YES, IMMIGRANT ---------------> If YES: How long have you been in Canada? YES, REFUGEE--------------------> LENGTH: ___________ DAYS | WEEKS | MONTHS | YEARS YES, REFUGEE CLAIMANT ----> OR DATE: ______/_______/______ DAY / MONTH / NO YEAR DON’T KNOW DON’T KNOW DECLINE TO ANSWER DECLINE TO ANSWER In the past year (12 months) have you: [Ask respondents to give their best estimate] BEEN TO AN EMERGENCY ROOM Y ____ # ________ Times N____ BEEN HOSPITALIZED Y ____ # ________ Times N____ DAYS YOU HAVE SPENT HOSPITALIZED ________ Days Total INTERACTED WITH POLICE (Tickets, Y ____ # ________ Times arrests, searches) N____ BEEN TO PRISON/JAIL Y ____ # ________ Times DAYS YOU HAVE SPENT IN PRISON/JAIL ________ Days Total Adult Individual VI-SPDAT (can’t change questions or order) (scored) Basic Information First Name Nickname Last Name Date of Birth Use Age and DOB here to Consent to participate Age complete Yes No Question #5 for Ontario DD/MM/YYYY ___/ /_______ 60 1.
YES, IMMIGRANT ---------------> YES, REFUGEE--------------------> YES, REFUGEE CLAIMANT ----> NO DON’T KNOW DECLINE TO ANSWER If YES: How long have you been in Canada? LENGTH: ___________ DAYS | WEEKS | MONTHS | YEARS OR DATE: ______/_______/______ DAY / MONTH / YEAR DON’T KNOW DECLINE TO ANSWER In the past year (12 months) have you: [Ask respondents to give their best estimate] BEEN TO AN EMERGENCY ROOM Y ____ N____ # ________ Times BEEN HOSPITALIZED Y ____ N____ # ________ Times DAYS YOU HAVE SPENT HOSPITALIZED ________ Days Total INTERACTED WITH POLICE (Tickets, arrests, searches) Y ____ N____ # ________ Times BEEN TO PRISON/JAIL Y ____ # ________ Times DAYS YOU HAVE SPENT IN PRISON/JAIL ________ Days Total Adult Individual VI-SPDAT (can’t change questions or order) (scored) Basic Information First Name Nickname Last Name Date of Birth Age Use Age and DOB here to complete Question #5 for Ontario Consent to participate DD/MM/YYYY ___/ /_______ Yes No 60 1.
VI-SPDAT-20K-RW-ONTARIO-ONLY-1.docx