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pdfNSYC-Alternative Questionnaire
Section A.
Background
A1
These next questions are about why you are here. When were you most recently admitted
here? Enter the month and year. (ENTER FOUR NUMBERS FOR THE YEAR, SUCH
AS 2002 OR 2003)
Date: _______________
DK/REF
A2
When were you first taken into custody for what led to your stay here? Enter the month
and year. (ENTER FOUR NUMBERS FOR THE YEAR, SUCH AS 2002 OR 2003)
Date: _______________
DK/REF
[IF A1=BLANK OR DK/REF, CONTINUE; OTHERWISE GO TO A4]
A3
How long have you been here?
Less than 1 month ....................................... 1
At least 1 month but less
than 6 months ................................ 2
At least 6 months but less
than 1 year..................................... 3
1 year or more............................................. 4
DK/REF
A4
Before this time, had you ever been admitted to this place before?
Yes ............................................................. 1
No............................................................... 2
DK/REF
A5
(GO TO A6)
Were you released from this place within the past 12 months?
Yes ............................................................. 1
No............................................................... 2
DK/REF
A6
DEFINE ADMIT: ADMIT DATE= DATE OF ADMISSION FOR THIS YOUTH
PROVIDED BY FACILITY
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A7
DEFINE DOAFILL1:
IF ADMIT 12 months, THEN DOAFILL1 = ‘During the past 12 months,’
IF ADMIT 12 months, OR AN ADMIT DATE WAS NOT PROVIDED BY
FACILITY FOR THIS YOUTH, THEN DOAFILL1 = ‘Since you got here,’
A8
Are you here because you were told you violated the terms of your probation or parole?
Yes ............................................................. 1
No............................................................... 2
You have never been on probation
or parole ................................... 3
DK/REF
A9
(GO TO A12)
(GO TO A12)
(GO TO A12)
Have you been convicted of anything as a result of violating your probation or parole?
To be convicted means a judge found you guilty or you pled guilty.
Yes ............................................................. 1
No............................................................... 2
DK/REF
(GO TO A16)
(GO TO A12)
(GO TO A12)
[A10 & A11 HAVE BEEN DELETED]
A12
Are you here because you have been convicted of a crime? To be convicted means a
judge found you guilty or you pled guilty to a crime.
Yes ............................................................. 1
No............................................................... 2
DK/REF
A13
(GO TO A16)
Are you here because you were accused of doing something against the law?
Yes ............................................................. 1
No............................................................... 2
DK/REF
(GO TO A16)
(GO TO A16)
(GO TO A16)
[A14 & A15 HAVE BEEN DELETED]
A16
Before you came here, had the police or the court ever sent you to a place where you had
to stay for at least one night?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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(GO TO A18)
(GO TO A18)
A17
Before you came here, how much time had you been in places like that?
Less than 6 months...................................... 1
At least 6 months but less than 1 year .......... 2
1 year or more............................................. 3
DK/REF
A18
These next few questions are about other parts of your life. As of today, what is the
highest grade in school that you attended?
I never attended school ................................ 1
Preschool or Kindergarten ........................... 2
1st grade ...................................................... 3
2nd grade ..................................................... 4
3rd grade...................................................... 5
4th grade ...................................................... 6
5th grade ...................................................... 7
6th grade ...................................................... 8
7th grade ...................................................... 9
8th grade ...................................................... 10
9th grade ...................................................... 11
10th grade .................................................... 12
11th grade .................................................... 13
12th grade .................................................... 14
Some college, but did not receive a degree... 15
Associate’s degree....................................... 16
Bachelor’s degree........................................ 17
Higher than a bachelor’s degree................... 18
DK/REF
(GO TO A23)
(GO TO A21)
(GO TO A24)
A19 FILL INSTRUCTIONS:
IF A18=ANY 2-14, FILL FOR A19 = ‘grade’
IF A18=ANY 16-18, FILL FOR A19 = ‘degree’
A19
Did you complete that (grade/degree)?
Yes ............................................................. 1
No............................................................... 2
DK/REF
A20
ROUTING INSTRUCTIONS:
IF A18 = 16 OR 17 OR 18, AND A19 = 1/YES OR 2/NO, GO TO A21.
IF A18 = 14 AND A19 = 1/YES, GO TO A21
IF A18 = 14 AND A19 = 2/NO, GO TO A23.
IF A18 = 1, GO TO A23
IF A18 = 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13, AND A19 =
1/YES OR 2/NO OR DK OR REF, GO TO A23.
[RESPONDENT CAN CLICK ON “GED” THROUGHOUT SURVEY AND RECEIVE THE
DEFINITION OF “General Equivalency Diploma.”]
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A21
Which did you get for finishing high school, a high school diploma or a GED?
High school diploma ................................... 1
GED ........................................................... 2
DK/REF
(GO TO A24)
(GO TO A24)
(GO TO A24)
[A22 DELETED]
[ASK A23 IF YOUTH IS ≥16 YEARS OLD. ELSE, GO TO A24.]
A23
Did you get a GED?
Yes ............................................................. 1
No............................................................... 2
DK/REF
A24
How tall are you?
_____Feet
_____Inches
DK/REF
A25
How much do you weigh now?
_____Pounds
DK/REF
A26
Are you Hispanic, Latino, or Spanish?
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
A26a
(GO TO A27)
(GO TO A27)
Which of these categories describes you? CHECK ALL THAT APPLY.
Mexican-American...................................... 1
Mexican............. ........................................ 2
Cuban ................ ........................................ 3
Puerto Rican or other Caribbean .................. 4
Central or South American Spanish ............. 5
Other Spanish..... ........................................ 6
DK/REF
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A27
Which of these describes your race? CHECK ALL THAT APPLY.
White.......................................................... 1
Black or African American.......................... 2
American Indian or Alaska Native ............... 3
Asian .......................................................... 4
Native Hawaiian or other Pacific Islander .... 5
DK/REF
A28
Do you think of yourself as…?
Male ........................................................... 1
Female ........................................................ 2
Something else............................................ 3
DK/REF
A29
Which of these best fits how you think of yourself?
Totally straight (heterosexual) ..................... 1
Mostly straight but kind of attracted to
people of your own sex .................. 2
Bisexual – that is attracted to males and
females equally.............................. 3
Mostly gay (homosexual) but kind of
attracted to people of the
opposite sex................................... 4
Totally gay (homosexual) ............................ 5
Not sexually attracted to either
males or females............................ 6
DK/REF
A30
Do you have any children?
