Attachment 3 - Adu Attachment 3 - Adult Survey

OMB # No. 0930-XXXX

Expiration Date: XX/XX/XXXX

Methamphetamine Use Prevention Initiative

Adult Programs Survey

(Participants Ages 18 and Older)

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

Adult Programs Survey Form

Use this Adult 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 topics 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 other identifying information. To help us keep your answers confidential, 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.

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.

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

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.

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 followup after exit Second followup 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? (Select one or more)
   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 some 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 three questions below check one box that shows HOW MUCH you think people RISK HARMING themselves physically or in other ways when they engage in the following behaviors:

		No risk	Slight risk	Moderate risk	Great risk	Don’t know or can’t say
7a.	When they smoke one or more packs of CIGARETTES per day?
7b.	When they smoke MARIJUANA once or twice a week?
7c.	When they have five or more drinks of an ALCOHOLIC BEVERAGE once or twice a week?

This section asks just a few additional questions about your attitudes and experiences.

8. 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
9. 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

10. Now think about the past 12 months through today. DURING THE PAST 12 MONTHS, how many times have you talked with your child about the dangers or problems associated with the use of tobacco, alcohol, or drugs?

Don’t have any children 0 times 1 to 2 times A few times Many times Don’t know or can’t say

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

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

Straight or heterosexual Bisexual Gay or lesbian Unsure

12. Describe your current relationship status.

Single (never married) Informally married or living with a permanent partner Legally married Separated Divorced or broken up from an informal marriage Widowed

13. 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 Doctorate or professional degree
14. Which of these characteristics best describes you? (Mark the one that fits best.)		Employed full time (35+ hours per week) Employed part time Unemployed (looking for work) Unemployed (disabled) Unemployed (volunteer work) Unemployed (retired) Unemployed (full-time student) Unemployed (full-time homemaker) Unemployed (other reason)

15. Think about the household members that live with you right now. About how much income have you and/or your family members made in the last year before taxes? (Include child support, and/or cash payments from the government, for example, welfare [TANF], SSI, or unemployment compensation)

$0–$10,000 $10,001–$20,000 $20,001–$30,000 $30,001–$40,000 $40,001–$50,000 $50,001–$60,000 More than $60,000

16. What is your primary spoken language?

English Spanish Asian (Chinese, Japanese, or other) American Indian (Apache, Blackfoot, Navajo, or other) Other

17. 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 With my spouse or significant other With my child or my children With roommates Other

18. Have you ever been in juvenile detention, jail, or prison for more than 3 days?

Yes No

19. If YES to question 18, how long has it been since you last got out of juvenile detention, jail, or prison?

Never in juvenile detention, jail, or prison Less than 30 days Between 30 days and 1 year Between 1 and 2 years Between 2 and 3 years Between 3 and 4 years Between 4 and 5 years More than 5 years

20. At what age did you have your first child?

No children 9 to 13 years old 14 to 18 years old 19 to 25 years old 26 to 35 years old 35 years old or older

21. How many children under the age of 18 are living with you?

0 1 to 2 3 to 4 5 to 6 More than 6

This section asks you some questions that describe your relationships with people close to you.

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

22. I’m available when others in my family want to talk to me.

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

23. Members of my family feel very close to each other.

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

24. Are there any people you could talk with about personal issues having to do with alcohol or drug use?

Yes, there are people I can talk with No, there is no one I can talk with

The next three questions are about your plans for the next 6 months. Even if you don’t have clear plans, we would like to learn your best guess about the chances that you will do certain things.

In the next 6 months, how likely are you...

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

Not at all likely A little likely Somewhat likely Very likely

26. To use methamphetamine?

Not at all likely A little likely Somewhat likely Very likely

27. To use any illegal drugs (including marijuana) to get high?

Not at all likely A little likely Somewhat likely Very likely

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.

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

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

29. How old were you the first time you used methamphetamine?

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

30. How do you feel about someone trying methamphetamine once or twice?

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

31. How much do people risk harming themselves physically or in other ways when they try methamphetamine once or twice?

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

32. 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

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.

33. Which of these might happen to people who use methamphetamine? (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

34. Whether you or someone you know uses meth, we would like to learn your ideas. Which of these statements do 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 euphoric/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 few questions are about young people in your community.

35. How likely do you think it is that teens or young adults in your community use meth?

Not at all likely A little likely Somewhat likely Very likely

36. How difficult or easy do you think it is for a teen in your community to get some meth, if they wanted to?

Very difficult Somewhat difficult Somewhat easy Very easy Don’t know or can’t say

37. To which of these sources, if any, do you think a teen in your community would go to find information about meth? (Mark all that apply)

They 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 next few questions are about your own thoughts and experiences.

38. If you found out your teenage child was using meth, what would you do? If you don’t have a child that age, think about what you would do if you had one. (Mark all that apply)	Be relieved it wasn’t anything worse Speak to teen’s pediatrician/a doctor Speak to teen’s teacher Speak to teen’s principal Speak to teen’s guidance counselor Speak to my spouse/partner Speak to teen Speak to a close friend of mine Seek religious/spiritual guidance Seek help on the Internet Try to find a drug treatment center Punish teen Forbid teen to do it Something not listed above Nothing
39. 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 Coworkers Health care provider Radio Magazines Books or pamphlets Other

The last question is about your answers to this survey.

40. 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 – Cohort 3 Page 0