GPRA 1. Currently
Employed or Engaged in Productive Activities
|
*Question
D. 1
|
Are you
currently enrolled in school or a job training program?
|
Modified
from
Addiction
Severity Index
|
N
|
Y
|
D.
3
|
Are
you currently employed?
|
Modified
from
Addiction
Severity Index
|
N
|
Y
|
D.
4
|
Approximately,
how much money did YOU receive (pre-tax individual income) in the
past 30 days from...?
|
Modified
from
Addition
Severity Index
|
N
|
Y
|
GPRA 2. Had a Permanent
Place to Live in the Community
|
Question
C.
1
|
In
the past 30 days, where have you been living most of the time?
|
Modified
from the McKinney Demonstration projects
|
N
|
Y
|
GPRA 3. Had No/Reduced
Involvement with the Criminal Justice System
|
Question
E. 1
|
In the
past 30 days, how many times have you been arrested?
|
Addiction
Severity Index
|
N
|
Y
|
E.
2
|
In the
past 30 days, how many times have you been arrested for
drug-related offenses?
|
Addiction
Severity Index
|
N
|
Y
|
E. 3
|
In the
past 30 days, how many nights have you spent in jail/prison?
|
Addiction
Severity Index
|
N
|
Y
|
E. 4
|
In the
past 30 days, how many times have you committed a crime?
|
Modified
from the 1999 Alcohol and Drug Services Study C52
|
N
|
Y
|
E. 5
|
Are you
currently awaiting charges, trial or sentencing?
|
Addiction
Severity Index
|
N
|
Y
|
E. 6
|
Are you
currently on parole or probation?
|
Addiction
Severity Index
|
N
|
Y
|
GPRA 4. Experience
No/Reduced Alcohol or Illegal Drug Related Health, Behavior, or
Social Consequences
|
Question
F. 1
|
How
would you rate your overall health right now?
|
SF-36
|
N
|
Y
|
F. 2.a
|
During
the past 30 days, did you receive Inpatient Treatment for
Physical
complaint
Mental
or emotional difficulties
Alcohol
or substance abuse
|
Health
services
utilization
from
McKinney
funded
Homeless
Projects
|
N
|
Y
|
F.
2.b
|
During
the past 30 days, did you receive Outpatient Treatment for
Physical
complaint
Mental
or emotional difficulties
Alcohol
or substance abuse
|
Health
services
utilization
from
McKinney
funded
Homeless
Projects
|
N
|
Y
|
F.
2.c
|
During
the past 30 days, did you receive Emergency Room Treatment for
Physical
complaint
Mental
or emotional difficulties
Alcohol
or substance abuse
|
Health
services
utilization
from
McKinney
funded
Homeless
Projects
|
N
|
Y
|
F.3
|
During
the past 30 days, did you engage in sexual activity?
|
Modified
Risk Assessment Behavior Battery (RABB)
|
N
|
Y
|
F. 4
|
In
the past 30 days (not due to your use of alcohol or drugs) how
many days have you:
a.
Experienced serious depression
b.
Experienced serous anxiety or tension
c.
Experienced hallucinations
d.
Experienced trouble understanding, concentrating, or remembering
e.
experienced trouble controlling violent behavior
f.
attempted suicide
g. Been
prescribed medication for psychological/emotional problem
|
Modified
from Addiction Severity Index
|
N
|
Y
|
F. 5
|
How
much have you been bothered by these psychological or emotional
problems in the past 30 days? (If you did not report any days to
the items in question 4, skip to the next question.)
|
Modified
from Addiction Severity Index
|
N
|
Y
|
C.
2
|
During
the past 30 days how
stressful
have things been for you because of your use of alcohol or other
drugs?
|
Modified
from Addiction Severity Index
|
N
|
Y
|
C.
3
|
During
the past 30 days has your
use
of alcohol or other drugs
caused
you to reduce or give up
important
activities?
|
Modified
from Addiction Severity Index
|
N
|
Y
|
C.
4
|
During
the past 30 days has your
use
of alcohol or other drugs
caused
you to have emotional
problems?
|
Modified
from Addiction Severity Index
|
N
|
Y
|
C. 5
|
[IF
FEMALE,] Are
you currently pregnant?
|
2004
National Household Survey on Drug Abuse HLTH01
|
N
|
Y
|
C. 6
|
Do
you have children?
a.