Yes ............................................................. 1
No............................................................... 2
DK/REF
A31
IF A28=3/SOMETHING ELSE OR DK/REF, USE PRELOADED GENDER DATA
TO DIRECT WHETHER TO USE MALE OR FEMALE VERSION OF ITEM.
IF A28 = 1/MALE: Is someone pregnant with your child now?
IF A28 = 2/FEMALE: Are you pregnant now?
Yes ............................................................. 1
No............................................................... 2
DK/REF
A32
Before you came to this place, had anyone ever forced you to have any kind of sexual
contact?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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(GO TO SECTION B)
(GO TO SECTION B)
A33
Before you came to this place, how many times were you forced to have sexual contact
with someone else?
__________ Times
DK/REF
A34
(GO TO SECTION B)
Did any of these times happen while you were in a corrections facility?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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(GO TO SECTION B)
(GO TO SECTION B)
(GO TO SECTION B)
Section B.
Facility Perceptions and Victimization
B1
These next questions ask about this place and the kinds of things that happen here. The
first questions ask about facility staff, that is, the people who work or volunteer here.
a.
Are the facility staff good role models?
Yes ............................................................. 1
No............................................................... 2
DK/REF
b.
Are the facility staff friendly?
Yes ............................................................. 1
No............................................................... 2
DK/REF
c.
Do the staff seem to genuinely care about you?
Yes ............................................................. 1
No............................................................... 2
DK/REF
d.
Are the staff helpful?
Yes ............................................................. 1
No............................................................... 2
DK/REF
e.
Are the staff disrespectful?
Yes ............................................................. 1
No............................................................... 2
DK/REF
f.
Are the staff hard to get along with?
Yes ............................................................. 1
No............................................................... 2
DK/REF
g.
Are the staff mean?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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h.
Are the staff fun to be with?
Yes ............................................................. 1
No............................................................... 2
DK/REF
i.
DOAFILL1, which, if any, of the following conditions have you seen a doctor,
nurse, or other health care person for? CHECK ALL THAT APPLY.
Illness ......................................................... 1
Injury.......................................................... 2
Eyes, teeth, or hearing ................................. 3
Other physical needs ................................... 4
None of the above ....................................... 5
DK/REF
B2
The next few questions are about what happens here. Are these statements true or false?
a.
Youth here are punished even when they don’t do anything wrong.
True ............................................................ 1
False ........................................................... 2
DK/REF
b.
Facility staff use force when they don’t really need to.
True ............................................................ 1
False ........................................................... 2
DK/REF
c.
Problems between facility staff and youth here can be worked out.
True ............................................................ 1
False ........................................................... 2
DK/REF
d.
Something bad might happen to me if I file a complaint.
True ............................................................ 1
False ........................................................... 2
DK/REF
e.
I usually deserve any punishment that I receive.
True ............................................................ 1
False ........................................................... 2
DK/REF
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f.
Punishments given are fair.
True ............................................................ 1
False ........................................................... 2
DK/REF
g.
The staff treat the youth fairly.
True ............................................................ 1
False ........................................................... 2
DK/REF
h.
It is very easy to get away with doing something that is against the rules.
Strongly agree ............................................ 1
Somewhat agree .......................................... 2
Somewhat disagree...................................... 3
Strongly disagree......................................... 4
DK/REF
i.
There are enough staff to monitor what is going on in this facility.
Strongly agree ............................................ 1
Somewhat agree .......................................... 2
Somewhat disagree...................................... 3
Strongly disagree......................................... 4
DK/REF
B3
Is there gang activity in this facility?
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
B4
(GO TO B8)
(GO TO B8)
DOAFILL1, have there been fights that involved rival gangs here?
Yes ............................................................. 1
No............................................................... 2
DK/REF
B5
Are you a member of a gang here?
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
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(GO TO B8)
(GO TO B8)
B6
Do you feel pressured to do things with the gang that you normally wouldn’t do?
Yes ............................................................. 1
No............................................................... 2
DK/REF
B7
Do you think you are safer inside this place if you belong to a gang?
Yes ............................................................. 1
No............................................................... 2
DK/REF
B8
Do you worry about being hit, punched, or assaulted by other youth while here?
Yes ............................................................. 1
No............................................................... 2
DK/REF
B9
DOAFILL1, have you ever been hit, punched, or assaulted by another youth here?
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
B10
(GO TO B11)
(GO TO B11)
DOAFILL1, how many times have you been hit, punched or assaulted by another youth
here?
__________ Times
DK/REF
B11
DOAFILL1, has another youth here physically hurt you on purpose?
Yes ............................................................. 1
No............................................................... 2
DK/REF
B12
(GO TO B15)
(GO TO B15)
DOAFILL1, how many times have you been physically hurt by another youth here on
purpose?
__________ Times
DK/REF
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B13
When another youth here hurt you on purpose, have you
a.
gotten bruises, a black eye, sprains, scratches, swelling, or welts?
Yes ............................................................. 1
No............................................................... 2
DK/REF
b.
been knocked out (unconscious)?
Yes ............................................................. 1
No............................................................... 2
DK/REF
c.
gotten internal injuries (for example, an injury to your stomach or
kidneys, or to your brain)?
Yes ............................................................. 1
No............................................................... 2
DK/REF
d.
had any teeth knocked out or chipped?
Yes ............................................................. 1
No............................................................... 2
DK/REF
e.
had bones broken?
Yes ............................................................. 1
No............................................................... 2
DK/REF
f.
been stabbed or cut?
Yes ............................................................. 1
No............................................................... 2
DK/REF
[IF ALL B13a-f = 2/NO, OR DK OR REF, GO TO B15. OTHERWISE, CONTINUE.]
B14
Did you see a doctor, nurse, or other health care person for any of these injuries?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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B15
DOAFILL1, have you ever been written up or charged with physically fighting with
youth here?
Yes ............................................................. 1
No............................................................... 2
DK/REF
B16
Do you worry about being hit, punched, or assaulted by facility staff here?
Yes ............................................................. 1
No............................................................... 2
DK/REF
B17
DOAFILL1, have you ever been hit, punched, or assaulted by facility staff here?
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
B18
(GO TO B19)
(GO TO B19)
DOAFILL1, how many times have you been hit, punched or assaulted by facility staff?
__________ Times
DK/REF
B19
DOAFILL1, has a staff member physically hurt you on purpose?
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
B20
(GO TO B23)
(GO TO B23)
DOAFILL1, how many times have you been physically hurt by staff on purpose?
__________ Times
DK/REF
B21
When a staff member hurt you on purpose, have you
a.
gotten bruises, a black eye, sprains, scratches, swelling, or welts?
