Attachment 2-2
CSAP GPRA Participant Outcome
Measures for Discretionary Programs
Instrument
Form Approved
OMB No. 0930-0208
Expiration Date 01/31/2007
CSAP GPRA Participant Outcome
Measures for Discretionary Programs
ADULTS
Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information, if all items are asked of a client/participant; to the extent that providers already obtain much of this information as part of their ongoing client/participant intake or followup, less time will be required. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 7-1044, 1 Choke Cherry Road, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The control number for this project is 0930-0208.
RECORD MANAGEMENT
Participant ID |____|____|____|____|____|____|____|____|____|____|____|
Contract/Grant ID |____|____|____|____|____|____|____|____|____|____|
Grant Year |____|____|____|____|
Year
Interview Date |____|____| / |____|____| / |____|____|____|____|
Interview Type
1. Pre-Test 2. Post-Test 3. 6-Month Follow-up
A. DEMOGRAPHICS (QUESTIONS 1-4 ASKED ONLY AT BASELINE)
1. Gender
Male
Female
2. Are you Hispanic or Latino?
Yes No
3. What is your race? (Select one or more)
Black or African American Alaska Native
Asian White
American Indian Other (specify)_____________
Native
Hawaiian or Other
Pacific
Islander
4. What is your date of birth? |____|____| / |____|____| / |____|____|____|____|
Month / Day / Year
B. DRUG AND ALCOHOL USE
0 0 days 1 1 or 2 days 2 3 to 5 days 3 6 to 9 days 4 10 to 19 days 5 20 to 29 days 6 all 30 days
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0 0 days 1 1 or 2 days 2 3 to 5 days 3 6 to 9 days 4 10 to 19 days 5 20 to 29 days 6 all 30 days
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0 0 days 1 1 or 2 days 2 3 to 5 days 3 6 to 9 days 4 10 to 19 days 5 20 to 29 days 6 all 30 days
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0 0 days 1 1 or 2 days 2 3 to 5 days 3 6 to 9 days 4 10 to 19 days 5 20 to 29 days 6 all 30 days
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0 0 days 1 1 or 2 days 2 3 to 5 days 3 6 to 9 days 4 10 to 19 days 5 20 to 29 days 6 all 30 days
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0 0 days 1 1 or 2 days 2 3 to 5 days 3 6 to 9 days 4 10 to 19 days 5 20 to 29 days 6 all 30 days
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0 0 days 1 1 or 2 days 2 3 to 5 days 3 6 to 9 days 4 10 to 19 days 5 20 to 29 days 6 all 30 days
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0 0 days 1 1 or 2 days 2 3 to 5 days 3 6 to 9 days 4 10 to 19 days 5 20 to 29 days 6 all 30 days
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0 0 days 1 1 or 2 days 2 3 to 5 days 3 6 to 9 days 4 10 to 19 days 5 20 to 29 days 6 all 30 days |
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10. How old were you the first time you smoked part or all of a cigarette?
years old If never smoked part or all of a cigarette please mark the box.
11. Think about the first time you had a drink of an alcoholic beverage. How old were you the first time you had a drink of an alcoholic beverage? Please do not include any time when you only had a sip or two from a drink.
years old If never had a drink of an alcoholic beverage please mark the box.
12. How old were you the first time you used marijuana or hashish?
years old If never used marijuana or hashish please mark the box.
13. How old were you the first time you used any other illegal drugs?
years old If never used any illegal drugs please mark the box.
D. EDUCATION, EMPLOYMENT, AND INCOME
1. What is the highest level of education you have finished, whether or not you received a degree? [01=1st grade, 12=12th grade, 13=college freshman, 16=college completion]
|____|____| level in years
1a. If less than 12 years of education, do you have a GED (General Equivalency Diploma)?
Yes No
G. ATTITUDES AND BELIEFS
1. How much do people risk harming themselves physically and in other ways when they smoke one or more packs of cigarettes per day?
No risk
Slight risk
Moderate risk
Great risk
2. How much do people risk harming themselves physically and in other ways when they smoke marijuana once a month?
No risk
Slight risk
Moderate risk
Great risk
How much do people risk harming themselves physically and in other ways when they:
a. Have four or five drinks of an alcoholic beverage nearly every day?
No risk
Slight risk
Moderate risk
Great risk
b. Have five or more drinks of an alcoholic beverage once or twice a week?
