Download:
pdf |
pdfIN5.
Interview start time
a.m. | p.m. [CIRCLE ONE]
[LABEL]
Send comments regarding this collection of information to the Office of Management and Budget, Paperwork Reduction Project, Washington, DC 20530.
DEMOGRAPHICS
[IF INTERVIEW COMPLETED, SKIP TO URINE SAMPLE REQUEST]
D1.
How old are you?
________
D2.
a) Are you of Hispanic or Latino/a origin or background? [0= NO, SKIP TO D3; 1= YES]
________
b) Which background describes you best:
IN7.
_______
1= Mexican, Mexican American, Chicano/a;
2= Puerto Rican; or,
3= Cuban?
4= OTHER [SPECIFY]
D3.
_______
1= White;
2= Black or African-American;
3= American Indian or Alaskan Native;
4= Native Hawaiian or Other Pacific Islander; or,
5= Asian? [ASK D3b]
6= OTHER [SPECIFY]
a) Partial interview end time
a) ___________ a.m. | p.m. [CIRCLE ONE]
b) Reason not completed
b) ______________________
1=
2=
3=
4=
5=
6=
7=
8=
9=
10=
__________________________________________________
a) How would you describe your racial background; that is, which group or groups describe you best:
[IF PARTIAL INTERVIEW, RECORD END TIME AND REASON]
________________________________________________________
DID NOT WANT TO
TAKEN TO COURT
RELEASED
TRANSFERRED
MEDICAL UNIT
VIOLENT OR UNCONTROLLED BEHAVIOR
PHYSICALLY ILL
LANGUAGE [SPECIFY]
SHIFT ENDED
OTHER [SPECIFY]
_______________________________
_______________________________
[IF NON-ASIAN, SKIP TO D4]
b) How would you describe yourself:
1= Asian Indian or Pakistani;
2= Chinese;
3= Filipino/a;
4= Japanese;
5= Korean; or,
6= Vietnamese?
7= OTHER [SPECIFY]
Urine Sample Request
_______
•••
As I mentioned at the start of the interview, we are also collecting urine specimens. Again, results are
completely confidential and unavailable to anyone else, so it cannot affect your case. (I am going to ask the
__________________________________________________
officer to take you to a restroom for me. After you’ve finished, I can give you a [incentive] for participating in
the study.) Thank you.
D4.
a) Were you born in the United States or U.S. Territories? [0= NO; 1= YES, SKIP TO D5]
b) In what country were you born? [SPECIFY]
_______
_______________________________
c) Are you now a United States citizen? [0= NO; 1= YES, SKIP TO D5]
_______
d) What is your current status:
_______
1= Permanent resident with green card;
2= Work or other visa;
3= Other legal documents; or,
4= No legal documents?
U1.
Urine specimen status
0= RESPONDENT REFUSED
1= SPECIMEN PROVIDED
2= RESPONDENT ATTEMPTED BUT NO SPECIMEN PROVIDED
3= RESPONDENT NOT AVAILABLE, e.g., TAKEN TO COURT
4= OTHER [SPECIFY]
________________________________________________________
D5.
a) What is the highest educational degree you have:
1= High school or GED;
2= Vocational or trade school;
3= Some college or two-year associate degree,
including nursing and teaching certification; or,
4= Four-year college degree or higher?
5= [NO DEGREE] [ASK D5b]
b)
D6.
}
[IF DEGREE, SKIP TO D6]
What is the last grade or year that you completed in school?
[0= NO SCHOOLING, 1-12= FIRST-TWELFTH GRADES]
What is your current work status:
1=
2=
3=
4=
5=
6=
7=
8=
9=
10=
11=
_____
_____
Working full-time; that is, 35 or more hours per week in one or more jobs, including self-employment;
Working part-time;
Currently on active military status;
Have a job, but out due to illness/leave/furlough/strike;
Have seasonal work, but currently not working;
Unemployed or laid off and looking for work;
Unemployed and not looking for work;
Full-time homemaker;
In school only;
Retired; or,
Disabled for work?
12= OTHER [SPECIFY]
D7.
_____
________________________________________________
a) Are you currently covered by health insurance?
[0= NO, SKIP TO D8; 1= YES]
b) What type:
______
______
1= Individually purchased;
2= Employer or union funded, this includes state employee benefits;
3= State government funded, this includes welfare or Medicaid;
4= Retirement Medicare; or,
5= Disability Medicare?
6= MULTIPLE TYPES [SPECIFY]
D8.
What is your most recent legal marital status:
1=
2=
3=
4=
5=
D9.
_____________________________________________
______
Single, never been married;
Divorced;
Legally separated;
Widowed; or,
Married, this includes common law marriages?