Yes ............................................................. 1
No............................................................... 2
DK/REF
b.
been knocked out (unconscious)?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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c.
gotten internal injuries (for example, an injury to your stomach or
kidneys, or to your brain)?
Yes ............................................................. 1
No............................................................... 2
DK/REF
d.
had any teeth knocked out or chipped?
Yes ............................................................. 1
No............................................................... 2
DK/REF
e.
had bones broken?
Yes ............................................................. 1
No............................................................... 2
DK/REF
f.
been stabbed or cut?
Yes ............................................................. 1
No............................................................... 2
DK/REF
[IF ALL B21a-f = 2/NO OR DK OR REF, GO TO B23. OTHERWISE, CONTINUE.]
B22
Did you see a doctor, nurse, or other health care person for any of these injuries?
Yes ............................................................. 1
No............................................................... 2
DK/REF
B23
DOAFILL1, have you ever been written up or charged with physically fighting with a
facility staff member?
Yes ............................................................. 1
No............................................................... 2
DK/REF
B24
DOAFILL1, have you ever been written up or charged with threatening a facility staff
member?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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B25
DOAFILL1, have you filed a written statement complaining about a facility staff
member?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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Section C.
Drug Use
C1
The next questions are about drugs you may have taken on your own – that is, without a
doctor telling you to take them.
Have you ever used...
a.
marijuana, hashish, blunts or other forms of THC (pot, herb, reefer, weed)?
Yes ............................................................. 1
No............................................................... 2
DK/REF
b.
crack, smoked rock or free-base cocaine?
Yes ............................................................. 1
No............................................................... 2
DK/REF
c.
other forms of cocaine?
Yes ............................................................. 1
No............................................................... 2
DK/REF
d.
inhalants such as aerosols, glue, or paint thinner?
Yes ............................................................. 1
No............................................................... 2
DK/REF
e.
methamphetamine such as ice, crank, crystal, or crystal meth?
Yes ............................................................. 1
No............................................................... 2
DK/REF
f.
heroin or heroin mixed with other drugs?
Yes ............................................................. 1
No............................................................... 2
DK/REF
g.
pain killers or other opiates (such as OxyContin®, Percocet, or codeine) without
a doctor's prescription or methadone outside a treatment program?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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h.
ecstasy, MDMA, or “E”?
Yes ............................................................. 1
No............................................................... 2
DK/REF
i.
PCP or angel dust (Phencyclidine)?
Yes ............................................................. 1
No............................................................... 2
DK/REF
j.
acid, LSD, ketamine, special K, mushrooms, or other hallucinogens?
Yes ............................................................. 1
No............................................................... 2
DK/REF
k.
“speed,” “uppers,” amphetamines, or other stimulants (such as Ritalin or
Dexedrine) without a doctor's prescription?
Yes ............................................................. 1
No............................................................... 2
DK/REF
l.
“downers” or sedatives such as GHB or Rohypnol (“Roofies”) without a doctor's
prescription?
Yes ............................................................. 1
No............................................................... 2
DK/REF
m.
anti-anxiety drugs or tranquilizers (such as Ativan, Valium, or Xanax) without a
doctor's prescription?
Yes ............................................................. 1
No............................................................... 2
DK/REF
n.
any other drugs not mentioned here?
Yes ............................................................. 1
No............................................................... 2
DK/REF
[FOR EACH C1a-n = 1/YES, ASK CORRESPONDING ITEM IN C2 AND C4 SERIES; IF NONE
OF C1a-n= 1/YES, GO TO SECTION D]
Version January 18, 2008 – NSYC –A
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C2
a.
Have you ever used marijuana, hashish, blunts or other forms of THC (pot, herb,
reefer, weed) once a week or more for at least 30 days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
b.
Have you ever used crack, smoked rock or free-base cocaine once a week or
more for at least 30 days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
c.
Have you ever used other forms of cocaine once a week or more for at least 30
days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
d.
Have you ever used inhalants such as aerosols, glue, or paint thinner once a
week or more for at least 30 days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
e.
Have you ever used methamphetamine such as ice, crank, crystal, or crystal
meth once a week or more for at least 30 days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
f.
Have you ever used heroin or heroin mixed with other drugs once a week or
more for at least 30 days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
g.
Have you ever used pain killers or other opiates (such as OxyContin®, Percocet,
or codeine) without a doctor's prescription, or methadone outside a treatment
program, once a week or more for at least 30 days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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h.
Have you ever used ecstasy, MDMA, or “E” once a week or more for at least
30 days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
i.
Have you ever used PCP or angel dust (Phencyclidine) once a week or more for
at least 30 days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
j.
Have you ever used acid, LSD, ketamine, special K, mushrooms, or other
hallucinogens once a week or more for at least 30 days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
k.
Have you ever used “speed,” “uppers,” amphetamines, or other stimulants (such
as Ritalin or Dexedrine) without a doctor's prescription once a week or more for
at least 30 days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
l.
Have you ever used “downers” or sedatives such as GHB or Rohypnol
(“Roofies”) without a doctor's prescription once a week or more for at least 30
days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
m.
Have you ever used anti-anxiety drugs or tranquilizers (such as Ativan, Valium,
or Xanax) without a doctor's prescription once a week or more for at least 30
days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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n.
Have you ever used any other drugs not mentioned here once a week or more for
at least 30 days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
C3
You said that you were taken into custody in [DATE FROM A2]. Think about before
[DATE FROM A2] as you answer the next set of questions.
C4
a.
During the 30 days before you were taken into custody, on how many days did
you use marijuana, hashish, blunts or other forms of THC (pot, herb, reefer,
weed)?
0 days ......................................................... 1
1-2 days ...................................................... 2
3-5 days ...................................................... 3
6-9 days ...................................................... 4
10-19 days .................................................. 5
20-30 days .................................................. 6
DK/REF
b.
During the 30 days before you were taken into custody, on how many days did
you use crack, smoked rock, or free-base cocaine?
0 days ......................................................... 1
1-2 days ...................................................... 2
3-5 days ...................................................... 3
6-9 days ...................................................... 4
10-19 days .................................................. 5
20-30 days .................................................. 6
DK/REF
c.
During the 30 days before you were taken into custody, on how many days did
you use other forms of cocaine?
0 days ......................................................... 1
1-2 days ...................................................... 2
3-5 days ...................................................... 3
6-9 days ...................................................... 4
10-19 days .................................................. 5
20-30 days .................................................. 6
DK/REF
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d.
During the 30 days before you were taken into custody, on how many days did
you use inhalants such as aerosols, glue or paint thinner?
