficulty O Quite a bit of difficulty O Extreme difficulty
16.Coping with problems in your life? Ψ [CARD #2]
O No difficulty O A little difficulty
O Moderate difficulty O Quite a bit of difficulty O Extreme difficulty
17.Concentrating? Ψ [CARD #2]
O No difficulty O A little difficulty
O Moderate difficulty O Quite a bit of difficulty O Extreme difficulty
During the PAST MONTH, how much of the time did you…
18.Get along with people in your family? Ψ [CARD #3 with response options]
O None of the time O A little of the time O Half of the time O Most of the time O All of the time
12/13/14 |
4 |
19.Get along with people outside your family? Ψ [CARD #3]
O None of the time O A little of the time O Half of the time O Most of the time O All of the time
20.Get along well in social situations? Ψ [CARD #3]
O None of the time O A little of the time O Half of the time O Most of the time O All of the time
21.Feel close to another person? Ψ [CARD #3]
O None of the time O A little of the time O Half of the time O Most of the time O All of the time
22.Feel like you had someone to turn to if you needed help? Ψ [CARD #3]
O None of the time O A little of the time O Half of the time O Most of the time O All of the time
23.Feel confident in yourself? Ψ [CARD #3]
O None of the time O A little of the time O Half of the time O Most of the time O All of the time
12/13/14 |
5 |
During the PAST MONTH, how much of the time did you…
24.Feel sad or depressed? Ψ [CARD #3]
O None of the time O A little of the time O Half of the time O Most of the time O All of the time
25.Think about ending your life? Ψ [CARD #3]
O None of the time O A little of the time O Half of the time O Most of the time O All of the time
26.Feel nervous? Ψ [CARD #3]
O None of the time O A little of the time O Half of the time O Most of the time O All of the time
During the PAST MONTH, how often did you…
27.Have thoughts racing through your head? Ψ [CARD #4 with response options]
O Never O Rarely
O Sometimes O Often
O Always
28.Think you had special powers? Ψ [CARD #4]
O Never O Rarely
O Sometimes O Often
O Always
12/13/14 |
6 |
29.Hear voices or see things? Ψ [CARD #4]
O Never O Rarely
O Sometimes O Often
O Always
30.Think people were watching you? Ψ [CARD #4]
O Never O Rarely
O Sometimes O Often
O Always
31.Think people were against you? Ψ [CARD #4]
O Never O Rarely
O Sometimes O Often
O Always
During the PAST MONTH, how often did you…
32.Have mood swings? Ψ [CARD #4]
O Never O Rarely
O Sometimes O Often
O Always
33.Feel short tempered? Ψ [CARD #4]
O Never O Rarely
O Sometimes O Often
O Always
12/13/14 |
7 |
34.Think about hurting yourself? Ψ [CARD #4]
O Never O Rarely
O Sometimes O Often
O Always
During the PAST MONTH, how often…
35.Did you have an urge to drink alcohol or take street drugs? Ψ [CARD #4]
O Never O Rarely
O Sometimes O Often
O Always
36.Did anyone talk to you about your drinking or drug use? Ψ [CARD #4]
O Never O Rarely
O Sometimes O Often
O Always
37.Did you try to hide your drinking or drug use? Ψ [CARD #4]
O Never O Rarely
O Sometimes O Often
O Always
38.Did you have problems from your drinking or drug use? Ψ [CARD #4]
O Never O Rarely
O Sometimes O Often
O Always
12/13/14 |
8 |
LEGAL SYSTEM INVOLVEMENT
*39. In the past six months have you been arrested?
ONo
OYes
*40. In the past six months have you been in either jail or prison?
ONo
OYes
EMPLOYMENT
Now let’s talk a little bit about your work situation.
*41. Are you currently employed? (see OMS Interview Guide for definition of “employment”)
ONo (continue to #42)
OYes (skip to #43)
*42. Have you been employed in the past six months? [mandatory only if Question 41 is “No”]
ONo (skip to #45)
OYes (continue to #43)
INTERVIEWER: (do not read aloud) If the person held more than one job in the past six months, please ask him or her to answer the following questions in terms of the most recent job.
43.How many hours a week (do/did) you usually work?
O
(INTERVIEWER: Read all the answer options to the client)
44.In general, how satisfied (are/were) you with this job? Ψ
O Not at all O A little bit O Somewhat O Quite a bit O Very much
12/13/14 |
9 |
SOMATIC HEALTH
*45. Do you smoke cigarettes?
ONo (skip to #47)
OYes (continue to #46)
46.How many cigarettes do you smoke per day? [one pack = 20 cigarettes]
ODo not smoke every day
O
O
O
O30+
(INTERVIEWER: Read all the answer options to the client and check all that apply)
*47. In the past month did you use any of the following tobacco products?
OCigars (e.g., cigarillos, little cigars)?
OSmokeless tobacco (e.g., chewing tobacco, dip, snuff)?
O
OPipes (e.g., hookah, water pipes)?
OOther tobacco product (e.g., bidis, kreteks, clove cigarettes)?
ONone
(INTERVIEWER: Read all the answer options to the client)
48.Would you say in general your health is: Ψ
O Excellent O Very good O Good
O Fair O Poor
49.How tall are you?
____ (feet) ______ (inches) [please write legibly]
50. How much do you currently weigh?
____________ pounds [whole numbers only; please write legibly]
ODon’t Know
ORefused
12/13/14 |
10 |
Clinician’s Notes (Optional)
12/13/14 |
11 |