No risk
Slight risk
Moderate risk
Great risk
How do you feel about adults smoking one or more packs of cigarettes per day?
Neither approve nor disapprove
Somewhat disapprove
Strongly disapprove
How do you feel about adults trying marijuana or hashish once or twice?
Neither approve nor disapprove
Somewhat disapprove
Strongly disapprove
How do you feel about adults having one or two drinks of an alcoholic beverage nearly every day?
Neither approve nor disapprove
Somewhat disapprove
Strongly disapprove
How do you feel about adults driving a car after having one or two drinks of an alcoholic beverage?
Neither approve nor disapprove
Somewhat disapprove
Strongly disapprove
Form Approved
OMB No. 0930-0208
Expiration Date 01/31/2007
CSAP GPRA Participant Outcome
Measures for Discretionary Programs
YOUTH - Age 12 to 17 Years
Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information, if all items are asked of a client/participant; to the extent that providers already obtain much of this information as part of their ongoing client/participant intake or followup, less time will be required. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 7-1044, 1 Choke Cherry Road, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The control number for this project is 0930-0208.
RECORD MANAGEMENT
Participant ID |____|____|____|____|____|____|____|____|____|____|____|
Contract/Grant ID |____|____|____|____|____|____|____|____|____|____|
Grant Year |____|____|____|____|
Year
Interview Date |____|____| / |____|____| / |____|____|____|____|
Interview Type
1. Pre-Test 2. Post-Test 3. 6-Month Follow-up
A. DEMOGRAPHICS (QUESTIONS 1-4 ASKED ONLY AT BASELINE)
1. Gender
Male
Female
2. Are you Hispanic or Latino?
Yes No
3. What is your race? (Select one or more)
Black or African American Alaska Native
Asian White
American Indian Other (specify)_____________
Native Hawaiian or
Other
Pacific
Islander
4. What is your date of birth? |____|____| / |____|____| / |____|____|____|____|
Month / Day / Year
B. DRUG AND ALCOHOL USE
1. How frequently have you smoked cigarettes during the past 30 days?
1 Not at all
2 Less than one cigarette per day
3 One to five cigarettes per day
4 About one-half pack per day
5 About one pack per day
6 About one and one-half packs per day
7 Two packs or more per day
2. How often have you taken smokeless tobacco during the past 30 days?
1 Not at all
2 Once or twice
3 Once to twice per week
4 Three to five times per week
5 About once a day
6 More than once a day
3. To be more precise, during the past 30 days about how many cigarettes have you smoked per day?
1 None
2 Less than 1 per day
3 1 to 2
4 3 to 7
5 8 to 12
6 13 to 17
7 18 to 22
8 23 to 27
9 28 to 32
10 33 to 37
11 38 or more
Alcoholic beverages include beer, wine, wine coolers, and liquor.
On how many occasions during the last 30 days have you had alcoholic beverages to drink (more than just a few sips)?
1 0 occasions
2 1 to 2 occasions
3 3 to 5 occasions
4 6 to 9 occasions
5 10 to 19 occasions
6 20 to 39 occasions
7 40 or more occasions
On how many occasions during the last 30 days (if any) have you been drunk or very high from drinking alcoholic beverages?
1 0 occasions
2 1 to 2 occasions
3 3 to 5 occasions
4 6 to 9 occasions
5 10 to 19 occasions
6 20 to 39 occasions
7 40 or more occasions
On how many occasions during the last 30 days (if any) have you used marijuana (grass, pot) or hashish (hash, hash oil)?
1 0 occasions
2 1 to 2 occasions
3 3 to 5 occasions
4 6 to 9 occasions
5 10 to 19 occasions
6 20 to 39 occasions
7 40 or more occasions
During the LAST MONTH, about how many marijuana cigarettes (joints, reefers), or the equivalent, did you smoke a day, on the average? (If you shared them with other people, count only the amount YOU smoked).
1 None
2 Less than 1 a day
3 1 a day
4 2 to 3 a day
5 4 to 6 a day
6 7 to 10 a day
7 11 or more a day
On how many occasions during the last 30 days (if any) have you sniffed glue, or breathed the contents of aerosol spray cans, or inhaled any other gases or sprays in order to get high?
