HRA – RAMP

1. What is your age?

2. Please specify your gender.

Male

Female

Other

3. Do you identify as Aboriginal/Indigenous?

Yes

No

4. Over the past 3 months, were you released from a correctional facility?

Yes

No

5. Over the past year, have you experienced a stressful life event that has disrupted your life in a major way? (such as death of spouse or close family member, divorce, detention, major injury or illness or being fired at work)

Yes

No

6. Over the past 6 months, have you experienced any symptoms of mental illness?

Yes

No

Please specify the mental illness(es)

Depression

Anxiety disorder

Other: Please specify

Please specify

7. Over the past 30 days, have you intentionally participated in any non-suicidal self-harm behaviours?

Yes

No

8. Over the past 30 days, have you thought about killing yourself?

Yes

No

9. Have you ever tried killing yourself?

Yes

No

10. Have you ever been a victim of abuse?

Yes

No

Please specify

11. Are you currently experiencing chronic pain (pain that lasts or recurs for more than 3 months)?

Yes

No

Please rate the pain on a typical day. (if you rather not answer this question, please select "N/A")*

12. Are you currently living with HIV?

Yes

No

13. Are you currently living with Hepatitis C?

Yes

No

14. Over the past 30 days, have you engaged in any of the following behaviours? (select all that apply)*

Injecting into an artery

Reusing needles

Driving while intoxicated

None of the above

15. Over the past 30 days, have you witnessed someone overdosing on opioids?

Yes

No

How many times have you witnessed someone overdosing?

17. Do you have any children?

Yes

No

Are they currently living with you?

Yes

No

18. Do you have a pet/pets currently living with you?

Yes

No

19. Have you set goals for yourself for the near future?

Yes

No

Please specify

20. Over the past 4 weeks, have you had a significant intimate partner(s)?

Yes

No

How would you rate the relationship(s) you have with your intimate partner(s)?

21. How many years of formal education do you have?

Please specify

22. Are you regularly involved in activities that you find meaningful?

Yes

No

Specify the activities

Please specify

23. Over the past 30 days, have you been in contact with any of the following people?

Family Members

Friends

None of the above

How often are you in contact with your family members?

How often are you in contact with your friends?

Please specify your current housing situation

Please specify

25. In the past 6 months, have you taken prescription opioids (e.g. codeine, morphine, oxycodone), without a doctor’s prescription or in larger doses than prescribed, to get high, buzzed, or numbed out?

Yes

No

In the past 6 months, have you used them alone?

In the past 6 months, have you injected them?

When did you last use prescription opioids?

26. In the past 6 months, have you taken street opioids (e.g. heroin or fentanyl)?

Yes

No

In the past 6 months, have you used them alone?

In the past 6 months, have you injected them?

When was your last use?

27. In the past 6 months, how many times did you overdose from opioids?

0 time

1 time

2-4 times

5+ times

For these overdoses, how many times have you been in the emergency department?

28. In the past 6 months, have you actively sought out fentanyl/fentanyl analogues?

Yes

No

29. Are you currently undergoing Opioid Agonist Treatment (OAT)?

Yes

No

What medication?

How satisfied are you with the treatment?

Over the past 6 months, have you been denied access to OAT?