0 days ......................................................... 1
1-2 days ...................................................... 2
3-5 days ...................................................... 3
6-9 days ...................................................... 4
10-19 days .................................................. 5
20-30 days .................................................. 6
DK/REF
e.
During the 30 days before you were taken into custody, on how many days did
you use methamphetamine such as ice, crank, crystal, or crystal meth?
0 days ......................................................... 1
1-2 days ...................................................... 2
3-5 days ...................................................... 3
6-9 days ...................................................... 4
10-19 days .................................................. 5
20-30 days .................................................. 6
DK/REF
f.
During the 30 days before you were taken into custody, on how many days did
you use heroin or heroin mixed with other drugs?
0 days ......................................................... 1
1-2 days ...................................................... 2
3-5 days ...................................................... 3
6-9 days ...................................................... 4
10-19 days .................................................. 5
20-30 days .................................................. 6
DK/REF
g.
During the 30 days before you were taken into custody, on how many days did
you use pain killers or other opiates (such as OxyContin®, Percocet, or codeine)
without a doctor’s prescription or methadone outside a treatment program?
0 days ......................................................... 1
1-2 days ...................................................... 2
3-5 days ...................................................... 3
6-9 days ...................................................... 4
10-19 days .................................................. 5
20-30 days .................................................. 6
DK/REF
h.
During the 30 days before you were taken into custody, on how many days did
you use ecstasy, MDMA, or “E”?
0 days ......................................................... 1
1-2 days ...................................................... 2
3-5 days ...................................................... 3
6-9 days ...................................................... 4
10-19 days .................................................. 5
20-30 days .................................................. 6
DK/REF
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i.
During the 30 days before you were taken into custody, on how many days did
you use PCP or angel dust (Phencyclidine)?
0 days ......................................................... 1
1-2 days ...................................................... 2
3-5 days ...................................................... 3
6-9 days ...................................................... 4
10-19 days .................................................. 5
20-30 days .................................................. 6
DK/REF
j.
During the 30 days before you were taken into custody, on how many days did
you use acid, LSD, ketamine, special K, mushrooms, or other hallucinogens?
0 days ......................................................... 1
1-2 days ...................................................... 2
3-5 days ...................................................... 3
6-9 days ...................................................... 4
10-19 days .................................................. 5
20-30 days .................................................. 6
DK/REF
k.
During the 30 days before you were taken into custody, on how many days did
you use “speed,” “uppers,” amphetamines, or other stimulants (such as Ritalin or
Dexedrine) without a doctor’s prescription?
0 days ......................................................... 1
1-2 days ...................................................... 2
3-5 days ...................................................... 3
6-9 days ...................................................... 4
10-19 days .................................................. 5
20-30 days .................................................. 6
DK/REF
l.
During the 30 days before you were taken into custody, on how many days did
you use “downers” or sedatives such as GHB or Rohypnol (“Roofies”) without a
doctor’s prescription?
0 days ......................................................... 1
1-2 days ...................................................... 2
3-5 days ...................................................... 3
6-9 days ...................................................... 4
10-19 days .................................................. 5
20-30 days .................................................. 6
DK/REF
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m.
During the 30 days before you were taken into custody, on how many days did
you use anti-anxiety drugs or tranquilizers (such as Ativan, Valium, or Xanax)
without a doctor’s prescription?
0 days ......................................................... 1
1-2 days ...................................................... 2
3-5 days ...................................................... 3
6-9 days ...................................................... 4
10-19 days .................................................. 5
20-30 days .................................................. 6
DK/REF
n.
During the 30 days before you were taken into custody, on how many days did
you use any other drugs not mentioned here?
0 days ......................................................... 1
1-2 days ...................................................... 2
3-5 days ...................................................... 3
6-9 days ...................................................... 4
10-19 days .................................................. 5
20-30 days .................................................. 6
DK/REF
C5
When the thing that you were (accused of/convicted of) doing happened, were you trying
to get money to buy drugs or obtain drugs for your use?
Yes ............................................................. 1
No............................................................... 2
DK/REF
C6
When the thing that you were (accused of/convicted of) doing happened, had you been
using drugs?
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
C7
(GO TO C8)
(GO TO C8)
What drugs were you using when it happened? CHECK ALL THAT APPLY.
[DISPLAY TEXT FROM ALL C1a-n FOR WHICH RESPONSE =1/YES]
[IF C4a-n ALL = “0 days” OR ALL = REF OR COMBO OF ALL = “0 days” AND REF, GO TO
C11. ELSE, CONTINUE]
C8
During the 30 days before you were taken into custody, how did you get the drugs that
you were using?
a.
Did you buy them from a stranger?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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b.
Did you buy them from a dealer you know?
Yes ............................................................. 1
No............................................................... 2
DK/REF
c.
Did you buy them from a friend?
Yes ............................................................. 1
No............................................................... 2
DK/REF
d.
Did you steal them?
Yes ............................................................. 1
No............................................................... 2
DK/REF
e.
Were they given to you by friends or acquaintances?
Yes ............................................................. 1
No............................................................... 2
DK/REF
f.
Did you use a fake or forged prescription?
Yes ............................................................. 1
No............................................................... 2
DK/REF
g.
Did you trade sex for drugs?
Yes ............................................................. 1
No............................................................... 2
DK/REF
h.
Did you get them from a home medicine cabinet ?
Yes ............................................................. 1
No............................................................... 2
DK/REF
i.
Did you get them another way?
Yes ............................................................. 1
No............................................................... 2
DK/REF
[IF 2 OR MORE C8a-i = 1/YES, GO TO C9; OTHERWISE GO TO C11]
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C9
What was the main source of the drugs that you were using?
[DISPLAY ONLY THOSE SOURCES CODED 1/YES IN C8a-i]
Bought from a stranger
Bought from a dealer you know
Bought from a friend
Stole them
Given to you by friends or acquaintances
Used a fake or forged prescription
Traded sex for drugs
Got them from a home medicine cabinet
Got them another way
DK/REF
[C10 DELETED]
C11
Now, think back over your whole life. Have you ever used a needle to inject or shoot up
any drug under your skin, into a muscle or into a vein, for non-medical reasons? Say
“Yes” if you were injected by someone else or if you injected yourself. Do NOT include
shots given by a doctor or nurse.
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
(GO TO C15)
(GO TO C15)
[ASK C12a-d IF CORRESPONDING DRUG TYPE (C1b AND/OR C1c AND/OR C1e AND/OR C1f
AND/OR C1g= 1/YES; ASK C12e IF ANY DRUG TYPE = 1/YES IN C1a-n.
ELSE, GO TO C15.]
