Ohio Mental Health Consumer Outcomes System (OMHCOS)
Ohio Department of Mental Health Office of Program Evaluation and Research (2004)
سامانه (نظام) برون داد سلامت روانی مراجع اوهایو
Adult Consumer Form A
Part 1
Below are some questions about how satisfied you are with various aspects of your life in the past 6 months. For each question‚ checkmark the answer that best describes how you feel.
How do you feel about:
1. The amount of friendship in your life?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
2. The amount of money you get?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
3. How comfortable and well-off you are financially?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
4. How much money you have to spend for fun?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
5. The amount of meaningful activity in your life (such as work‚ school‚ volunteer activity‚ leisure activity)?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
6. The amount of freedom you have?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
7. The way you and your family act toward each other?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
· Does not apply
8. Your personal safety?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
9. The neighborhood in which you live?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
10. Your housing/living arrangements?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
11. Your health in general?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
12. How often do you have the opportunity to spend time with people you really like?
· Never
· Seldom/rarely
· Sometimes
· Often
· Always
Part 2
These next few items ask you about your health and medications within the past 6 months.
13. How often does your physical condition interfere with your day-to-day functioning?
· Never
· Seldom/rarely
· Sometimes
· Often
· Always
14. Concerns about my medications (such as side effects‚ dosage‚ type of medication) are addressed:
· Never
· Seldom/rarely
· Sometimes
· Often
· Always
· Not applicable/no medications
The next two items deal with how you have been treated by other people.
15. I have been treated with dignity and respect at this agency.
· Never
· Seldom/rarely
· Sometimes
· Often
· Always
16. How often do you feel threatened by people’s reactions to your mental health problems?
· Never
· Seldom/rarely
· Sometimes
· Often
· Always
Part 3
The following questions ask you about how much you were distressed or bothered by some things during the last seven days.
Please mark the answer that best describes how you feel.
17. Nervousness or shakiness inside
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
18. Being suddenly scared for no reason
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
19. Feeling fearful
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
20. Feeling tense or keyed up
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
21. Spells of terror or panic
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
22. Feeling so restless you couldn’t sit still
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
23. Heavy feelings in arms or legs
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
24. Feeling afraid to go out of your home alone25. Feeling of worthlessness
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
25. Feeling of worthlessness
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
26. Feeling lonely even when you are with people
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
27. Feeling weak in parts of your body
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
28. Feeling blue
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
29. Feeling lonely
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
30. Feeling no interest in things
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
31. Feeling afraid in open spaces or on the streets
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
32. How often can you tell when mental or emotional problems are about to occur?
· Never
· Seldom/rarely
· Sometimes
· Often
· Always
33. When you can tell‚ how often can you take care of the problems before they become worse?
· Never
· Seldom/rarely
· Sometimes
· Often
· Always
Part 4
Below are several statements relating to one’s view about life and having to make decisions. Please check the response that is closest to how you feel about the statement. Check the word or words that best describes how you feel now.
34. I can pretty much determine what will happen in my life.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
35. People are limited only by what they think is possible.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
36. People have more power if they join together as a group.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
37. Getting angry about something never helps.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
43. Making waves never gets you anywhere.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
44. People working together can have an effect on their community.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
45. I am often able to overcome barriers.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
46. I am generally optimistic about the future.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
47. When I make plans‚ I am almost certain to make them work.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
48. Getting angry about something is often the first step toward changing it.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
49. Usually I feel alone.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
54. You can’t fight city hall (authority).
· Strongly agree
· Agree
· Disagree
· Strongly disagree
55. I feel powerless most of the time.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
50. Experts are in the best position to decide what people should do or learn.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
51. I am able to do things as well as most other people.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
52. I generally accomplish what I set out to do.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
53. People should try to live their lives the way they want to.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
54. You can’t fight city hall (authority).
· Strongly agree
· Agree
· Disagree
· Strongly disagree
55. I feel powerless most of the time.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
56. When I am unsure about something‚ I usually go along with the rest of the group.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
57. I feel I am a person of worth‚ at least on an equal basis with others.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
58. People have a right to make their own decisions‚ even if they are bad ones.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
59. I feel I have a number of good qualities.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
60. Very often a problem can be solved by taking action.
· Strongly agree
· Agree
· Disagree
· Strongly
61. Working with others in my community can help to change things for the better.
· Strongly agree
· Agree
· Disagree
· Strongly disagree
Part 5
Please tell us some things about yourself.
