Recovery Residence Form

Your Name *
First
Last

Your Title (in relation to the recovery residence) *
If you are with an Oxford House, you can state that you are resident if you are not currently an officer.

Your email address *
Provide the email address we should use to email you a survey link, passcode, and information about the study, or to ask you questions about your recovery residence.

Your phone number

Recovery Residence Name *
PLEASE NAME ONE OF YOUR RESIDENCES ONLY. The name of the recovery residence you want to take the NSTARR survey for and/or add to the NSTARR database.

Is this residence an Oxford House? *
Yes
No

Recovery Residence Address *
Address Line 1
Address Line 2
City
State
Zip Code
The address of the recovery residence listed above. We will not share this information if you indicate that preference in a following question.

Recovery Residence Phone Number

Recovery Residence Website / URL

Do you want to complete a voluntary survey for NSTARR? *
Yes
No
If you select yes, and we don’t already have a completed survey for this residence, we will email you a survey link and passcode to take the survey.

We will not share your name or contact information with anyone else. Researchers who study recovery residences may be interested in knowing about your residence. Can we share your residence address information with other researchers if they agree not to provide it to anyone else? *
Yes
No - Do not share my residence address information

Parent Organization Name
The name of the organization that operates or manages the recovery residence listed above.

Parent Organization Address
Address Line 1
Address Line 2
City
State
Zip Code
*Skip this question if this is an Oxford House

Parent Organization Phone Number

Parent Organization Website

How many recovery residences does this organization operate?

If the parent organization operates other recovery residences, please list the name(s) and the address(es) of those here.