C12
What kinds of drugs have you ever shot up with a needle?
a.
Cocaine other than crack?
Yes ............................................................. 1
No............................................................... 2
DK/REF
b.
Methamphetamine such as ice, crank, crystal, or crystal meth?
Yes ............................................................. 1
No............................................................... 2
DK/REF
c.
Heroin?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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d.
Pain killers or other opiates (such as OxyContin®, Percocet, or codeine) without
a doctor's prescription or methadone outside a treatment program?
Yes ............................................................. 1
No............................................................... 2
DK/REF
e.
Another drug?
Yes ............................................................. 1
No............................................................... 2
DK/REF
C13
Have you ever used a needle that you knew or suspected had been used by someone else
for injecting drugs?
Yes ............................................................. 1
No............................................................... 2
DK/REF
C14
Have you ever shared a needle that you had used with someone else?
Yes ............................................................. 1
No............................................................... 2
DK/REF
C15
You said you have used [DISPLAY ALL DRUGS = 1/YES FROM C1a-n]. How old
were you the first time you used any of these drugs?
____ years old
DK/REF
DRUG ABUSE
[C16 DELETED]
C17
During the 12 months before you were taken into custody,
a.
did you get into situations while using drugs or right after using drugs that
increased your chances of getting hurt — like driving a car or other vehicle,
swimming, using machinery or walking in a dangerous area or around heavy
traffic?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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b.
did you have serious arguments with your parents, other family members,
boyfriend or girlfriend, or friends while using or right after using drugs?
Yes ............................................................. 1
No............................................................... 2
DK/REF
c.
did you have frequent arguments with your parents, other family members, or
boyfriend/girlfriend, about your drug use?
Yes ............................................................. 1
No............................................................... 2
DK/REF
d.
did you lose a job because of your drug use?
Yes ............................................................. 1
No............................................................... 2
DK/REF
e.
did you have school or job trouble because of your drug use – like missing too
much school or work, getting lower grades or not doing your work well, or
being suspended, expelled, or dropping out of school?
Yes ............................................................. 1
No............................................................... 2
DK/REF
f.
did you have legal problems, get arrested or held at a police station because of
your drug use?
Yes ............................................................. 1
No............................................................... 2
DK/REF
g.
did you get into a physical fight while using drugs or right after using drugs?
Yes ............................................................. 1
No............................................................... 2
DK/REF
DRUG DEPENDENCE
C18
During the 12 months before you were taken into custody,
a.
did you often use a drug in larger amounts or for a longer than you meant to?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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b.
did you more than once try by yourself to cut down on your drug use or stop
using drugs but found you couldn't do it?
Yes ............................................................. 1
No............................................................... 2
DK/REF
c.
did you often want to control your drug use?
Yes ............................................................. 1
No............................................................... 2
DK/REF
d.
did you spend a lot of time getting drugs, using them or getting over bad aftereffects of using?
Yes ............................................................. 1
No............................................................... 2
DK/REF
e.
did using drugs or being sick from using drugs keep you from doing work, going
to school, or caring for children?
Yes ............................................................. 1
No............................................................... 2
DK/REF
f.
did you give up activities that you were interested in or that were important to
you so you could use drugs — like school, work, hobbies, or being with family
and friends?
Yes ............................................................. 1
No............................................................... 2
DK/REF
g.
did you continue to use drugs even though it was causing emotional or
psychological problems?
Yes ............................................................. 1
No............................................................... 2
DK/REF
C19
During the 12 months before you were taken into custody,
a.
did you continue to use drugs even though it was causing problems with family,
friends, school or work?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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b.
did you continue to use drugs even though it was causing physical health or
medical problems?
Yes ............................................................. 1
No............................................................... 2
DK/REF
c.
did you have to use more drugs or greater quantities of the drugs to get the effect
you wanted?
Yes ............................................................. 1
No............................................................... 2
DK/REF
d.
did you find that you had some bad after-effects of using drugs after cutting
down on your drug use or stopping your drug use – like shaking, sweating,
feeling nervous or anxious, feeling sick to your stomach or restless, having
trouble sleeping, having fits or seizures, or seeing, feeling, or hearing things that
weren't really there?
Yes ............................................................. 1
No............................................................... 2
DK/REF
e.
did you ever keep using drugs to get over any bad after-effects of a drug or to
keep from having bad after-effects?
Yes ............................................................. 1
No............................................................... 2
DK/REF
C20
When you were arrested the last time, were you tested for drugs?
Yes ............................................................. 1
No............................................................... 2
DK/REF
C21
(GO TO C22)
(GO TO C22)
What was the result of the drug test?
Positive for drug use.................................... 1
Negative...................................................... 2
Neither, inconclusive................................... 3
DK/REF
C22
Have you been tested for drugs since your admission to this facility?
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
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(GO TO C24)
(GO TO C24)
C23
Have you been told the results of any of the drug tests?
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
C24
Were any of the drug tests positive?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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(GO TO SECTION D)
(GO TO SECTION D)
Section D.
Alcohol Use
D1
The next questions are about alcoholic beverages that you might have had, such as beer,
wine, wine coolers, liquor, mixed drinks, and cocktails. We are not asking about when
you only had a sip or two from a drink.
.
Have you ever, even once, had a drink of any alcoholic beverage, that is, more than a few
sips?
Yes ............................................................. 1
No............................................................... 2
DK..............................................................
REF ............................................................
(GO TO D3)
(DISPLAY HOT KEY TEXT)
(DISPLAY HOT KEY TEXT)
(GO TO ALC. & DRUG ROUTE)
HOTKEY TEXT:
“The answers that people give us about their use of alcohol are important to this study’s
success. We know that this information is personal, but remember that your answers will
be kept confidential. Please think again about answering this question.”
[REPEAT D1; THEN IF
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
(GO TO D3)
(GO TO ALC. & DRUG ROUTE)
(GO TO ALC. & DRUG ROUTE)
[ALCOHOL & DRUG ROUTE:
IF D1 = 2/NO OR DK OR REF AND ANY C1a – C1n = 1/YES, GO TO E1.
IF D1 = 2/NO OR DK OR REF AND ALL C1a – C1n = 2/NO OR DK OR REF, GO TO F1.]
D3
Think about the first time you had a drink of an alcoholic beverage. How old were you
the first time you had more than a few sips of any alcoholic beverage?
____ years old
DK/REF
D4
Have you ever drunk alcohol more than once a week for more than a month?
Yes ............................................................. 1
No............................................................... 2
DK/REF
D5
You said that you were taken into custody in [DATE FROM A2]. Think about before
[DATE FROM A2] as you answer the next set of questions.