62. What was the last school grade you completed?
· Less than 1st grade
· 1st grade
· 2nd grade
· 3rd grade
· 4th grade
· 5th grade
· 6th grade
· 7th grade
· 8th grade
· 9th grade
· 10th grade
· 11th grade
· High school diploma/GED
· Trade/Tech school
· Some college
· 2 yr college/Associate degree
· Graduate school courses
· 4 yr college/Undergraduate degree
· Graduate degree
· Post-graduate studies
· Further special studies
63. Race (check all that apply):
· White
· Native American/Pacific Islander
· Black/African-American
· Hispanic/Latino
· Asian
· Other
64. What is your marital status?
· Never married
· Married
· Separated
· Divorced
· Widowed
· Living together
65. What is your current living situation?
· Your own house/apartment
· Friend’s home
· Relative’s home
· Supervised group living
· Supervised apartment
· Boarding home
· Crisis residential
· Child foster care
· Adult foster care
· Intermediate care facility
· Skilled nursing facility
· Respite care
· MR intermediate care facility
· Licensed MR facility
· State MR institution
· State MH institution
· Hospital
· Correctional facility
· Homeless
· Rest home
· Other
66. What is your employment status?
· Employed full time
· Employed part time
· Sheltered employment
· Unemployed
· Homemaker
· Retired
· Disabled
· Inmate of institution
67. Are you in treatment because you want to be?
· Yes
· No
****************
Adult Consumer Form B
Part 1
Below are some questions about how satisfied you are with various aspects of your life in the past 6 months. For each question‚ checkmark the answer that best describes how you feel.
How do you feel about:
1. The amount of friendship in your life?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
2. The amount of money you get?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
3. How comfortable and well-off you are financially?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
4. How much money you have to spend for fun?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
5. The amount of meaningful activity in your life (such as work‚ school‚ volunteer activity‚ leisure activity)?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
6. The amount of freedom you have?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
7. The way you and your family act toward each other?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
· Does not apply
8. Your personal safety?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
9. The neighborhood in which you live?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
10. Your housing/living arrangements?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
11. Your health in general?
· Terrible
· Mostly dissatisfied
· Equally satisfied/dissatisfied
· Mostly satisfied
· Very pleased
12. How often do you have the opportunity to spend time with people you really like?
· Never
· Seldom/rarely
· Sometimes
· Often
· Always
Part 2
These next few items ask you about your health and medications within the past 6 months.
13. How often does your physical condition interfere with your day-to-day functioning?
· Never
· Seldom/rarely
· Sometimes
· Often
· Always
14. Concerns about my medications (such as side effects‚ dosage‚ type of medication) are addressed:
· Never
· Seldom/rarely
· Sometimes
· Often
· Always
· Not applicable/no medications
The next two items deal with how you have been treated by other people.
15. I have been treated with dignity and respect at this agency.
· Never
· Seldom/rarely
· Sometimes
· Often
· Always
16. How often do you feel worried by people’s reactions to the problems that brought you to the agency?
· Never
· Seldom/rarely
· Sometimes
· Often
· Always
Part 3
The following questions ask you about how much you were distressed or bothered by some things during the last seven days.
Please mark the answer that best describes how you feel.
During the past 7 days‚ about how much were you distressed or bothered by:
17. Nervousness or shakiness inside
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
18. Being suddenly scared for no reason
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
19. Feeling fearful
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
20. Feeling tense or keyed up
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
21. Spells of terror or panic
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
22. Feeling so restless you couldn’t sit still
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
23. Heavy feelings in arms or legs
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
24. Feeling afraid to go out of your home alone
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
25. Feeling of worthlessness
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
26. Feeling lonely even when you are with people
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
27. Feeling weak in parts of your body
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
28. Feeling blue
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
29. Feeling lonely
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
30. Feeling no interest in things
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
31. Feeling afraid in open spaces or on the streets
· Not at all
· A little bit
· Some
· Quite a bit
· Extremely
32. How often can you tell when mental or emotional problems are about to occur?
· Never
· Seldom/rarely
· Sometimes
· Often
· Always
33. When you can tell‚ how often can you take care of the problems before they become worse?
· Never
· Seldom/rarely
· Sometimes
· Often
· Always
Part 4
Please tell us some things about yourself.
