Department of Human Services (DHS)Division of Addiction Services (DAS)Information Systems Management Unit (ISM)
NJSAMS - 1Data Entry form on Paper
NJSAMS Administrative ModuleAdmission and Discharge
Press < ctrl+p > to print
(Note: Press <ctrl > key and < p > key at the same time)
Press “Back Button” from top menu bar to Main NJSAMS Homepage
(Please download and keep extra copies at all time in case of Internet Connection failure)
NJSAMS Training and Demonstration Site
http://samsdev.rutgers.edu/samstraining/mainhome.htm
NJSAMS Real-time Data System (Do not use training or demo. purposes)
https://njsams.rutgers.edu/samsmain/mainhome.htm
If you have any questions please call customer service at
Phone: 609-292-3331; 609-943-5905; 609-292-1466
Email: or
Updated: 06/15/2006
8
Adult ASI Questionnaire Page of 13 Compliments of Accurate Assessments 800-324-7966
NJSAMS Data Entry Forms Any questions please call (609) 292-1466, (609) 943-5905
CLIENT ADMINISTRATIVE INFORMATION (Admission)
NJSAMS Data Entry Forms Page 9 of 9 Any questions please call (609) 292-1466, (609) 943-5905
Client’s:
______
First name Middle name Last name
Social Security# - - -
Gender (M/F/Transgender/Other):
Date of birth: / /
Date of Admission: / / / /
Date of Interview: / /
In-House Case #
*Client Type:
1. Alcohol/Drug Abuser
2. Co-Dependent/ Family (non-substance abuser)
*Treatment Type:
1. Admission in a New Episode
2. Continuing Care within same Agency
3. Continuing Care Transfer from another Agency
*Level Of Care (LOC):
1. Standard/Traditional Outpatient
2. Intensive Outpatient
3. Partial Hospitalization
4. Transitional Care/ Extended Care
5. Halfway House
6. Long-Term Residential
7. Short-Term Residential (Medically Monitored)
8. Hospital-Based (acute) Residential
9. Detox-Free-Standing Residential (Sub-Acute)
10. Detox-Hospital Inpatient
11. Detox-Outpatient (Non-Methadone)
12. OPIOID Maintenance-Outpatient
13. Detox-Mehtadone Outpatient
14. Non-Traditional Program
15. OPIOID Maintenance-Intensive Outpatient
*Site Location: ______
*Methadone: Is use of methadone planned as part of treatment?
1. Yes
2. No
3. Don’t Know
Living Arrangement at admission:
1. Homeless-Shelter
2. Homeless-Streets
3. Dependent Living/Institution
4. Independent Living
Address : ______
City, State, Zip ______
Residence Code:
Phone #: (______) ______- ______
Email: ______
Contact name: ______
Contact Address: ______
Contact City, State, Zip ______
Contact Phone #: (______) ______- ______
Contact Email: ______
Length of time at current address: ______(Years) , _____ (Months)
Latino or Hispanic Origin:
1. Not of Hispanic Origin
2. Puerto Rican
3. Mexican
4. Cuban
5. Dominican
6. Other Hispanic SPECIFY: ______
Race: (Select up to two choices):
1. White
2. Black
3. Asian
4. Alaskan Native
5. American Indian
6. Native Hawaiian or other Pacific Islander
Household Income Per Year: $______
Household Size: ______
Number of past Alcohol & Drug Treatment Episode:
Self-help Group ever participated in
1. Narcotic Anonymous
2. Alcohol Anonymous (AA)
3. None
4. Other
What is your religious preference?
1. Protestant
2. Catholic
3. Jewish
4. Islamic
5. Other…………SPECIFY:______
6. None
8. Refused
9. Don’t Know
Is the client a Veteran 1. Yes 2. No
Is the client a Katrina evacuee 1. Yes 2. No
What is the highest grade you completed in school?
Do you have a high school diploma or GED
1. No
2. Yes
Are you currently enrolled in school or a job training program?
- Not enrolled (If not enrolled answer the following if applicable..)
1.Dropped out
2.Expelled
3.Suspended
(Admission Contd ……)
4.Medical Leave
5.Home Study
6.Other
2. Enrolled Full –Time
3. Enrolled Part –Time
4. Other
Which best describes your CURRENT employment situation?
1. Full-time work or military (35 hours a week or more)
2. Part-time (regular hours)
3. Part-time (not regular hours)
4. Student
5. Home Maker
6. Retired or Disabled
7. Unemployed: Actively looking for work
8. Unemployed: Not looking for work
9. Unemployed: Volunteer work
10. Living in an institution, like a jailor prison, hospital or overnight treatment program
What is your current marital status?
- Never Married
- Married
- Widowed
- Separated
- Divorced
If not “married”: Are you currently living with a significant other?
1. No
2. Yes
What is your Current Legal Status?
1. No Legal Problem
2. Case Pending
3. Drug Court
4. Probation
5. Parole
6. DWI License Suspension
7. Jail/Prison Inmate
8. DYFS or Family Court
9. Other
If other; Specify ______
How many times have you been arrested and charged for an offense in the past 30 days?