How many children do you have?
b.
Are any of your children living
with
someone else due to a child
protection
court order?
c.
How many of your children are
living
with someone else due to a
child
protection court order?
d.
For how many children have you
lost
parental rights?
|
Modified
from the 1999 Alcohol and Drug Services Study A17, A18, B22
|
N
|
Y
|
CSAT
B.
3
|
In
the past 30 days have you injected drugs?
|
Modified
from Addiction Severity Index
|
N
|
Y
|
B. 4
|
In the
past 30 days, how often did you use a syringe, cooker, cotton or
water that someone else used?
|
Modified
RA BB
|
N
|
Y
|
B. 5
|
How old
were you the first
time you smoked
part or all of a cigarette?
|
2002
National
Household
Survey on Drug Abuse CG04
|
Y
Asked
of youth and adults
|
N
|
B.
6
|
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
anytime when you only had a sip or two from a drink.
|
2002
National
Household
Survey on Drug Abuse
AL02
|
Y
Asked
of youth and adults
|
N
|
B. 7
|
How old
were you the first
time you used
marijuana or hashish?
|
2002
National Household Survey on Drug Abuse
MJ02
|
Y
Asked
of youth and adults
|
N
|
B. 8
|
How old
were you when you first used any other illegal drugs?
|
2002
National Household Survey on Drug Abuse- Modified
|
Y
Asked
of youth and adults
|
N
|
GPRA 5. Percent
Increase of Adults And/or Youth 12 to 17 Years Receiving Services
Who Had No past Month Substance Use
|
Question
B.
1
|
During
the past 30 days how many days have you used:
a.
Any alcohol
b1.
Alcohol to intoxication (5+ drinks in one sitting)
b2.
Alcohol to intoxication (4 or fewer drinks in one sitting and
felt high)
c.
Illegal drugs
d. Both
alcohol and drugs (on same day)
|
Modified
from Addiction Severity Index
|
N
|
Y
Y
Y
Y
Y
|
B.
2
|
Route
of Administration
During
the past 30 days, how many days have you used any of the
following:
a.
Cocaine/Crack
b.
Marijuana/hashish
c.
Heroin or other opiates
d.
Non Prescription methadone
e.
PCP or other Hallucinogens/ psychedelics
f.
Methamphetamine or other amphetamines
g.
Benzodiazepines, barbiturates, other tranquilizers,
sedatives, or hypnotics
h.
Inhalants
i.
Other drugs Specify:______________
|
Modified
from Addiction Severity Index
|
N
|
N
|
B. 2
|
During
the past 30 days, how many days have you used any of the
following:
a.
Cocaine/Crack
b.
Marijuana/Hashish [Pot, Joints,
Blunts,
Chronic, Weed, Mary Jane]
c.
Opiates:
c.1.
Heroin [Smack, H, Junk, Skag]
c.2.
Morphine
c.3.
Diluadid
c.4.
Demerol
c.5.
Percocet
c.6.
Darvon
c.7.
Codein
c.8.
Tylenol 2,3,4
c9.
Oxycontin/Oxycodone
d.
Non Prescription methadone
e.
Hallucinogens/psychedelics, PCP
[Angel
Dust, Ozone, Wack, Rocket
Fuel]
MDMA [Ecstasy, XTC, X,
Adam],
LSD [Acid, Boomers,
Yellow
Sunshine], Mushrooms or
Mescaline
f.
Methamphetamine or other
amphetamines
[Meth, Uppers,
Speed,
Ice, Chalk, Crystal, Glass,
Fire,
Crank]
g.
1. Benzodiazepines: Diazepam
(Valium);
Alprazolam (Xanax);
Triazolam
(Halcion); and
Estasolam
(Prosom and
RohypnolBalso
known as roofies,
roche,
and cope)
g.2.
Barbiturates: Mephobarbital
(Mebacut);
and pentobarbital
sodium
(Nembutal)
g.3.
