Form Attachment 2 - You Attachment 2 - You Attachment 2 - Youth Survey

OMB # No. 0930-XXXX

Expiration Date: XX/XX/XXXX

Methamphetamine Use Prevention Initiative

Youth Programs Survey

(Participants Ages 12–17)

TO BE FILLED OUT BY THE LOCAL GRANT SITE DATA COLLECTOR

Last Name___________________, First Name___________________, M.I.______

Participant ID

RESPONDENT OR PARTICIPANT: Before answering any of the questions, please make sure your name is correct. If incorrect, make the change in the box above. Do not write your name on any other page in this questionnaire. Thank you.

Methamphetamine Use Prevention Initiative

Youth Programs Survey Form

Use this Youth Programs Survey Form for participants in prevention interventions who are expected to complete survey forms at baseline, exit, and followup periods.

Funding for data collection supported by the
Center for Substance Abuse Prevention (CSAP)
Substance Abuse and Mental Health Services Administration (SAMHSA)

U.S. Department of Health and Human Services (HHS)

Thank you for agreeing to participate in this voluntary survey. If you choose to take it, you may skip any question you don’t want to answer.

This survey asks about your experience and opinion on a number of things related to alcohol, tobacco, and drug use. Your answers to these questions will be confidential. That means no one will connect your answers with your name or any other information about you that can identify who you are. To help us keep your answers secret, please do not write your name on this survey form.

The information in this survey will be used to learn more about the effectiveness of programs in preventing substance abuse and protecting youth.

This is not a test, so there are no right or wrong answers. Some questions may ask you to select all of the answers that are relevant, and others ask you to select a single answer. If the question asks for a single answer and you don’t find an answer that exactly fits, choose one that comes closest.

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Notice: Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-xxxx. Public reporting burden for this collection of information is estimated to average 1 hour per client per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions reducing this burden to SAMHSA Reports Clearance Officer, 1 Choke Cherry rd, Room7-1044, Rockville, Maryland 20857.

efore we begin, let me read the following to you:

RECORD MANAGEMENT: Your survey administrator will tell you what to fill in for these administrative questions. You may leave all but Date Completed blank if you are not given any instructions.

Participant ID

Grant ID

Date Completed

	/		/
Month		Day		Year

Survey Type (Check one)

Baseline Exit First follow-up after exit Second follow-up after exit

Study Design Group (Check one)

Intervention Comparison

Program Name

­­­­­­­­­­Cohort Number

These questions ask for general information about you. Please mark the response that best describes you.

1. What is your gender? (Check one)
   Male Female

2. Are you Hispanic or Latino? (Check one)
   Yes No

3. What is your race? (Mark all that apply)
   Alaska Native
   American Indian
   Asian
   Black or African American
   Native Hawaiian or Other Pacific Islander Asian
   White

4. What is your date of birth?

	/		/
Month		Day		Year

The next few questions ask about your use of and attitudes toward tobacco, alcohol, and other substances.

5. Think back over the past 30 days and report how many days, if any, you used the
following substances:

			Fill in number of days (0 – 30)	Check if don’t know or can’t say
Cigarettes: Include menthol and regular cigarettes and loose tobacco rolled into cigarettes	5a.	During the past 30 days, on how many days did you smoke part or all of a cigarette?
Other tobacco products: Include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe	5b.	During the past 30 days, on how many days did you use other tobacco products?
Alcoholic beverages: Include beer, wine, wine coolers, malt beverages, and liquor	5c.	During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage?
Marijuana or hashish: Also known as grass, pot, hash, or hash oil	5d.	During the past 30 days, on how many days did you use marijuana or hashish?
Other illegal drugs: Include substances like: Heroin, crack or cocaine, methamphetamine Hallucinogens (drugs that cause people to see or experience things that are not real) such as LSD (sometimes called acid), Ecstasy (sometimes called MDMA), PCP or peyote (sometimes called angel dust) Inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to “feel good” or to get high) Prescription drugs without a doctor’s orders, just to “feel good” or to get high	5e.	During the past 30 days, on how many days did you use any other illegal drug?