Pregnancy Questions
How many times in your life have you been pregnant?
times
How many of these pregnancies resulted in a live birth?
pregnancies
Have you given birth to a child in the past 12 months?
1. No
2. Yes
Are you pregnant now?
1. Yes
2. No
3. Don’t know
How many of your children are still living today?
children
Health Care Coverage (Check all that apply):
1. Medicaid
2. Medicare
3. NJ FamilyCare
4. VA/Champus
5. Insurance paid by client or client’s employer (BCBS, Aetna etc.)
6. Other Coverage (eg. Worker’s Compensation)
7. Uninsured
Is Client in a managed care plan like HMO or Provider Network, PPO etc.?
1. No
2. Yes
3. Don’t know
Dependent Children:
Is the client bringing dependent children into treatment?
1. No
2. Yes, If Yes, how many Children
Referral Source (Check only one – Numeric Field):
1. Self
2. Family/Friend
3. Addiction Services
31 = Addiction Treatment Program
32 = County Drug and Alcohol Coordinator
33 = South Jersey Initiative
34 = Other
4. Corrections Related Programs
41 = Municipality - Municipal Court
If “Municipal Court” is selected, enter 4-digit
municipality code :
42 = County - Family Court
43 = County - Drug Court
44 = County - Other
45 = County - Probation
46 = County - Detention Center
If any county related is selected
Enter County Code :
47 = STATE - NJ Department of Correction
48 = STATE – NJ State Parole Board/Parole District Office
49 = FEDERAL - US Federal Prison
50 = FEDERAL - US Federal Court
52 = Juvenile Justice Commission (JJC)
53 = Other
5. Intoxicated Drivers Resource Center (IDRC)
If “IDRC” is selected, enter county code of IDRC
County Code:
6. Mental Health
61 = Mental Health Screening Center
62 = Mental Health Provider/Clinic
63 = Hospital
65 = MICA Program
64 = Other
7. Medical/Health
71 = County or Municipal Health Department
72 = Hospital, Crisis Emergency Room
73 = Other Hospital
74 = Health Care Agency/Private Physician
75 = Other
8. Welfare/Social Services
81 = NJ Dept. of Human Services – DYFS
82 = WFNJ-Substance Abuse Initiative (SAI)
83 = Substance Abuse Research Demonstration
84 = Other
9. Employee Assistance Program
10. Hotline
11. Other
(Admission Contd ……)
Does client currently use any tobacco products?
(Not including nicotine replacement)
1. No
2. Yes
Tobacco products used (Check all that apply):
1. Cigarettes
2. Cigar
3. Pipe
4. Chewing Tobacco
Number of cigarettes smoked per day (Indicate number of cigarettes-not
number of packs, 1 pack=20 cigarettes; 0=none)
cigarettes
Does the client want to stop using tobacco or cut down from their current tobacco use?
1. Quit
2. Cut Down
3. No
Is the client currently using any Nicotine Replacement Therapy? (Check one of the following)
1. No
2. Gum
3. Patch
4. Other
Does the client have a disease or symptoms that they believe
are caused by or made worse by smoking or other tobacco use?
1. No
2. Yes
Prior to coming to this facility, estimate how soon (in minutes) after
The Client wakes, do they use tobacco or smoke their first cigarette?
Number of past attempts to stop smoking or stop tobacco use times
Primary Drug Problem:
Drug Name:
1. Alcohol
2. Heroin
3. Marijuana/Hashish
4. Cocaine – Powder
5. Crack
6. Amnphetemines/Methamphetamines
7. Barbituates
8. Benzodiazepine
9. Ecstacy
10. GHB
11. Hallucinogens – LSD
12. Hallucinogens – PCP
13. Hallucinogens – Other
14. Inhalants
15. Ketamine, Special K
16. Methadone (non-prescription)
17. Opiate – Other
18. Oxycontin
19. Rohypnol (Roche, Rope, Roach)
20. Other
Frequency of Use (Primary Drug):
1. No use past month
2. Less than weekly
3. 1 to 2 times per week
4. 3 to 6 times per week
5. Daily
Age at first use for Primary years-old
Route of Administration (Primary Drug):
1. Oral
2. Inhalation/Sniffing
3. Smoking
4. Intramuscular/sub-cutaneous
5. Intravenous
Secondary Drug Problem:
Drug Name:
1. Alcohol
2. Heroin
3. Marijuana/Hashish
4. Cocaine – Powder
5. Crack
6. Methamphetamines
7. Barbituates
8. Benzodiazepine
9. Ecstacy
10. GHB
11. Hallucinogens – LSD
12. Hallucinogens – PCP
13. Hallucinogens – Other
14. Inhalants
15. Ketamine, Special K
16. Methadone (non-prescription)
17. Opiate – Other
18. Oxycontin
19. Rohypnol (Roche, Rope, Roach)
20. Other
21. None
22. Other Amphetemines
Frequency of Use (Secondary Drug):
1. No use past month
2. Less than weekly
3. 1 to 2 times per week
4. 3 to 6 times per week
5. Daily
6. N/A
Age at first use for Secondary years-old
Route of Administration (Secondary Drug):
1. Oral