Non-prescription GHB (known as
Grievous
Bodily Harm; Liquid
Ecstasy;
and Georgia Home Boy)
g.4.
Ketamine (known as Special K or
Vitamin
K)
g.5.
Other tranquilizers, downers,
sedatives
or hypnotics
h.
Inhalants (poppers, snappers, rush,
whippets)
i.
Other illegal drugs (specify)
|
Modified
from Addiction Severity Index
|
N
|
Y
|
B. 9
|
What is
your best estimate of the number of days you used chewing tobacco
during the past 30 days?
|
2000
National
Household
Survey on Drug Abuse
CG21DKRE
|
Y
Adult
Only
|
N
|
B. 10
|
What is
your best estimate of the number of days you smoked all or part
of a cigarette during the past 30 days?
|
2000
National
Household
Survey on Drug Abuse
CG07DKRE
|
Y
Adult
Only
|
N
|
B. 11
|
What is
your best estimate of the number of days you drank alcohol during
the past 30 days?
|
2000
National
Household
Survey on Drug Abuse
AL06DKRE
|
Y
Adult
Only
|
N
|
B. 12
|
What is
your best estimate of the number of days you used marijuana or
hashish during the past 30 days?
|
2000
National
Household
Survey on Drug Abuse
MJCC13b
|
Y
Adult
Only
|
N
|
B. 13
|
What is
your best estimate of the number of days you used cocaine during
the past 30 days?
|
2000
National
Household
Survey on Drug Abuse
CC06DKRE
|
Y
Adult
Only
|
N
|
B. 14
|
What is
your best estimate of the number of days you used Acrack@
during the past 30 days?
|
2000
National
Household
Survey on Drug Abuse
CK06DKRE
|
Y
Adult
Only
|
N
|
B. 15
|
What is
your best estimate of the number of days you used any inhalant
for kicks or to get high during the past 30 days?
|
2000
National
Household
Survey on Drug Abuse
IN06DKRE
|
Y
Adult
Only
|
N
|
B. 16
|
What is
your best estimate of the number of days you used heroin during
the past 30 days?
|
2000
National
Household
Survey on Drug Abuse
HE06DKRE
|
Y
Adult
Only
|
N
|
B.17
|
What is
your best estimate of the number of days you used hallucinogens
during the past 30 days?
|
2000
National
Household
Survey on Drug Abuse
LS04DKRE
|
Y
Adult
Only
|
N
|
B. 18
|
How
frequently have you smoked cigarettes during the past 30 days?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 19
|
How
often have you taken smokeless tobacco during the past 30 days?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 20
|
To be
more precise, during the past 30 days about how many cigarettes
have you smoked per day?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 21
|
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)?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 22
|
On how
many occasions during the last 30 days (if any) have you been
drunk or very high from drinking alcoholic beverages?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 23
|
On how
many occasions during the last 30 days (if any) have you used
marijuana (grass, pot) or hashish (hash, hash oil)?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 24
|
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).
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 25
|
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?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 26
|
On how
many occasions (if any) during the last 30 days have you taken
LSD (>acid=)?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 27
|
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?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 28
|
On how
many occasions (if any) during the last 30 days have you taken
>crack=
(cocaine in chunk or rock form)?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 29
|
On how
many occasions (if any) during the last 30 days have you taken
cocaine in any other form (like cocaine powder)?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 30
|
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?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 31
|
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?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 32
|
On how
many occasions (if any) have you smoked (or inhaled the fumes of)
crystal meth (>ice=)...during
the last 30 days?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 33
|
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?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 34
|
On how
many occasions (if any) have you used heroin...during the last 30
days?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 35
|
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?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 36
|
On how
many occasions (if any) have you used MDMA (>ecstasy=)
during the last 30 days?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 37
|
On how
many occasions (if any) have you used Rohypnol (>rophies,=
>roofies=)
during the last 30 days?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 38
|
During
the last 30 days, on how many occasions (if any) have you used
GHB (>liquid
G,=
>grievous
bodily harm=)?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
B. 39
|
During
the last 30 days, on how many occasions (if any) have you used
Ketamine (>special
K=,
>super
K=)?
|
Monitoring
the Future
|
Y
Youth
Only
|
N
|
ATTITUDES
AND BELIEFS (CSAP only)
|
Question
G.