During the past 30 days, where have you lived most of the time:
1=
2=
2=
3=
4=
5=
6=
______
Your own house, mobile home, or apartment;
Someone else’s house mobile home, or apartment;
Residential hotel, rooming house, dormitory, group home, student housing, or military base;
Hospital, treatment facility, or extended care facility;
[SKIP TO
Jail, prison, or correctional boot camp;
CALENDAR;
Shelter; or,
TURN PAGE]
No fixed residence or homeless?
7= OTHER [SPECIFY]
}
__________________________________________________________
H0
O L I D A
I RT H D
T H E R
H3
H2
E S I D E
H7
1 2
H8
H9
H10
M O N T H S
START HERE
Y S
AY S
E V E N T S
H4
H5
H6
N C Y
PA S T
H11
1 2
Are there other dates associated with birthdays, anniversaries, or significant events that we can note on the calendar? You
don’t need to tell me anything that you think is too personal.
When is your birthday?
To begin, let’s note some dates that may help you remember things. For example, there’s New Year’s Day in winter, the
Fourth of July in summer, Thanksgiving in fall, and your birthday.
[SHOW CALENDAR TO RESPONDENT]
Next we’re going to talk about your experiences month-by-month in the past year. To help organize this information, we’re
going to use this calendar, which allows us to record your answers according to when something occurred. We’ll start with
the first month [month 1] and move forward by month through today [date], but please feel free to go back if you recall
something we missed along the way.
ANCHORS:
[TURN PAGE, COMPLETE ALL EVER QUESTIONS]
This is completely confidential so no information will be used to identify you in any way. I will ask you questions about your housing situation and contact with different health care providers—including substance abuse treatment programs—as well as about arrests, times in
jail or prison, and use of alcohol and other drugs. You do not need to tell me anything specific about what happened or why.
H
B
O
H1
R
1
Calendar
COUNT
PRIOR TO
12
MONTHS
d)
q Bought them from the internet
q Bought them from someone else dealing meth
q Bought them from someone else dealing chemicals
q Bought them over the counter from a retail store
q Bought them from a mail order catalog
q Bought them from an employee at a retail store who was seling them on his/her own
q Stole them
q Traded something for them
q Other [SPECIFY] ______________________________________________________________
METH3.
IN6.
Where did you get the [ephedrine/pseudoephedrine/OTC pills] you used to make
meth [got for someone else]?
e)
Was it hard to get the ephedrine/pseudoephedrine? [YES/NO/SOMETIMES]
f)
Where did you cook it?
q Didn’t cook it
q Your own house/apt/mobile home
q Someone else’s house/apt/mobile home
q Hotel/motel
q Vehicle
q Storage unit
q Outdoors
q Other [SPECIFY] ______________________________________________________________
g)
What did you do with the leftover ingredients?
Interview end time
_________________
a.m. | p.m.
________
q Other [SPECIFY] ______________________________________________________________
q Left it in containers
q Dumped it in the ground or in a stream/river
q Buried it
q Poured it down the drain
[If Yes to METH 2a]:How did you learn to cook meth?
q Friend
q Parent
q Family member (other then parent)
q Cell mate
q Dealer
q Another user
q From the internet
q Book or other printed recipe
q Other [SPECIFY] ______________________________________________________________
[CIRCLE ONE]
Methamphetamine
METH1.
0=NO
1=YES
You said you’ve used meth in the past 30 days.
The last time you used meth, was it meth you made yourself?
________
Y/N [If Yes, skip to METH2b]
Have you ever made/ manufactured methamphetamine? By manufacture,
we mean cooked methamphetamine out of raw materials or chemicals.
________
b) [If Yes] Have you made methamphetamine in the past 30 days?
________
c) [If No] In the past 30 days, have you gotten chemicals or ingredients
for someone else to make meth with?
________
d) [IF YES TO 2B OR 2C] The last time you [made meth] [or got chemicals],
what chemicals did you use [get]?
[CHECK ALL THAT APPLY]
q Ephedrine
q
q
q
q
q
q
q
q
q
q
q
Pseudoephedrine
Freon
Red phosphorous
Tablets [over the counter] [SPECIFY TYPE] __________________________
Caffeine
Vitaflex
Lactose
MSM
Iodine
Hydrochloric gas/acid
Other [SPECIFY] ___________________________________________
NEX T
Don’t Know
[RECORD HOUSING SITUATION; CODE 1-7 FOR MONTHS 2-11]
A different country [SPECIFY] ___________________________________
Did your housing situation change between [month 1] and [1st anchor]?
This country
H2-H11.