6. Think back over your entire lifetime and try to remember whether you have EVER used any of the following substances. If so, what was your age the FIRST TIME you used the substance:

			Only Check if NEVER USED	Fill in your age when you first used (in years)	Only Check if you don’t know or can’t say what age you were when you first used
Cigarettes: Include menthol and regular cigarettes and loose tobacco rolled into cigarettes	6a.	Ever smoked part or all of a cigarette?
Other tobacco products: Include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe	6b.	Ever used any other tobacco product?
Alcoholic beverages: Include beer, wine, wine coolers, malt beverages, and liquor	6c.	Ever had a drink of an alcoholic beverage? Do NOT include any time when you only had a sip or two from a drink.
Marijuana or hashish: Also known as grass, pot, hash, or hash oil	6d.	Ever used marijuana or hashish?
Other illegal drugs: Include substances like: Heroin, crack or cocaine, methamphetamine Hallucinogens (drugs that cause people to see or experience things that are not real) such as LSD (sometimes called acid), Ecstasy (sometimes called MDMA), PCP or peyote (sometimes called angel dust) Inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to “feel good” or to get high) Prescription drugs without a doctor’s orders, just to “feel good” or to get high	6e.	Ever used any other illegal drug?

7. For each of the following five questions below check the box that shows how you think or feel.

		Neither approve nor disapprove	Somewhat disapprove	Strongly disapprove	Don’t know or can’t say
7a.	How do you feel about someone your age smoking one or more packs of cigarettes a day?
7b.	How do you think your close friends would feel about YOU smoking one or more packs of cigarettes a day?
7c.	How do you feel about someone your age trying marijuana or hashish once or twice?
7d.	How do you feel about someone your age using marijuana once a month or more?
7e.	How do you feel about someone your age having one or two drinks of an alcoholic beverage nearly every day?

8. For each of the three questions below check one box that shows HOW MUCH you think
people RISK HARMING themselves physically or in other ways when they do the following

things:

		No risk	Slight risk	Moderate risk	Great risk	Don’t know or can’t say
8a.	When they smoke one or more packs of CIGARETTES per day?
8b.	When they smoke MARIJUANA once or twice a week?
8c.	When they have five or more drinks of an ALCOHOLIC BEVERAGE once or twice a week?

This section asks some additional questions about your attitudes and experiences.

9. Would you be more or less likely to want to work for an employer that tests its employees for drug or alcohol use on a random basis? Would you say more likely, less likely, or would it make no difference to you? (Check one)

More likely Less likely Would make no difference Don’t know or can’t say

10. DURING THE PAST 12 MONTHS, have you driven a vehicle while you were under the influence of alcohol?

Yes No Don’t know or can’t say

11. Now think about the past 12 months through today. DURING THE PAST 12 MONTHS, have you talked with at least one of your parents about the dangers of tobacco, alcohol, or drug use? By PARENTS, we mean your biological parents, adoptive parents, stepparents, or adult guardians—whether or not they live with you.

Yes No Don’t know or can’t say

12. During the past 12 months, do you recall hearing, reading, or watching an advertisement about prevention of substance abuse?

Yes No Don’t know or can’t say

Now we would like to ask some additional questions about you and your relationships.

13. How would you describe yourself? (Mark the one that fits best)

Straight or heterosexual Bisexual Gay or lesbian Unsure

14. What is the highest level of education you have finished? (Mark the highest grade or degree you have completed)

1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade 7th grade 8th grade 9th grade 10th grade 11th grade High school completion or GED Community college or trade school Four-year college Master’s degree

15. With whom do you live? (Mark all that apply)

Alone With my mother With my father With my brother(s) and/or sister(s) With my grandparent(s) With other relatives or guardian(s) With my spouse or significant other With my child or my children With roommates Other

Indicate how true you think each of the next two statements is:

16. Members of my family like to spend free time with each other.

I don’t have any family Not true Sometimes true Usually true Always true

My friends ask each other for help.

I don’t have any friends Not true Sometimes true Usually true Always true

The next few questions are about your school experiences.

18. Are you enrolled in school?

Yes No

19. What were your most recent grades in school?

I am not in school Mostly As Mostly Bs Mostly Cs Mostly Ds Mostly Fs

Have you ever been suspended from school for drug or alcohol use?	Yes No
Now, we would like to ask you some more questions about substances that some people use.
21. During the past 30 days, on how many days have you sniffed glue or breathed the contents of aerosol spray cans, or inhaled (huffed) any other gases or sprays in order to get high?	____ day (Enter number of days from 0 to 30) Don’t know or can’t say

22. How old were you the first time you sniffed glue or breathed the contents of aerosol spray cans, or inhaled (huffed) any other gases or sprays in order to get high?