34. What was the last school grade you completed?
· Less than 1st grade
· 1st grade
· 2nd grade
· 3rd grade
· 4th grade
· 5th grade
· 6th grade
· 7th grade
· 8th grade
· 9th grade
· 10th grade
· 11th grade
· High school diploma/GED
· Trade/Tech school
· Some college
· 2 yr college/Associate degree
· Graduate school courses
· 4 yr college/Undergraduate degree
· Graduate degree
· Post-graduate studies
· Further special studies
35. Race (check all that apply):
· White
· Native American/Pacific Islander
· Black/African-American
· Hispanic/Latino
· Asian
· Other
36. What is your marital status?
· Never married
· Married
· Separated
· Divorced
· Widowed
· Living together
37. What is your current living situation?
Your own house/apartment
· Friend’s home
· Relative’s home
· Supervised group living
· Supervised apartment
· Boarding home
· Crisis residential
· Child foster care
· Adult foster care
· Intermediate care facility
· Skilled nursing facility
· Respite care
· MR intermediate care facility
· Licensed MR facility
· State MR institution
· State MH institution
· Hospital
· Correctional facility
· Homeless
· Rest home
· Other
38. What is your employment status?
· Employed full time
· Employed part time
· Sheltered employment
· Unemployed
· Homemaker
· Retired
· Disabled
· Inmate of institution
39. Are you in treatment because you want to be?
· Yes
· No
********************
Ohio Mental Health Consumer Outcomes System
Provider Form A
Please circle the appropriate response for each statement that corresponds with the client’s highest level of functioning in the past 6 months.
1. Does the client initiate non-professional social contact or respond to others’ initiation of social contact?
Withdrawn/isolated‚ Minimal contact‚ Moderate contact‚ Optimal contact‚ Unsure
2. How effectively does this client interact with others? NOTE: “Effectively” refers to how successfully and appropriately the client behaves in social settings (i.e.‚ how well she/he minimizes interpersonal friction‚ meets personal needs‚ achieves personal goals in socially appropriate manner).
Very ineffectively‚ Ineffectively‚ Mixed or dubious effectiveness‚ Effectively‚ Very Effectively Unsure
4. Please rate the client’s housing stability
Moved very frequently. Moved often‚ Moved a few times‚ Moved once‚ Did not move‚ Unsure
3. How effective is the client’s social support network in helping the client meet his/her needs?
NOTE: A support network may consist of interested family‚ friends‚ acquaintances‚ coworkers‚ peers‚ or social clubs‚ etc.
Very ineffective‚ Ineffective‚ Mixed or dubious effectiveness‚ Effective‚ Very Effective‚ Unsure
5. Has the client been forced/compelled to move from his/her living arrangements?
Yes‚ No‚ Unsure
6. How well does the client perform independently in the following day-to-day living activities?
1=Task is not completed‚ 2=Someone other than the client completes task‚ 3=Client needs extensive supervision or assistance‚ 4= Client needs some supervision or assistance‚ 5=Client acts independently‚ ?=Unsure or not applicable
A. Personal hygiene 1 2 3 4 5 ?
B. Dressing appropriately 1 2 3 4 5 ?
C. Obtaining regular nutrition 1 2 3 4 5 ?
D. Using public transportation 1 2 3 4 5 ?
E. Shopping 1 2 3 4 5 ?
F. Doing laundry 1 2 3 4 5 ?
G. Housekeeping 1 2 3 4 5 ?
H. Managing money 1 2 3 4 5 ?
7. To what extent has the client engaged in the following meaningful activities?
1=Almost Never (<1x / mo.)‚ 2= Seldom (<1x / week)‚ 3= Sometimes (1-2x / week)‚ 4= Often (3-4x / week)‚ 5= Almost always (>5x / week)‚ ?= Unsure or not applicable