The state you live in
Your own house, mobile home, or apartment;
Someone else’s house, mobile home, or apartment;
Residential hotel, rooming house, dormitory, group home, student housing, or military base;
Hospital, treatment facility, or extended care facility;
Jail, prison, or correctional boot camp;
Shelter; or,
No fixed residence or homeless?
OTHER
METH2.
The county you live in
1=
2=
3=
4=
5=
6=
7=
8=
q
q
q
q
q
Starting in [month 1], where did you live most of the time:
[CHECK ALL THAT APPLY]
q The city/town you live in
H1.
c) Was the meth made in…
In the past 12 months, how many places did you live in?
________
H0.
b) [If yes] Was it the person who sold it to you?
OK, let’s start with where you have lived. We’ll use the calendar to record where you lived each month over the last 12 months.
a) [IF NO] Do you personally know the person who made/cooked your meth? ________
CUT 2”
cut
2.75”
T5
T19
T18
T1.
T7
T21
T6
T20
T22
T8
T23
T9
Did you ever stay at least
overnight in an inpatient
or residential drug or
alcohol treatment
program, for example,
detox, rehab, a therapeutic
community, or a hospital?
T38
T24
T10
T12
T26
T40
T11
T25
T39
T41
T27
T13
T42
T28
T14
T16
T30
T44
T15
T29
T43
T17.
◆ Please tell me your best estimate of the number of nights you spent in inpatient programs
altogether prior to [month 1]. [RECORD NUMBER OF NIGHTS]
Before [month 1], did you stay at least overnight in an inpatient drug or alcohol treatment program,
for example, detox, rehab, a therapeutic community, or a hospital?
[IF NO, CODE 0 AND SKIP TO T18]
T16. How many different times were you admitted into an inpatient drug or alcohol treatment
program over the past twelve months?
[RECORD NUMBER OF ADMISSIONS]
◆ When? [FOR EACH MONTH INPATIENT]
◆ How many nights did you stay overnight?
[RECORD 0=NONE, 1-30=NIGHTS]
[IF NO HEALTHCARE/TREATMENT (T1-T3), FLIP PAGE]
Using the calendar, now let’s look at your health care and treatment experiences, month-by-month over the last twelve
months.
T4-T15. [IF EVER INPATIENT] Between [month 1] and today, did you stay at least overnight in an
inpatient or residential drug or alcohol treatment program, for example, detox, rehab, a
[IF NO, CODE 0 IN EACH CELL AND SKIP TO T17]
therapeutic community, or a hospital?
O U T PAT I E N T
T32
T34
T35
T36
T37
T33
M E N TA L H E A LT H
I N PAT I E N T
T4
EVER [0=NO, 1=YES]
T3
T2
T1
T45
T31
T17
•••NONCASH•••
MU26.
MU27.
How much of the [drug]
you [got /made/harvested]
was for you to use
yourself?
MA26
CC26
PC26
HE26
ME26
%
MU28.
On that same day, how
many times did you
get [drug] in any way
without paying cash
for it?
MA27
CC27
PC27
HE27
ME27
MU29.
Thinking about this last
week, on how many of the
past 7 days did you get
[drug] without
paying any cash?
MA28
%
CC28
%
%
PC28
HE28
%
ME28
/7
On how many of the past
30 days did you get [drug]
without paying any cash?
CUT 2”
MA29
/7
/30
CC29
/7
/30
PC29
/7
/30
HE29
/7
/30
ME29
/30
MULTIPLE
IF NO
SKIP TO
USE
IF NO
SKIP TO
USE
IF NO
SKIP TO
USE
IF NO
SKIP TO
USE
IF YES
MULTIPLE
SPECIFY
CC23
IF YES
MULTIPLE
SPECIFY
PC23
IF YES
MULTIPLE
SPECIFY
HE23
IF YES
MULTIPLE
SPECIFY
ME23
SPECIFY
1= Page the person on
a beeper;
2= Call the person on a
telephone and speak with
the person directly;
3= Go to a house or
apartment;
4= Approach the person in
public such as on the
street, in a store, or park; or,
5= Were you with the person
already at work or in a
social setting?
6= OTHER [SPECIFY]
MA24
CC24
PC24
HE24
ME24
SPECIFY
CODES:
1= BAG OR BALLOON
2= CAPSULE
3= FOIL PACKET
4= GRAM
5= JOINT
6= LINE
7= OUNCE
8= POUND
9= ROCK
10= VIAL
11= OTHER [SPECIFY]
MA25a
SPECIFY
CC25a
SPECIFY
PC25a
SPECIFY
HE25a
SPECIFY
ME25a
MA25b
OTHER
SPECIFY
SPECIFY
CC25b
OTHER
SPECIFY
SPECIFY
PC25b
OTHER
SPECIFY
SPECIFY
HE25b
OTHER
SPECIFY
SPECIFY
ME25b
OTHER
SPECIFY
SPECIFY
NEX T
IF YES
a) # OF UNITS
b) TYPE OF UNITS
Have you ever stayed at
least overnight for
mental health treatment
–not for drug or alcohol
use– at a psychiatric unit
of a hospital or other
facility?