1 0 occasions
2 1 to 2 occasions
3 3 to 5 occasions
4 6 to 9 occasions
5 10 to 19 occasions
6 20 to 39 occasions
7 40 or more occasions
On how many occasions (if any) during the last 30 days have you taken LSD (‘acid’)?
1 0 occasions
2 1 to 2 occasions
3 3 to 5 occasions
4 6 to 9 occasions
5 10 to 19 occasions
6 20 to 39 occasions
7 40 or more occasions
Amphetamines are sometimes called: uppers, ups, speed, bennies, dexies, pep pills, diet pills, meth or crystal meth. They include the following drugs: Benzedrine, Dexedrine, Methedrine, Ritalin, Preludin, Dexamyl, and Methamphetamine.
On how many occasions (if any) during the last 30 days have you taken amphetamines on your own that is, without a doctor telling you to take them?
1 0 occasions
2 1 to 2 occasions
3 3 to 5 occasions
4 6 to 9 occasions
5 10 to 19 occasions
6 20 to 39 occasions
7 40 or more occasions
On how many occasions (if any) during the last 30 days have you taken ‘crack’ (cocaine in chunk or rock form)?
1 0 occasions
2 1 to 2 occasions
3 3 to 5 occasions
4 6 to 9 occasions
5 10 to 19 occasions
6 20 to 39 occasions
7 40 or more occasions
On how many occasions (if any) during the last 30 days have you taken cocaine in any other form (like cocaine powder)?
1 0 occasions
2 1 to 2 occasions
3 3 to 5 occasions
4 6 to 9 occasions
5 10 to 19 occasions
6 20 to 39 occasions
7 40 or more occasions
Tranquilizers are sometimes prescribed by doctors to calm people down, quiet their nerves, or relax their muscles. Librium, Valium, and Miltown are all tranquilizers. On how many occasions (if any) have you taken tranquilizers on your own that is, without a doctor telling you to take them...during the last 30 days?
1 0 occasions
2 1 to 2 occasions
3 3 to 5 occasions
4 6 to 9 occasions
5 10 to 19 occasions
6 20 to 39 occasions
7 40 or more occasions
Barbiturates are sometimes prescribed by doctors to help people relax or get to sleep. They are sometimes called downs, downers, goofballs, yellows, reds, blues, rainbows. On how many occasions (if any) have you taken barbiturates on your own that is, without a doctor telling you to take them...during the last 30 days?
1 0 occasions
2 1 to 2 occasions
3 3 to 5 occasions
4 6 to 9 occasions
5 10 to 19 occasions
6 20 to 39 occasions
7 40 or more occasions
15. On how many occasions (if any) have you smoked (or inhaled the fumes of) crystal meth (‘ice’)...during the last 30 days?
1 0 occasions
2 1 to 2 occasions
3 3 to 5 occasions
4 6 to 9 occasions
5 10 to 19 occasions
6 20 to 39 occasions
7 40 or more occasions
Amphetamines have been prescribed by doctors to help people lose weight or to give people more energy. They are sometimes called uppers, ups, speed, bennies, dexies, pep pills, and diet pills. Drugstores are not supposed to sell them without a prescription from a doctor. Amphetamines do NOT include any non-prescription drugs, such as over-the-counter diet pills (like Dexatrim) or stay-awake pills (like No-Doz), or any mail-order drugs. On how many occasions (if any) have you taken amphetamines on your own that is, without a doctor telling you to take them...during the last 30 days?
1 0 occasions
2 1 to 2 occasions
3 3 to 5 occasions
4 6 to 9 occasions
5 10 to 19 occasions
6 20 to 39 occasions
7 40 or more occasions
On how many occasions (if any) have you used heroin...during the last 30 days?
1 0 occasions
2 1 to 2 occasions
3 3 to 5 occasions
4 6 to 9 occasions
5 10 to 19 occasions
6 20 to 39 occasions
7 40 or more occasions
There are a number of narcotics other than heroin, such as methadone, opium, morphine, codeine, demerol, paregoric, talwin, and laudanum. They are sometimes prescribed by doctors. On how many occasions (if any) have you taken narcotics other than heroin on your own that is, without a doctor telling you to take them...during the last 30 days?
1 0 occasions
2 1 to 2 occasions
3 3 to 5 occasions
4 6 to 9 occasions
5 10 to 19 occasions
6 20 to 39 occasions
7 40 or more occasions
On how many occasions (if any) have you used MDMA (‘ecstasy’) during the last 30 days?