2. Inhalation/Sniffing
3. Smoking
4. Intramuscular/sub-cutaneous
5. Intravenous
6. N/A
Tertiary Drug Problem:
Drug Name:
1. Alcohol
2. Heroin
3. Marijuana/Hashish
4. Cocaine – Powder
5. Crack
6. Amphetemines
7. Barbituates
8. Benzodiazepine
9. Ecstacy
10. GHB
11. Hallucinogens – LSD
12. Hallucinogens – PCP
13. Hallucinogens – Other
14. Inhalants
15. Ketamine, Special K
16. Methadone (non-prescription)
17. Opiate – Other
18. Oxycontin
19. Rohypnol (Roche, Rope, Roach)
20. Other
21. None
(Admission Contd ……)
Frequency of Use (Tertiary Drug):
1. No use past month
2. Less than weekly
3. 1 to 2 times per week
4. 3 to 6 times per week
5. Daily
6. N/A
Age at first use for Tertiary
Route of Administration of Tertiary Drug):
1. Oral
2. Inhalation/Sniffing
3. Smoking
4. Intramuscular/sub-cutaneous
5. Intravenous
6. N/A
In the past 30 days, has client lived in a 24-hour controlled environment
such as Prison, Jail, Residential Drug Treatment Program,? (If client has
lived more than one controlled environment, select 2 choices)
1. No
2. Jail
3. Alcohol/Drug Treatment
4. Medical Treatment
5. Psychiatric Treatment
6. Other
In the past 30 days, all together how many days did client live in a controlled environment? (enter number of days 0 thru 30)
In the past 30 days, how many days has the client been treated as an
outpatient for alcohol or drug problems?
(enter number of days 0 thru 30) days
In the past 30 days, has the client been treated in an
emergency room for alcohol/drug problems?
1. No
2. Yes
How many days did the client wait to enter treatment
since first requesting admission from this agency?
(enter number of days 0 thru 30) days
Reimbursement Source (Check all that Apply)
1. Division of Addiction Services
a. Block Grant
1. General DAS Funding
2. Block Grant Set-Aside, Women’s
3. Block Grant Set-Aside, HIV
4. Block Grant Set-Aside, Other
b. Special Initiatives
1. Targeted capacity Expansion
2. South Jersey Initiative
3. DYFS/Women and Children
4. CWRP Adult
5. CWRP Adolescent
6. Deaf, Hard of Hearing and Disabled
7. DEDR – HIV Prevention
8. Work First Substance Abuse Initiative
9. Compulsive Gambling
10. IDRC Expansion Fund
11. WTC-New Jersey Recovers
12. Other Special Initiatives
If “Other Special Initiatives” is selected, specify
reimbursement source ______
2.Criminal Justice
a. DAS Funded
1. Mutual Agreement Program (MAP)
2. Drug Court (Prison Bound) – Residential
3. Drug Court (Prison Bound) – Aftercare
4. Drug Court (Non-Prison Bound) – OJP
5. Juvenile Justice Initiative
6. DWI/DUI Grants
b. Other Funded
1. Residential Community Release Program
2. Residential Parole Violator Program
3. Parole Day Reporting/Aftercare
4. Juvenile Justice Commission
5. Administrative Office of the Courts
6. Probation Aftercare – US Dept. of Justice
3. Public Assistance
1. TANF
2. General Assistance
3. Food Stamps
4. Charity Care
5. Medicaid
6. Medicare
7. NJ Family Care
4.County LACADA
1. Chapter 51
2. Enhancement
3. PRCC
4. Direct County Funding
5. Sub-Acute Detoxification
6. Youth Service Commission
7. Other
5.Other Funding
1. Division of AIDS Prevention and Control
2. Division of Family Health Services
3. Division of Mental Health Services
4. Division of Youth and Family Services (DYFS)
5. Ryan White
6. Private Insurance
7. Client Fees or Family Payment
8. No reimbursement Source/No fee
9. Other
If “Other” is selected, specify ______
Gambling Questions
1. Have you often spent a lot of time thinking about past gambling experience or planning future gambling ventures or bets?
1. No
2. Yes
2. Have you ever lied to family members, friends or others about how often you gamble or how much money you lost gambling?
1. No
2. Yes
3. After losing at gambling, do you try to return as quickly as possible to win back your losses
1. No
2. Yes
………… End of Admission …………….
NJSAMS Data Entry Forms Page 9 of 9 Any questions please call (609) 292-1466, (609) 943-5905
DISCHARGE MODULE
NJSAMS Data Entry Forms Page 9 of 9 Any questions please call (609) 292-1466, (609) 943-5905
Client Information
Date of Admission: / / / /
(to this level of care)
Client’s:
______
First name Middle name Last name
Address : ______
City, State, Zip ______
Phone #: (______) ______- ______
Email: ______
Gender (M/F):
Social Security# - - -
Case No:
Date of birth: / /
In-House Case # ______
Date of Discharge: / /
Date Entered: // / /
Contact name: ______
Contact Address: ______
Contact Phone: (______) ______- ______
Contact Email: ______