MA23
The last time you got [drug]
without cash, how did you contact the person who gave it to
you? Did you:
T3.
Think about the last time you got
[drug] without paying any cash for
it. Did you:
1= [IF MARIJUANA] harvest
Marijuana you grew yourself;
[IF CRACK] make it yourself;
[IF CRYSTAL METH] make it
yourself;
2= Get it on credit and will pay
cash later;
3= Get it fronted to sell;
4= Trade other drugs;
5= Trade property/merchandise;
6= Transport drugs;
7= Steal the drug;
8= Trade sex;
9= Receive it as a gift; or,
10= Trade Chemicals?
11= OTHER [SPECIFY]
12= MULTIPLE [SPECIFY]
[IF 1, SKIP TO MU25]
Have you ever been
admitted to an outpatient
drug or alcohol treatment
program, not including
meetings like AA or NA?
By “outpatient program”
I mean a drug or alcohol
treatment program where
you do not stay overnight.
IF NO
SKIP TO
USE
◆ Please tell me your best estimate of the number of times you were admitted to an outpatient
drug or alcohol treatment program before [month 1].
[RECORD NUMBER OF ADMISSIONS]
Before [month 1], were you in any outpatient drug or alcohol treatment programs, not
including meetings like AA or NA?
[IF NO, CODE 0 AND SKIP TO T32]
T45.
CUT .5”
◆ Please tell me your best estimate of the number of nights you spent in a psychiatric unit of a
hospital or other facility– not for drug or alcohol use– altogether before [month 1].
[RECORD NUMBER OF NIGHTS]
Before [month 1], were you admitted for mental health treatment–not for drug or alcohol
use–to a psychiatric unit of a hospital or other facility?
[IF NO, CODE 0 AND SKIP TO NEXT PAGE]
T44. How many different times were you admitted for mental health treatment–not for drug or
alcohol use–over the past twelve months?
[RECORD NUMBER OF ADMISSIONS]
◆ When? [FOR EACH MONTH IN PSYCH UNIT]
◆ How many nights did you stay overnight?
[RECORD 0=NONE, 1-30=NIGHTS]
T32-T43. [IF EVER MENTAL HEALTH] Between [month 1] and today, were you in mental health
treatment–not for drug or alcohol use– in a psychiatric unit of a hospital or other facility for
at least one overnight stay?
[IF NO, CODE 0 IN EACH CELL AND SKIP TO T45]
T31.
T30. How many different times were you admitted into an outpatient drug or alcohol treatment
program over the past twelve months?
[RECORD NUMBER OF ADMISSIONS]
◆ When? [CODE 0=NO, 1=IN PROGRAM FOR EACH MONTH]
MU24.
T18-T29. [IF EVER OUTPATIENT] Between [month 1] and today, were you in any outpatient drug or
alcohol treatment programs? By outpatient, I mean a drug or alcohol treatment program where you
do not stay overnight. Do not include AA or NA.
[IF NO, CODE 0 IN EACH CELL AND SKIP TO T31]
MU23.
T2.
cut 1.75
These next
questions
deal with the
last time you
got [drug]
without
paying any
cash in the
last 30 days.
•••NONCASH•••
MU25.
How much [drug] did you [get/
make/harvest] that last time?
◆ Please tell me your best estimate of the total number of times in your life you were arrested
prior to [month 1], not including juvenile arrests.
[RECORD NUMBER OF ARRESTS]
Before [month 1], were you arrested at any time, not including juvenile arrests?
[IF NO, CODE 0 AND SKIP TO C16]
◆ When? [FOR EACH MONTH ARRESTED]
◆ Please tell me your best estimate of the number of times you were arrested that month.
[RECORD 0=NONE, OR NUMBER OF ARRESTS]
On how
many of
the past
30 days
did you
buy [drug]?
MU18.
In the past
30 days,
how many
different
people did
you buy
[drug]
from?
MU19.
Was there a time
in the past 30
days when you
tried to buy [drug]
and had the cash,
but you did not
buy any?
0= NO
1= YES
[IF 0=NO, SKIP
TO NON-CASH,
TURN PAGE]
MU20.
MU21.