1 0 occasions
2 1 to 2 occasions
3 3 to 5 occasions
4 6 to 9 occasions
5 10 to 19 occasions
6 20 to 39 occasions
7 40 or more occasions
On how many occasions (if any) have you used Rohypnol (‘rophies,’ ‘roofies’) during the last 30 days?
1 0 occasions
2 1 to 2 occasions
3 3 to 5 occasions
4 6 to 9 occasions
5 10 to 19 occasions
6 20 to 39 occasions
7 40 or more occasions
During the last 30 days, on how many occasions (if any) have you used GHB (‘liquid G,’ ‘grievous bodily harm’)?
1 0 occasions
2 1 to 2 occasions
3 3 to 5 occasions
4 6 to 9 occasions
5 10 to 19 occasions
6 20 to 39 occasions
7 40 or more occasions
During the last 30 days, on how many occasions (if any) have you used Ketamine (‘special K,’ ‘super K’)?
1 0 occasions
2 1 to 2 occasions
3 3 to 5 occasions
4 6 to 9 occasions
5 10 to 19 occasions
6 20 to 39 occasions
7 40 or more occasions
23. On how many occasions (if any) in your lifetime have you had an alcoholic beverage-more than just a few sips?
Never
1 to 2
3 to 5
6 to 9
10 to 19
20 to 39
40 or more
24. How old were you the first time you smoked part or all of a cigarette?
years old If you never smoked part or all of a cigarette please mark the box.
25. Think about the first time you had a drink of an alcoholic beverage. How old were you the first time you had a drink of an alcoholic beverage? Please do not include any time when you only had a sip or two from a drink.
years old If never had a drink of an alcoholic beverage please mark the box.
26. How old were you the first time you used marijuana or hashish?
years old If never used marijuana or hashish please mark the box.
27. How old were you the first time you used any other illegal drugs?
years old If never used any illegal drugs please mark the box.
D. EDUCATION, EMPLOYMENT, AND INCOME
1. What is the highest level of education you have finished, whether or not you received a degree? [01=1st grade, 12=12th grade, 13=college freshman, 16=college completion]
|____|____| level in years
G. ATTITUDES AND BELIEFS
It is clear to my friends that I am committed to living a drug-free life.
False
Maybe
True
I have made a final decision to stay away from marijuana.
False
Maybe
True
I have decided that I will smoke cigarettes.
False
Maybe
True
I plan to get drunk sometime in the next year.
False
Maybe
True
5. How much do you think people risk harming themselves (physically or in other ways) if they smoke one or more packs of cigarettes per day?
No risk
Slight risk
Moderate risk
Great risk
Can’t say/Drug unfamiliar
6. How much do you think people risk harming themselves (physically or in other ways) if they try marijuana once or twice?
No risk
Slight risk
Moderate risk
Great risk
Can’t say/Drug unfamiliar
7. How much do you think people risk harming themselves (physically or in other ways) if they smoke marijuana regularly?
No risk
Slight risk
Moderate risk
Great risk
Can’t say/Drug unfamiliar
8. How much do you think people risk harming themselves (physically or in other ways) if they take one or two drinks nearly every day?
No risk
Slight risk
Moderate risk
Great risk
Can’t say/Drug unfamiliar
9. How much do you think people risk harming themselves (physically or in other ways) if they have five or more drinks once or twice each weekend?
No risk
Slight risk
Moderate risk
Great risk
Can’t say/Drug unfamiliar
10. How wrong do you think it is for someone your age to drink beer, wine or hard liquor (for example, vodka, whiskey or gin) regularly?
Very wrong
Wrong
A little bit wrong
Not wrong at all
How wrong do you think it is for someone your age to smoke cigarettes?
Very wrong
Wrong
A little bit wrong
Not wrong at all
How wrong do you think it is for someone your age to smoke marijuana?
Very wrong
Wrong
A little bit wrong
Not wrong at all
How wrong do you think it is for someone your age to use LSD, cocaine, amphetamines or another illegal drug?
Very wrong
Wrong
A little bit wrong
Not wrong at all
| File Type | application/msword |
| File Title | Form Approved |
| Author | proth |
| Last Modified By | proth |
| File Modified | 2006-11-27 |
| File Created | 2006-07-17 |