A. Work 1 2 3 4 5 ?
B. School 1 2 3 4 5 ?
C. Volunteer activity 1 2 3 4 5 ?
D. Parenting 1 2 3 4 5 ?
E. Homemaking 1 2 3 4 5 ?
F. Leisure activity 1 2 3 4 5 ?
8. Of the roles listed above‚ in general how well is the client performing in his/her primary role?
Extremely poorly‚ Poorly‚ Satisfactorily‚ Well‚ Extremely well‚ Unsure
9. How frequently is the client’s functioning compromised by addictive or compulsive behaviors (e.g.‚ alcohol abuse‚ drug abuse‚ gambling)?
Almost always (>5x / week)‚ Often (3-4x / week)‚ Sometimes (1-2x / week)‚ Seldom (<1x / week)‚ Almost never (<1x / month)‚ Unsure
10. Has the client abided by the law sufficiently to avoid incarceration and/or criminal justice system involvement?
No‚ Yes‚ Unsure
11. Has the client attempted to or actually physically harmed someone?
Yes‚ No‚ Unsure
12. Has the client been a victim of:
a) rape Yes‚ No‚ Unsure
b) assault Yes‚ No‚ Unsure
c) threats Yes‚ No‚ Unsure
d) exploitation Yes‚ No‚ Unsure
e) harassment Yes‚ No‚ Unsure
f) suicide attempt Yes‚ No‚ Unsure
g) other type of harm to self Yes‚ No‚ Unsure
h) hate crimes Yes‚ No‚ Unsure
i) theft‚ robbery‚ vandalism Yes‚ No‚ Unsure
شرح سایت روان سنجی: این ابزار برای جمع آوری اطلاعات و آگاهی از پیامدهای نظام سلامت روانی پدید آمده است.
زمینه های هر نسخه
Adult Consumer Form A Domains: Overall Quality of Life‚ Quality of Life (Independent items)‚ Financial Status (Subscale)‚ Safety and Health (Independent items)‚ Symptoms Distress (Scale) ‚ Additional symptom items‚ Overall Empowerment (Scale)‚ Self-Esteem/Self-efficacy (Subscale) ‚ Power/Powerlessness (Subscale) ‚ Community Activism and Autonomy (Scale)‚ Optimism and Control Over the Future (Subscale)‚ Righteous Anger (Subscale)
Adult Consumer Form B Domains: Overall Quality of Life (Scale)‚ Quality of Life (Independent items)‚ Financial Status (Subscale)‚ Safety and Health (Independent items)‚ Symptom Distress (Scale)
Provider Adult Form A Domains: Community Functioning (Social Contact‚ Social Interaction‚ Social Support‚ Housing Stability‚ Forced Moves‚ Activities of Daily Living (Subscale)‚ Meaningful Activities (Subscale)‚ Primary Role‚ Addictive Behaviors‚ Criminal Justice‚ Aggressive Behavior) and Safety and Health (Independent items)
اعتبار: آلفا کرونباخ
Adult Consumer Form A:
· Making Decisions Empowerment Scale (alpha .77)
· Quality of Life items (alpha .86)
· Symptom Distress Scale(alpha .93)
Provider Adult Form A
· Community Functioning Scale (alpha .72)
Adult Consumer Form B
· Quality of Life items (alpha .92)
· Symptom Distress Scale (alpha .97)
Test- retest: 1 week r=0.91‚ 2 week r= 0.91
چگونگی دستیابی
منبع برای آگاهی بیشتر
Ohio Mental Health Outcomes Task Force. (2001‚ Revised and updated). Vital signs: a statewide approach to measuring consumer outcomes in Ohio’s publicly –supported community mental health system. Final report of the Ohio Mental Health Outcomes Task Force. (1996-1997). Columbus‚ OH. Ohio Department of Mental Health. http://www.mh.state.oh.us/oper/outcomes/outcomes.index.html
Ohio Department of Mental Health. (2004a‚ February). The Ohio Mental Health Consumer Outcomes System: Frequently asked questions. Columbus‚ OH. Ohio Department of Mental Health. http://www.mh.state. oh.us/oper/outcomes/outcomes.index.html