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D6
During the 12 months before you were taken into custody, did you ever have five or
more drinks in a row? By a “drink” we mean a can or bottle of beer, a glass of wine or a
wine cooler, a shot of liquor, or a mixed drink with liquor in it.
Yes ............................................................. 1
No............................................................... 2
DK/REF
D7
Now think about the 30 days before you were taken into custody. On how many days
did you have more than a few sips of any alcoholic beverage?
0 days ......................................................... 1
1 to 2 days................................................... 2
3 to 5 days................................................... 3
6 to 9 days................................................... 4
10 to 19 days ............................................... 5
20 to 30 days ............................................... 6
DK/REF......................................................
D8
(GO TO D9)
(GO TO D9)
During the 30 days before you were taken into custody, how many days did you have
five or more drinks in a row?
0 days ......................................................... 1
1 to 2 days................................................... 2
3 to 5 days................................................... 3
6 to 9 days................................................... 4
10 to 19 days ............................................... 5
20 to 30 days ............................................... 6
DK/REF
D9
When the thing that you were (accused of/convicted of) doing happened, had you been
drinking any alcohol?
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
D10
(GO TO D11a)
(GO TO D11a)
How many hours had you been drinking alcohol?
____ hours
DK/REF
D11
Had you had five or more drinks in a row?
Yes ............................................................. 1
No............................................................... 2
DK/REF
D11a
These next questions are still asking you about before you were taken into custody in
[DATE FROM A2].
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ALCOHOL ABUSE
D12
During the 12 months before you were taken into custody,
a.
did you get into situations while drinking or right after drinking that increased
your chances of getting hurt – like driving a car or other vehicle, swimming,
using machinery or walking in a dangerous area or around heavy traffic?
Yes ............................................................. 1
No............................................................... 2
DK/REF
b.
did you have serious arguments with your parents, other family members,
boyfriend or girlfriend, husband or wife, or friends while drinking or right after
drinking?
Yes ............................................................. 1
No............................................................... 2
DK/REF
c.
did you have frequent arguments with your parents, other family members,
boyfriend or girlfriend, or husband or wife about your alcohol use?
Yes ............................................................. 1
No............................................................... 2
DK/REF
d.
did you lose a job because of your drinking?
Yes ............................................................. 1
No............................................................... 2
DK/REF
e.
did you have trouble with school or with a job because of your drinking – like
missing too much school or work, getting lower grades or not doing your work
well, or being suspended, expelled, or dropping out of school?
Yes ............................................................. 1
No............................................................... 2
DK/REF
f.
did you get arrested or held at a police station because of your drinking?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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g.
did you have legal problems such as a DWI/DUI or getting arrested for
possession of alcohol or underage drinking?
Yes ............................................................. 1
No............................................................... 2
DK/REF
h.
did you get into a physical fight while drinking or right after drinking?
Yes ............................................................. 1
No............................................................... 2
DK/REF
ALCOHOL DEPENDENCE
D13
During the 12 months before you were taken into custody…
a.
did you often drink more or for a lot longer than you meant to?
Yes ............................................................. 1
No............................................................... 2
DK/REF
b.
did you more than once try by yourself to cut down on your drinking or to stop
drinking alcohol but found you couldn't do it?
Yes ............................................................. 1
No............................................................... 2
DK/REF
c.
did you often want to control your alcohol use?
Yes ............................................................. 1
No............................................................... 2
DK/REF
d.
did you spend a lot of time getting alcohol, drinking, or getting over bad aftereffects of drinking?
Yes ............................................................. 1
No............................................................... 2
DK/REF
e.
did your drinking or being sick from drinking keep you from doing work, going
to school, or caring for children?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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f.
did you give up activities that you were interested in or were important to you so
you could drink – like school, work, hobbies, or being with family and friends?
Yes ............................................................. 1
No............................................................... 2
DK/REF
g.
did you continue to drink even though it was causing emotional or psychological
problems?
Yes ............................................................. 1
No............................................................... 2
DK/REF
D14
During the 12 months before you were taken into custody…
a.
did you continue to drink even though it was causing problems with family,
friends, school or work?
Yes ............................................................. 1
No............................................................... 2
DK/REF
b.
did you continue to drink even though it was causing physical health or medical
problems?
Yes ............................................................. 1
No............................................................... 2
DK/REF
c.
did you have to drink more alcohol to get the effect you wanted?
Yes ............................................................. 1
No............................................................... 2
DK/REF
d.
did you ever have the shakes or tremors of your hands after stopping or cutting
down on drinking, or had that feeling the morning after drinking?
Yes ............................................................. 1
No............................................................... 2
DK/REF
e.
did you find that you had some other bad after-effects of drinking after cutting
down on your drinking or stopping drinking – such as feeling restless, sweating,
having trouble sleeping, having fits or seizures, or seeing, feeling or hearing
things that weren't really there?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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f.
did you sometimes drink alcohol to get over a hangover or any bad after-effects
of drinking or to keep from having them?
Yes ............................................................. 1
No............................................................... 2
DK/REF
D15
When you were arrested the last time, were you tested for alcohol using a breathalyzer or
other test?
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
D16
(GO TO D17)
(GO TO D17)
What was the result of the alcohol test?
Positive for alcohol use................................ 1
Negative...................................................... 2
Neither, inconclusive................................... 3
DK/REF
D17
Have you been tested for alcohol use since your admission to this facility?
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
D18
Have you been told the results of any of your alcohol tests?
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
D19
(GO TO SECTION E)
(GO TO SECTION E)
Were any of the alcohol tests positive?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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(GO TO SECTION E)
(GO TO SECTION E)
Section E.
Treatment
E1
The next questions are about any drug or alcohol treatment programs you may have
attended before you were taken into custody – that is before [DATE FROM A2]. Do
not count any treatment that was only for physical health or psychological problems.
E2
Before you were taken into custody, had you ever…
a.
been admitted overnight to a residential, inpatient, or hospital program for your
alcohol or drug use problems for up to 3 days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
b.
been admitted overnight to a residential, inpatient, or hospital program for your
alcohol or drug use problems for more than 3 days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
c.
received drug or alcohol counseling while NOT living in a special facility or
unit?
Yes ............................................................. 1
No............................................................... 2
DK/REF
d,
attended Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Cocaine
Anonymous (CA), or another self-help group?
Yes ............................................................. 1
No............................................................... 2
DK/REF
e.
been given medication like methadone, antabuse, naltrexone, or
buprenorphine (Suboxone®) to help with withdrawal or cravings?