1
|
How
much do people risk harming themselves physically and in other
ways when they smoke one or more packs of cigarettes per day?
|
2002
National Household Survey on Drug Abuse
RK01a
|
Y
Adults
Only
|
N
|
G.
2
|
How
much do people risk harming themselves physically and in other
ways when they smoke marijuana once a month?
|
2002
National Household Survey on Drug Abuse
RK01b
|
Y
Adults
Only
|
N
|
G.
3
|
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?
B. Have
five or more drinks of an alcoholic beverage once or twice a
week?
|
2002
National Household Survey on Drug Abuse
RK01j,
RK01k
|
Y
Adults
Only
|
N
|
G.
4
|
How do
you feel about adults smoking one or more packs of cigarettes per
day?
|
2002
National Household Survey on Drug Abuse
SEN13a
|
Y
Adults
Only
|
N
|
G.
5
|
How do
you feel about adults trying marijuana or hashish once or twice?
|
2002 National Household
Survey on Drug Abuse
SEN13b
|
Y
Adults
Only
|
N
|
G. 6
|
How
do you feel about adults having one or two drinks of an alcoholic
beverage nearly every day?
|
2002
National Household Survey on Drug Abuse
SEN13c
|
Y
Adults
Only
|
N
|
G.
7
|
How do
you feel about adults driving a car after having one or two
drinks of an alcoholic beverage?
|
2002
National
Household Survey on Drug Abuse
SEN13d
|
Y
Adults
Only
|
N
|
G.
8
|
It is
clear to my friends that I am committed to living a drug-free
life.
|
Tanglewood
Research Mediators Survey
|
Y
Youth
only
|
N
|
G.
9
|
I have
made a final decision to stay away from marijuana.
|
Tanglewood
Research Mediators Survey
|
Y
Youth
only
|
N
|
G. 10
|
I have
decided that I will smoke cigarettes.
|
Tanglewood
Research Mediators Survey
|
Y
Youth
only
|
N
|
G. 11
|
I plan
to get drunk sometime in the next year.
|
Tanglewood
Research Mediators Survey
|
Y
Youth
only
|
N
|
G.
12
|
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?
|
Monitoring
the Future Form A 16a
|
Y
Youth
only
|
N
|
G.
13
|
How
much do you think people risk harming themselves (physically or
in other ways) if they try marijuana once or twice?
|
Monitoring
the Future Form A 16c
|
Y
Youth
only
|
N
|
G.
14
|
How
much do you think people risk harming themselves (physically or
in other ways) if they smoke marijuana regularly?
|
Monitoring
the Future Form A 16e
|
Y
Youth
only
|
N
|
G.
15
|
How
much do you think people risk harming themselves (physically or
in other ways) if they take one or two drinks nearly every day?
|
Monitoring
the Future Form A 16k
|
Y
Youth
only
|
N
|
G.
16
|
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?
|
Monitoring
the Future Form A 16l
|
Y
Youth
only
|
N
|
G.
17
|
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?
|
Student
Survey of Risk and Protective Factors and Prevalence of Alcohol,
Tobacco and Other Drug Use
|
Y
Youth
only
|
N
|
G.
18
|
How
wrong do you think it is for someone your age to smoke
cigarettes?
|
Student Survey of Risk and
Protective Factors and Prevalence of Alcohol, Tobacco and Other
Drug Use
|
Y
Youth
only
|
N
|
G.
19
|
How
wrong do you think it is for someone your age to smoke marijuana?
|
Student
Survey of Risk and Protective Factors and Prevalence of Alcohol,
Tobacco and Other Drug Use
|
Y
Youth
only
|
N
|
Social
Connectedness (CSAT only) (GPRA
6. Was Socially Connected)
|
Question
G. 1
|
In the
past 30 days, did you attend any voluntary self-help groups for
recovery that were not affiliated with a religious or faith-based
organization? In other words, did you participate in a
non-professional, peer-operated organization that is devoted to
helping individuals who have addiction related problems such as:
Alcoholics Anonymous, Narcotics Anonymous, Oxford House, Secular
Organization for Sobriety, or Women of Sobriety, etc.
|
Modified
from the 2004 National Survey on Drug Use and Health TX04h
|
N
|
Y
|
G. 2
|
In the
past 30 days, did you attend any religious/faith affiliated
recovery self-help groups?
|
Modified
from the 2004 National Survey on Drug Use and Health TX04h
|
N
|
Y
|
G. 3
|
In the
past 30 days, did you attend meetings of organizations that
support recovery other than the organizations described above?
|
Modified
from the 2004 National Survey on Drug Use and Health TX04i
|
N
|
Y
|
G.