I have never used any inhalants ____ years old Don’t know or can’t say

23. During the past 30 days, on how many days did you use cocaine or crack?

____ day (Enter number of days from 0 to 30) Don’t know or can’t say

24. How old were you the first time you used cocaine or crack?

I have never used any cocaine or crack ____ years old Don’t know or can’t say

25. Which of these statements do you agree with: (mark all that apply)

I would be able to say no if a friend offered me a drink of alcohol. I would be able to say no if a friend offered me a cigarette. I would be able to refuse if a friend offered me methamphetamine. I would be able to refuse if a friend offered me any marijuana I would be able to refuse if a friend offered me any cocaine, or crack I would be able to refuse if a friend offered me any illegal drugs, other than marijuana.

In the next three questions, mark the circle that best describes how likely you are to do the things indicated in the question.

In the next 3 months, how likely are you...

26. To drink five or more alcoholic drinks in one sitting?

Not at all likely A little likely Somewhat likely Very likely

27. To use methamphetamine?

Not at all likely A little likely Somewhat likely Very likely

28. To use marijuana or any other illegal drugs to get high?

Not at all likely A little likely Somewhat likely Very likely

Teenagers get information about substance abuse from many different sources. The next question is about some of these sources.

29. Please tell us whether you have learned about prevention of substance abuse from any of these sources: (Mark all that apply)

Your friends, brothers, or sisters Your parents or guardians Teachers, school nurses, or classes at school A doctor or other health care provider Television shows or movies Books or pamphlets Popular magazines The Internet

The questions in this section ask about your thoughts, beliefs, and experiences related to methamphetamine, also called meth, ice, glass, crank, crystal, speed, chalk, tina, go-fast, or yaba. Some of the following questions refer to methamphetamine as “meth” for short.

30. During the past 30 days, on how many days did you use methamphetamine?

____ day (Enter number of days from 0 to 30) Don’t know or can’t say

31. How old were you the first time you used methamphetamine? (Also called meth, ice, glass, crank, crystal, speed, chalk, tina, go-fast, or yaba)

I have never used methamphetamine ____ years old Don’t know or can’t say

32. How do you feel about someone your age using methamphetamine once or twice?

Neither approve nor disapprove Somewhat disapprove Strongly disapprove Don’t know or can’t say

33. How do you think your close friends would feel about YOU using methamphetamine once or twice a month?

Neither approve nor disapprove Somewhat disapprove Strongly disapprove Don’t know or can’t say

34. How much do people risk harming themselves physically or in other ways when they use methamphetamine once or twice a month?

No risk Slight risk Moderate risk Great risk Don’t know or can’t say

35. Whether or not you or someone you know uses meth, we would like to learn your ideas. Please indicate which of these statements you agree with: (Mark all that apply)

Meth helps people escape their problems. Meth helps people study. Meth gives people energy. Meth helps people deal with boredom. Meth makes people feel very happy Meth helps people lose weight. Meth makes people more intelligent. Meth makes people more popular. Meth makes people feel attractive. Meth makes people have better sex.

The next question is about your thoughts on the possible effects of methamphetamine use. Whether or not you or someone you know uses meth, we would like to learn your ideas.

36. Which of these might happen to people who use meth? (Mark all that apply)

Getting hooked on meth Becoming Violent Feeling suicidal Becoming paranoid Suffering brain damage Suffering tooth decay Insomnia (not being able to sleep) Having sex with multiple partners Having unprotected sex (that is, sex without a barrier such as a latex condom, dental dam, or female condom) Being a negative influence on a younger brother or sister Stealing

The next few questions are about some other thoughts and experiences you may have had related to meth.

37. Has anyone ever offered you meth?

Yes No Don’t know or can’t say

38. If you wanted to get some meth, how difficult or easy do you think it would be for you to get some?

Very difficult Somewhat difficult Not sure Somewhat easy Very easy

39. During the past 12 months, do you recall hearing, reading, or watching an advertisement about prevention of meth use?

Yes No Don’t know or can’t say

40. In the past 30 days, have you been in any classes or programs where they talked about preventing meth use?

Yes No

41. To which of these sources, if any, would you go to find information about meth? (Mark all that apply)

I wouldn’t go to any source Parents Friends The Internet, Web sites Television Teachers Nurses or guidance counselors at school Healthcare professional outside of school Radio Magazines Books or pamphlets Other

The last question is about your answers to this survey.

42. How comfortable was it for you to answer the questions in this survey?

Very comfortable

Somewhat comfortable

Somewhat uncomfortable

Very uncomfortable

YOU ARE DONE!

Thank you for your help!

National Methamphetamine Use Prevention Initiative – Youth Programs Survey Form Page 0