The last time that
happened, why
didn’t you buy
[drug]:
1= No dealers
were
available;
2= Dealers did
not have any;
3= Dealers did
not have the
quality you
wanted; or,
4= Police activity
kept you from
the dealers?
5= OTHER
[SPECIFY]
Did you buy
another drug or
alcohol instead?
MU22.
What did you buy instead?
0= NO
1= YES
cut 1.75
[IF 0=NO, SKIP
TO NON-CASH,
TURN PAGE]
1= ALCOHOL
2= MARIJUANA OR
HASHISH
3= CRACK OR ROCK
COCAINE
4= POWDER COCAINE
5= HEROIN
6= METHAMPHETAMINE
7= OTHER [SPECIFY]
8= MULTIPLE [SPECIFY]
MA22
MA20
MA17
MA18
MA21
MA19
/30
SPECIFY
OTHER
SPECIFY
MULTIPLE
CC18
CC17
CC21
CC19
/30
SPECIFY
OTHER
SPECIFY
MULTIPLE
PC18
PC21
PC19
/30
SPECIFY
SPECIFY
C15.
MULTIPLE
HE18
SPECIFY
OTHER
SPECIFY
MULTIPLE
juvenile arrests.
one? Please do not include
holding facility like this
warrant and booked at a
offense or picked up on a
is, charged on a criminal
HE21
HE19
/30
ME18
SPECIFY
ME22
ME20
ME17
SPECIFY
HE22
HE20
HE17
SPECIFY
PC22
PC20
PC17
SPECIFY
CC22
CC20
OTHER
ever been arrested—that
[IF NO ARRESTS/JAIL (C1-C2), FLIP PAGE]
Now let’s talk about your experiences with the criminal justice system before this arrest.
[IF EVER ARRESTED] Between [month 1] and this arrest, were you arrested and booked? Please
C3-C14.
do not include juvenile arrests.
[IF NO, CODE 0 AND SKIP TO C15]
C1. Before this arrest, have you
C2
MU17.
EVER [0=NO, 1=YES]
C28
C27
C25
C21
C22
C23
C24
C26
C15
C12
C11
C10
C9
C8
C4
C5
C6
C7
A R R E S T
C16
J A IC17L / PC18 R I C19S O C20
N
C3
C1
C1
FOLD OUT
CUT .5”
C13
C14
•••CASH•••
ME21
ME19
/30
OTHER
SPECIFY
MULTIPLE
SPECIFY
SPECIFY
How much [drug] did you
get for that amount of
cash?
MA12
MA13a
CC13a
CC12
PC12
PC13a
HE13a
HE12
ME13a
ME12
$
SPECIFY
How much of the
[drug] you bought
was for you to use
yourself?
a) # OF UNITS
b) TYPE OF UNITS
$
MA14
$
CC14
PC14
$
$
HE14
ME14
%
MU16.
How many times
did you buy [drug]
on that same day?
Thinking about
this last week,
on how many of
the past
7 days did you
buy [drug]?
CODES:
1= BAG OR
BALLOON
2= CAPSULE
3= FOIL PACKET
4= GRAM
5= JOINT
6= LINE
7= OUNCE
8= POUND
9= ROCK
10= VIAL
11= OTHER [SPECIFY]
MA13b
%
MA15
CC15
PC15
HE15
ME15
MA16
/7
SPECIFY
CC13b
CC16
%
/7
SPECIFY
PC13b
PC16
%
/7
SPECIFY
HE13b
%
HE16
/7
SPECIFY
ME13b
ME16
/7
◆ Please tell me your best estimate of the total number of days in your life you were in jail or
correctional facilities before [month 1]. [RECORD NUMBER OF DAYS]
Before [month 1], were you held in jail, or did you serve time in a jail, prison, juvenile
[IF NO, CODE 0 AND SKIP TO NEXT PAGE]
detention facility, or boot camp?
◆ When? [FOR EACH MONTH INCARCERATED]
◆ Please tell me your best estimate of the number of days you were in jail, prison, juvenile
detention facility or boot camp that month.
[RECORD 0=NONE, 1-30=DAYS]
[IF EVER JAIL/PRISON] Between [month 1] and today, were you held in jail for at least 24
hours, or did you serve time in a jail, prison, juvenile detention facility, or boot camp?
[IF NO, CODE 0 IN EACH CELL AND SKIP TO C28]
MU15.
NEXT
CUT
2.25”
MU14.
C28.
How much cash
did you pay for
[drug] that last
time you bought
it?
MU13.
C2. Were you ever held in jail
for at least 24 hours, or
did you serve time in a
jail, prison, juvenile
detention facility, or boot
camp?
MU12.
C16-C27.
•••CASH•••
CUT 5.375”
•••CASH•••
MU8.