Yes ............................................................. 1
No............................................................... 2
DK/REF
f.
received any other type of alcohol or drug treatment?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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[FOR EACH E2a-f = YES, ASK E3a-f, E4a-f, and E5a-f. IF NO E2a-f = YES, GO TO E6]
E3
Keep thinking about the time before you were taken into custody for what led to your stay here.
a.
When you were admitted overnight to a residential, inpatient, or hospital program for
your alcohol or drug use problems for up to 3 days, was it for problems with alcohol,
drugs, or both?
Alcohol ....................................................... 1
Drugs.......................................................... 2
Both............................................................ 3
DK/REF
b.
When you were admitted overnight to a residential, inpatient, or hospital program for
your alcohol or drug use problems for more than 3 days, was it for problems with
alcohol, drugs, or both?
Alcohol ....................................................... 1
Drugs.......................................................... 2
Both............................................................ 3
DK/REF
c.
When you received drug or alcohol counseling while not living in a special facility or
unit, was it for problems with alcohol, drugs, or both?
Alcohol ....................................................... 1
Drugs ......................................................... 2
Both............................................................ 3
DK/REF
d.
When you attended Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Cocaine
Anonymous (CA), or another self-help group, was it for problems with alcohol, drugs, or
both?
Alcohol ....................................................... 1
Drugs ......................................................... 2
Both............................................................ 3
DK/REF
e.
When you received medication like methadone, antabuse, naltrexone, or buprenorphine
(Suboxone®) to help with withdrawal or cravings, was it for problems with alcohol,
drugs, or both?
Alcohol ....................................................... 1
Drugs ......................................................... 2
Both............................................................ 3
DK/REF
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f.
When you received any other type of alcohol or drug treatment, was it for problems with
alcohol, drugs, or both?
Alcohol ....................................................... 1
Drugs ......................................................... 2
Both............................................................ 3
DK/REF
[FOR E4a-f SERIES, ASK ITEM THAT CORRESPONDS TO ANY E2a-f THAT =1/YES.]
E4
a.
Were you required to be admitted overnight to a residential, inpatient, or hospital
program for your alcohol or drug use problems for up to 3 days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
b.
Were you required to be admitted overnight to a residential, inpatient, or hospital
program for your alcohol or drug use problems for more than 3 days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
c.
Were you required to receive drug or alcohol counseling while not living in a special
facility or unit?
Yes ............................................................. 1
No............................................................... 2
DK/REF
d.
Were you required to attend Alcoholics Anonymous (AA), Narcotics Anonymous (NA),
Cocaine Anonymous (CA), or another self-help group?
Yes ............................................................. 1
No............................................................... 2
DK/REF
e.
Were you required to receive medication like methadone, antabuse, naltrexone, or
buprenorphine (Suboxone®) to help with withdrawal or cravings?
Yes ............................................................. 1
No............................................................... 2
DK/REF
f.
Were you required to receive any other type of alcohol or drug treatment?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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National Study
[IF A8 = 1/YES AND ANY E2a-f = 1/YES, ASK E5a-f ITEMS THAT CORRESPOND TO E2a-f =
1/YES.
ELSE, GO TO E6]
E5
a.
When you were on probation or parole, were you required to be admitted overnight to a
residential, inpatient, or hospital program for your alcohol or drug use problems for up to
3 days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
b.
When you were on probation or parole, were you required to be admitted overnight to a
residential, inpatient, or hospital program for your alcohol or drug use problems for more
than 3 days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
c.
When you were on probation or parole, were you required to receive drug or alcohol
counseling while not living in a special facility or unit?
Yes ............................................................. 1
No............................................................... 2
DK/REF
d.
When you were on probation or parole, were you required to attended Alcoholics
Anonymous (AA), Narcotics Anonymous (NA), Cocaine Anonymous (CA), or another
self-help group?
Yes ............................................................. 1
No............................................................... 2
DK/REF
e.
When you were on probation or parole, were you required to receive medication like
methadone, antabuse, naltrexone, or buprenorphine (Suboxone®) to help with withdrawal
or cravings?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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f.
When you were on probation or parole, were you required to receive any other type of
alcohol or drug treatment?
Yes ............................................................. 1
No............................................................... 2
DK/REF
DEFINE DOAFILL2:
IF ADMIT DATE 12 months OR A3 = 4, THEN DOAFILL2 = “the past 12 months that you’ve
been in this facility.”
IF ADMIT DATE 12 months OR A3 = 1, OR 2 OR 3 OR 98 OR 99, THEN DOAFILL2 = “the
time since you were taken into custody in [DATE FROM A2].”
E6
Now, think about DOAFILL2.
E7
Since then, have you ever…
a.
been admitted overnight to a residential, inpatient, or hospital program for your alcohol or
drug use problems for up to 3 days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
b.
been admitted overnight to a residential, inpatient, or hospital program for your alcohol
or drug use problems for more than 3 days?
Yes ............................................................. 1
No............................................................... 2
DK/REF
c.
received drug or alcohol counseling while NOT living in a special facility or unit?
Yes ............................................................. 1
No............................................................... 2
DK/REF
d.
attended Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Cocaine
Anonymous (CA), or another self-help group?
Yes ............................................................. 1
No............................................................... 2
DK/REF
e.
been given medication like methadone, antabuse, naltrexone, or buprenorphine
(Suboxone®) to help with withdrawal or cravings?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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f.
received any other type of alcohol or drug treatment?
Yes ............................................................. 1
No............................................................... 2
DK/REF
[ASK E8 a-f FOR EACH PROGRAM TYPE THAT E7a-f = 1/YES. OTHERWISE GO TO
SECTION F]
E8
a.
Now, keep thinking about DOAFILL2. When you were admitted overnight to a
residential, inpatient, or hospital program for up to 3 days, was it for problems with
alcohol, drugs, or both?
Alcohol ....................................................... 1
Drugs ......................................................... 2
Both............................................................ 3
DK/REF
b.
Keep thinking about DOAFILL2. When you were admitted overnight to a residential,
inpatient, or hospital program for your alcohol or drug use problems for more than 3
days, was it for problems with alcohol, drugs, or both?
Alcohol ....................................................... 1
Drugs ......................................................... 2
Both............................................................ 3
DK/REF
c.
Keep thinking about DOAFILL2. When you received drug or alcohol counseling while
not living in a special facility or unit, was it for problems with alcohol, drugs, or both?
Alcohol ....................................................... 1
Drugs.......................................................... 2
Both............................................................ 3
DK/REF
d.
Keep thinking about DOAFILL2. When you attended Alcoholics Anonymous (AA),
Narcotics Anonymous (NA), Cocaine Anonymous (CA), or another self-help group, was
it for problems with alcohol, drugs, or both?