4
|
In the
past 30 days, did you have interaction with family and/or friends
that are supportive of your recovery?
|
|
N
|
Y
|
G.5
|
To whom
do you turn to when you are in trouble?
|
|
N
|
Y
|
RECORD
MANAGEMENT
|
|
Client/Participant
Id
|
|
Y
|
Y
|
|
Client
Type:
treatment/recovery
|
|
N
|
Y
|
|
Contract
Grant ID
|
|
Y
|
Y
|
|
(Asked
only of SBIRT clients) How did the client screen?
|
|
N
|
Y
|
|
(Asked
only of SBIRT clients) What was his/her screening score?
|
|
N
|
Y
|
|
(Asked
only of SBIRT clients) Was he/she willing to continue his/her
participation in the SBIRT program?
|
|
N
|
Y
|
|
Interview
Date
|
|
Y
|
Y
|
|
Interview
Type
|
|
Y
|
Y
|
|
Services (Planned)
Modality
Treatment Services
Case Management
Services
Medical Services
After Care Services
Education Services
Peer-to-Peer Recovery
Support
Services
|
Standard
Item
Modified
from the 1999 Alcohol and Drug Services Study Client Abstract 67,
77
|
N
|
Y
|
A. RECORD MANAGEMENT -
DEMOGRAPHICS
|
Question
A.1
|
What is
your gender?
|
Standard
Item
|
Y
|
Y
|
A. 2
|
Are you
Hispanic or Latino?
|
Office
of Management and Budget
|
Y
|
Y
|
A.
3
|
What is
your race?
|
Office
of Management and Budget
|
Y
|
Y
|
A. 4
|
What is
your date of birth?
|
Standard
Item
|
Y
|
Y
|
D. 2
|
What is
the highest level of education you have finished, whether or not
you received a degree?
|
Modified
from the Addiction Severity Index
|
Y
|
Y
|
D. 2.a
|
Do you
have a GED (General Equivalency Diploma)?
|
Modified
from the Addiction Severity Index
|
Y
Adults
Only
|
Y
|
I.
FOLLOW-UP STATUS
(REPORTED BY PROGRAM
STAFF ABOUT CLIENT ONLY AT FOLLOW-UP)
|
Question
I. 1
|
What is
the follow-up status of the client?
|
|
N
|
Y
|
I. 2
|
Is the
client still receiving services from your program?
|
|
N
|
Y
|
J. DISCHARGE STATUS
(REPORTED BY PROGRAM
STAFF ABOUT CLIENT ONLY AT DISCHARGE)
|
Question
J.1
|
On what
date was the client discharged?
|
Standard
Item
|
N
|
Y
|
J.2
|
What
is the client=s
discharge status?
If
the client was terminated, what was the reason for termination?
|
Standard
Item
|
N
|
Y
|
K. Services (GPRA 7.
Participated in Recovery Support Services)
(REPORTED BY PROGRAM
STAFF ABOUT CLIENT ONLY AT DISCHARGE)
|
|
Identify
the number of DAYS of services provided to the client during the
client=s
course of treatment/recovery.
Modality
|
Standard
Item
Modified
from the 1999 Alcohol and Drug Services Study Client Abstract 67
|
N
|
Y
|
|
Identify
the number of SESSIONS provided tot he client during the client=s
course of treatment/recovery.
Treatment
Services
Case
Management Services
Medical
Services
After
Care Services
Education
Services
Peer-To-Peer
Recovery Support
Services
|
Standard
Item
Modified
from the 1999 Alcohol and Drug Services Study Client Abstract 67,
77
|
N
|
Y
|