S43
S54
S65
S76
S87
S98
S42
S53
S64
S75
S86
S97
A L C O H O L
S34
S35
S33
S36
S37
S38
S39
S40
S41
M A R I J UA N A
S45
S44
S46
S47
S48
S49
S50
S51
S52
C R A C K O R R O C K C O C A I N E
S56
S55
S57
S58
S59
S60
S61
S62
S63
P O W D E R C O C A I N E
S67
S66
S68
S69
S70
S71
S72
S73
S74
H E R O I N
S78
S77
S79
S80
S81
S82
S83
S84
S85
M E T H A M P H E TA M I N E
S89
S88
S90
S91
S92
S93
S94
S95
S96
O T H E R D R U G
S32
S30
1= Your regular source;
2= An occasional
source; or,
3= A new source for
[drug]?
MU10.
MU11.
The last time you bought [drug],
how did you contact the person you
bought from? Did you first:
That last time you bought
[drug], at what type of
place did you get it:
Did you buy it:
1= Page the person on a
beeper;
2= Call the person on a telephone
and speak with the person
directly;
3= Go to a house or
apartment;
4= Approach the person
in public such as on
the street, in a store, or
park; or,
5= Were you with the
person already at work
or in a social setting?
6= OTHER [SPECIFY]
S29
MA9
1= In a house or
apartment;
2= In a public building
such as a store, bus
station, gas station,
or restaurant;
3= In an abandoned
building;
4= On a street, alley, or
road; or,
5= Other outdoor area
such as a park, lot,
etc.?
6= OTHER [SPECIFY]
1= In the
neighborhood
where you live;
or,
2= Outside your
neighborhood?
S28
MA11
SPECIFY
CC9
S27
CUT
2.25”
MA10
MA8
SPECIFY
CC10
CC8
CC11
S26
SPECIFY
PC9
SPECIFY
PC10
PC11
S25
PC8
S24
SPECIFY
HE9
SPECIFY
HE10
HE8
S23
HE11
SPECIFY
ME9
S4
SPECIFY
ME10
ME8
S20a
12
mo
12
mo
12
mo
12
mo
12
mo
EA
S5
S6
EA
S8
S7
S9
EA
S10 S11 S12
EA
S13 S14 S15
EA
S16 S17 S18
EA
S19 S20b S21
EA
12
mo
S22
12
mo
S3
S2
S1
cut
5.375”
or 1/8”
from top
of table
S31
Is the person you bought it
from:
MU9.
ME11
SPECIFY
SPECIFY
Noncash
PC3
Cash
HE2
OBTAINED
HE3
Cash
ME2
OBTAINED
ME3
IF YES
IF YES
IF YES
ASK
NONCASH
OTHER
POWDER COCAINE
IF YES
ASK
NONCASH
HEROIN
IF YES
ASK
NONCASH
METHAMPHETAMINE LIKE CRYSTAL METH
SPECIFY
MULTIPLE
OTHER
MULTIPLE
OTHER
MULTIPLE
OTHER
MULTIPLE
SPECIFY
PC5
PC4
SPECIFY
SPECIFY
HE5
HE4
SPECIFY
SPECIFY
ME5
ME4
SPECIFY
SPECIFY
CC7
PC6
PC7
HE6
HE7
ME6
ME7
[ IF NO, SKIP ]
Used Heroin?
Used Powder Cocaine?
Used Crack or Rock
Cocaine?
How old were
you the first time
you used that
drug?
S20b.
Which drug did you use
most often?
[RECORD DRUG]
S20a.
Used Crystal Meth?
S17.
S14.
S11.
S8.
Used Marijuana or
Hashish?
Use Crack or Rock
Cocaine?
Use Heroin?
DRUG GATEWAY
GO TO
Did you use [drug] in the
past 12 months— that is,
between [month 1] and
today?
S21.
Use Crystal Meth?
S18.
S15.
Use Powder Cocaine?
S12.
S9.
Use Marijuana or
Hashish?
[IF OTHER DRUG (S21) ONLY]
MONTH DRUG USE]
[IF NO TWELVE
DRUG GATEWAY
[IF C1=NO; TURN PAGE]
[IF EVER ARRESTED
(C1=YES)], TURN PAGE,
GO TO C0
_______________________________
Smoke it;
Sniff it through your nose or snort it;
Inject it by needle; or,
Eat it or swallow it?
5= OTHER [SPECIFY]
1=
2=
3=
4=
Did you:
Think about the last time you used [drug]. How did you use it?
[IF ANY 12 MONTH
DRUG USE
(S6 – S21),
GO TO ANCHORS
(TOP OF
CALENDAR)]
MU34.