Alcohol ....................................................... 1
Drugs.......................................................... 2
Both............................................................ 3
DK/REF
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e.
Keep thinking about DOAFILL2. When you received medication like methadone,
antabuse, naltrexone, or buprenorphine (Suboxone®) to help with withdrawal or
cravings, was it for problems with alcohol, drugs, or both?
Alcohol ....................................................... 1
Drugs.......................................................... 2
Both............................................................ 3
DK/REF
f.
Keep thinking about DOAFILL2. When you received any other type of alcohol or drug
treatment, was it for problems with alcohol, drugs, or both?
Alcohol ....................................................... 1
Drugs.......................................................... 2
Both............................................................ 3
DK/REF
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Section F. Family and Peer Background
F1
In the 30 days before you were taken into custody, was anyone living with you?
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
F2
Not counting yourself, how many people lived with you?
____ People
DK/REF
F3
(GO TO F8)
(GO TO F8)
(IF RESPONSE = 0, GO TO F8)
How many of these [PEOPLE REPORTED IN F2] were adults aged 18 and over?
____ Adults 18 and over
DK/REF
[F4 DELETED]
[F5 DELETED]
F6
And how were the people that you lived with related to you? CHECK ALL THAT
APPLY.
Your children or stepchildren ...................... 1
Your parents or stepparents ......................... 2
Your grandparents....................................... 3
Your brothers/sisters or
stepbrothers/stepsisters ......................... 4
Your girlfriend or boyfriend ........................ 5
Your husband or wife .................................. 6
Other children under 18 not related to you ... 7
Other relatives............................................. 8
Friends........................................................ 9
Other non-relatives including foster family .. 10
DK/REF
F7
Before you were taken into custody, who did you live with most of the time?
Your children or stepchildren ...................... 1
Your parents or stepparents ......................... 2
Your grandparents....................................... 3
Your brothers/sisters or
stepbrothers/stepsisters ......................... 4
Your girlfriend or boyfriend ........................ 5
Your husband or wife .................................. 6
Other children under 18 not related to you ... 7
Other relatives............................................. 8
Friends........................................................ 9
Other non-relatives including foster family .. 10
No one. I lived alone. .................................. 11
DK/REF
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[IF F6 OR F7 = FOSTER (10), GO TO F9. OTHERWISE GO TO F8]
F8
Was there ever a time when you lived in a foster home, agency, or institution?
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
F9
(GO TO F10)
(GO TO F10)
Was it a foster home, agency or institution, or both?
Foster home ................................................ 1
Agency or institution ................................... 2
Both............................................................ 3
DK/REF
F10
Have any of your parents or guardians ever abused alcohol or drugs?
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
F11
(GO TO F12)
(GO TO F12)
Was it alcohol, drugs, or both?
Alcohol ....................................................... 1
Drugs.......................................................... 2
Both............................................................ 3
DK/REF
F12
Have any of your parents or guardians ever been sentenced and served time in jail or
prison?
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
F13
(GO TO F14)
(GO TO F14)
Who was that? CHECK ALL THAT APPLY.
Mother/stepmother ...................................... 1
Father/stepfather.......................................... 2
Your grandparents....................................... 3
Other relatives............................................. 4
Foster mother or father ................................ 5
Someone else .............................................. 6
DK/REF
F14
How many brothers and sisters have you had? Include half and step brothers and sisters.
____ Brothers or sisters
DK/REF
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[IF F14 = 0 OR DK OR REF, GO TO F15. IF F14 = 1 OR MORE, GO TO F14a.]
F14a
Have any of your brothers or sisters ever abused alcohol or drugs? Include any stepfamily.
Yes ............................................................. 1
No............................................................... 2
DK/REF
F14b
(GO TO F14b)
(GO TO F15)
(GO TO F15)
Was it alcohol, drugs, or both?
Alcohol ....................................................... 1
Drugs.......................................................... 2
Both............................................................ 3
DK/REF
F15
Have any of your girlfriends or boyfriends, or your husband or wife ever abused alcohol
or drugs?
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
F16
(GO TO F17)
(GO TO F17)
Was it alcohol, drugs, or both?
Alcohol ....................................................... 1
Drugs.......................................................... 2
Both............................................................ 3
DK/REF
F17
Have any of your brothers or sisters, girlfriends or boyfriends, or your husband or wife
ever been sentenced and served time in jail or prison? Include any step-family.
Yes ............................................................. 1
No............................................................... 2
DK/REF......................................................
F18
Who was that? CHECK ALL THAT APPLY.
Your brother or stepbrother ......................... 1
Your sister or stepsister ............................... 2
Your girlfriend or boyfriend ........................ 3
Your husband or wife .................................. 4
DK/REF
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(GO TO F19)
(GO TO F19)
F19
Before you were taken into custody for what led to your stay here, did you have friends
you hung around who engaged in activities such as…
a.
using drugs?
Yes ............................................................. 1
No............................................................... 2
DK/REF
b.
destroying or damaging property that did not belong to them?
Yes ............................................................. 1
No............................................................... 2
DK/REF
c.
shoplifting?
Yes ............................................................. 1
No............................................................... 2
DK/REF
d.
stealing motor vehicles or parts from motor vehicles?
Yes ............................................................. 1
No............................................................... 2
DK/REF
e.
selling stolen property?
Yes ............................................................. 1
No............................................................... 2
DK/REF
f.
breaking into homes or other buildings?
Yes ............................................................. 1
No............................................................... 2
DK/REF
g.
selling, importing, or manufacturing drugs?
Yes ............................................................. 1
No............................................................... 2
DK/REF
h.
mugging, robbing, or extorting money from people?
Yes ............................................................. 1
No............................................................... 2
DK/REF
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i.
any other illegal activity?
Yes ............................................................. 1
No............................................................... 2
DK/REF
F20
Who do you expect to live with upon your release from this facility?
CHECK ALL THAT APPLY.
No one. You expect to live alone .........................................
Your parents or stepparents .................................................
Your grandparents...............................................................
Your brothers or sisters, or stepbrothers or stepsisters ..........
Your girlfriend or boyfriend ................................................
Your husband or wife ..........................................................
Other relatives.....................................................................
Your friends........................................................................
A foster family ....................................................................
A halfway house or treatment facility ..................................
DK/REF
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| File Type | application/pdf |
| File Title | Specifications for non-JSA 10% Questionnaire |
| Author | Teresa Koenig |
| File Modified | 2008-02-21 |
| File Created | 0000-00-00 |