• Other Drug
How about between [month 1] and [1st anchor]?
On how many of the past 30 days did you use [drug]?
During the past 7 days, on how many days did you use [drug]?
During the past 3 days, on how many days did you use [drug]?
[FOR EACH DRUG USED PAST 12 MONTHS (S6 – S18)]
• Marijuana or Hashish
• Crack or Rock Cocaine
• Powder Cocaine
• Heroin
• Methamphetamine like Crystal Meth
S33-S98. Please tell me your best estimate of the level that
represents the number of days you used [drug] in [month 1].
•••CASH•••
ever used any other drug,
not counting drugs for
which you have a
prescription or over the
counter drugs?
IF Not including alcohol and
NO these five drugs, have you
IF YES
Used any
Methamphetamine like
Crystal Meth?
IF YES
Used any Heroin?
IF YES
Used any Powder
Cocaine?
IF YES
Used any Crack or Rock
Cocaine?
IF YES
Used any Marijuana or
Hashish?
How about between [month 1] and [1st anchor]?
[RECORD LEVELS 0-3 FOR ALL MONTHS]
S22-S32. Please tell me your best estimate of the level that represents the
number of days you had five or more drinks–including wine,
beer, or any type of alcohol on the same day in [month 1].
Now let’s talk about your use of alcohol or other drugs. You can use this
showcard, which shows the different levels for your answers.
[REVIEW LEVELS WITH RESPONDENT]
[IF NO PAST 12 MONTHS ALCOHOL (S3), SKIP TO S33-S98]
CC6
S19.
OBTAINED
IF YES
CC4
IF
NO
Cash
PC2
CC5
S16.
Noncash
CC3
IF YES
ASK
NONCASH
SPECIFY
IF
NO
OBTAINED
IF YES
MULTIPLE
S13.
❂ CRACK OR ROCK COCAINE
SPECIFY
IF
NO
Noncash
CC2
OTHER
MA7
S10.
Cash
IF YES
ASK
NONCASH
MA6
IF
NO
Noncash
MA3
MA4
S7.
Noncash
IF YES
IF
NO
OBTAINED
MA5
S6.
❂ MARIJUANA OR HASHISH
TURN PAGE]
[IF MU7=2,
SKIP TO
MU12,
S5.
include making it yourself.
1=CASH
2=COMBINATION
[IF MU4=1,
SKIP TO MU6]
IF YES
could include making it yourself.
S4.
❂ [IF CRYSTAL METH] This could
Have 5 or more drinks on
the same day?
Marijuana you grew yourself.
Had at least 5 or more
drinks on the same day?
❂ [IF CRACK OR ROCK COCAINE] This
2= Someone
not
working
with a
dealer?
Had 5 or more drinks of
beer, wine, or any other
type of alcohol on the
same day?
❂ [IF MARIJUANA] This could include
Did you pay cash
only, or did you pay
cash and something
else?
MU7.
IF
NO
Cash
MA2
MU4.
1= Someone
working
with
a dealer; or,
S3.
In the past 30 days, did you get any
[drug] without paying cash for it?
1= Get it on credit and
will pay cash later
2= Get it fronted
to sell
3= Trade other drugs; 1= Buy it directly
yourself; or,
4= Trade property/
merchandise;
2= Give someone the
5= Transport drugs;
cash to buy it for
6= Steal the drug;
you?
7= Trade sex; or,
8= Trade Chemicals?
9= OTHER [SPECIFY]
[IF MU6=1,
SKIP TO MU8]
10=MULTIPLE [SPECIFY]
Is the person
you gave
the cash to:
S2.
MU3.
That last time you
What else, besides
cash, was exchanged or bought [drug], did
traded the last time you you:
bought [drug]?
Did you also:
IF YES
In the past 30 days, did you pay any
cash for [drug]?
MU6.
S1.
❂
[0=NO, 1=YES]
Think about the last time you
paid any cash for [drug]. This
could include any you were
fronted to sell or received on
credit, and paid for at a later
time.
MU5.
HAVE YOU EVER...
MU2.
The next several questions
deal with drugs that you paid
cash for in the last 30 days.
IN THE PAST 12 MONTHS
HOW OLD WERE YOU (THAT IS, BETWEEN [MONTH
THE FIRST TIME YOU... 1] AND TODAY) DID YOU…
ASK BOTH MU2 AND MU3 FOR
EACH DRUG OBTAINED BEFORE
ASKING MU4
Dependence and Abuse
ASK ONLY IF NO 12-MONTH DRUG USE
DRUGS
ALCOHOL
DA0a.
DA0b.
DA1a.
DA1b.
[REFER TO CALENDAR AOD 12 MONTH USE (S3-S21)]
You said you were arrested before this arrest. Please give me your best estimate of the number of
times you were arrested in the past 12 months; that is, between [month 1] and this arrest.
Do not include juvenile arrests. [RECORD NUMBER OF ARRESTS, TURN PAGE]
C0.
MU35a.
In the past 30 days, did you have five or more drinks of beer, wine, or any other type of alcohol on the same day?
MU35a.
Please tell me your best estimate of the number of days you had five or more drinks on the
same day in the past 30 days. [RECORD NUMBER OF DAYS (1-30)]
Secondary Drug Use
[IF NO 12 MONTH ALCOHOL OR DRUG USE, SKIP TO MARKET AND USE]
________
________
________
0=NO
1=YES, PRESCRIBED
2=YES, NOT PRESCRIBED
Now I would like to ask you about experiences related to alcohol or
drug use that you may have had in the past 12 months. [0= NO, 1= YES]
DA1.
In the past 12 months, have you spent more time:
DA2.
Have you neglected some of your usual responsibilities: a) because of using alcohol?
b) because of using drugs?
DA2a.
DA2b.
DA3.
Have you wanted to cut down:
a) on your drinking?
b) on your drug use?
DA3a.
DA3b.
DA4.
In the past 12 months, has anyone objected to:
a) your use of alcohol?
b) your drug use?
DA4a.
DA4b.
DA5.
Have you frequently found yourself thinking about:
a) drinking?
b) using drugs?
DA5a.
DA5b.
DA6.
Have you:
a) used alcohol to relieve feelings
such as sadness, anger, or boredom?
b) used drugs to relieve feelings
such as sadness, anger, or boredom?
DA6a.
DA6b.
Finally, I’d like to ask you about your use of other drugs, including prescription drugs. As I read down the list, please tell me if
you used any of these drugs in the past 3 days.
MU36.
a) drinking than you intended?
b) using drugs than you intended?
In the past 3 days, did you use any:
[IF NO ALCOHOL USE (DA0a=0), SKIP TO DA7b]
[IF NO TO ALL ALCOHOL DA1a -DA6a, SKIP TO DA7b]
DRUG:
a)
Methadone;
__________
b)
Amphetamines like Benzedrine, Dexedrine, or Ritalin, sometimes called “bennies” or “dex,” not
including methamphetamine;
__________
c)
Barbiturates like Seconal, sometimes called “blues” or “reds”;
__________
d)
Tranquilizers or sedatives like Xanax, Valium, Rohypnol, sometimes called “tranqs” or “roofies”;
__________
e)
Any of the following painkillers: Codeine, Dilaudid, Vicodin, OxyContin, or Percocet;
__________
f)
Darvon;
__________
g)
Demerol, Fentanyl;
__________
h)
Ecstasy, MDMA;
__________
i)
PCP, Angel Dust;
__________
j)
LSD, Acid;
__________
k)
Any other hallucinogen like mescaline or magic mushrooms;
__________
l)
Inhalants like glue, paint, aerosols, “poppers”;
__________
Did you get any Marijuana or Hashish? This could include harvesting Marijuana you grew yourself.
m)
Anti-depressants like Zoloft, Prozac, or Paxil; or,
__________
Did you get or make any Crack or Rock Cocaine?
n)
Any other drugs?
__________
Did you get any Powder Cocaine?
OTHER [SPECIFY]
_____________________________________________________________________
C0.
DA7a. You said that, in the past 12 months, you
[READ ALL ALCOHOL ITEMS CODED YES].
DA7b. You said that, in the past 12 months, you
[READ ALL ALCOHOL ITEMS CODED YES].
When was the last time any of these things happened:
1=Within the past 7 days;
2=Within the past 8 to 30 days;
3=Within the last six months but more than one month ago; or,
4=More than six months ago but within the last 12 months?
When was the last time any of these things happened:
1=Within the past 7 days;
2=Within the past 8 to 30 days;
3=Within the last six months but more than one month ago; or,
4=More than six months ago but within the last 12 months?
DA7b.
DA7a.
Market and Use
MU1.
[FOR EACH DRUG, TURN PAGE AND RECORD:
1=YES FOR DRUGS OBTAINED AND 0=NO FOR NO DRUGS OBTAINED]
In the past 30 days, regardless of whether or not you used it yourself: [0= NO, 1= YES]
Did you get any Heroin?
Did you get or make any Methamphetamine like Crystal Meth?
[IF ALL
0= NO,
SKIP TO
PRIMARY
DRUG USE
(MU 30)]
| File Type | application/pdf |
| File Title | ADAMeng.qxd |
| File Modified | 2007-01-05 |
| File Created | 2006-12-06 |