ADAM II Facesheet

VERBAL CONSENT SCRIPT
I work for a private research firm called Abt Associates. We are conducting a Federally funded project designed to collect
information about drug use, illegal activities, and service needs among individuals who have been arrested. Your participation is
voluntary and confidential. We will not include or record your name anywhere on the information you provide. Any information you
provide is confidential, unavailable to anyone outside the research project, and will not help or hurt your case.
We have a Confidentiality Certificate from the US government that adds special protection for the research information about you. This
does not imply government approval or disapproval of this project. It says we do not have to identify you, even under a court order or
subpoena. Still, we may report medical information (if you need medical help), probable harm to yourself or others, or probable child
abuse or neglect. The government may see your information if it audits us, but your name will not be part of any of the information
we collect.
I will ask you a series of questions that will take approximately 20 to 30 minutes. You may find some questions embarrassing or
distressing, and you can refuse to answer any question. At the end of the interview, I will ask you to provide a urine sample. If you
listen to all my questions and provide the urine sample, you will be given a [incentive]. Can we begin now?

Interview Status
IN1.

a) Interviewer initials and b) ID#

IN2.

a) Interview status

a) _________________

b)__________________

a) _______________________

1= AGREED TO INTERVIEW [SKIP TO IN3]
2= DECLINED INTERVIEW
3= NOT AVAILABLE

}

[RECORD IN2b]

b) Reason
1=
2=
3=
4=
5=
6=
7=
8=
9=
10=

DID NOT WANT TO
TAKEN TO COURT
RELEASED
TRANSFERRED
MEDICAL UNIT
VIOLENT OR UNCONTROLLED BEHAVIOR
PHYSICALLY ILL
LANGUAGE [SPECIFY]
SHIFT ENDED
OTHER [SPECIFY]

b) ______________________

__________________________________________
__________________________________________

[IF DID NOT AGREE, DISCONTINUE INTERVIEW]
IN3.

Language form [1= ENGLISH, 2= SPANISH]

_____________

IN4.

How many hours ago were you arrested? [RECORD NUMBER OF HOURS]

_____________

[IF GREATER THAN 48 HOURS, DISCONTINUE INTERVIEW]

ADAM FACESHEET
INTERVIEW IDENTIFICATION
ID1.

Respondent ID#

[LABEL]

ID2.

ADAM site ID#

_________________

ID3.

Booking facility ID#

_________________

ID4.

ADAM data collection quarter

ID5.

Data collection date

_________________
_________/___________/ 20___ ___

ARREST RECORD
AR1.

Arrest Date

_________/___________/ 20___ ___

AR2.

Arrest time

________________________ a.m. | p.m. | military [CIRCLE ONE]

AR3.

Arrest precinct

________________

AR4.

Arresting agency ID#

________________

AR5.

a) Arrest location and b) ZIP

AR6.

Respondent birthdate

AR7.

Gender [1= MALE, 2= FEMALE, 3= OTHER]

AR8.

Race/Ethnicity
______________
1= WHITE
2= BLACK OR AFRICAN-AMERICAN
3= HISPANIC/LATINO
4= AMERICAN INDIAN OR ALASKAN NATIVE
8= NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
9= ASIAN
6= OTHER [SPECIFY]
_________________________________________________________

AR9.

Respondent address ZIP

AR10.

3 Most serious arrest charges:

a) PENAL CODE

a)__________________________________b)______________
_____________/____________/ 19___ ___
______________

___________________________
SEVERITY: 1= Felony, 2= Misdemeanor, 3= Traffic Violation, 4= Municipal/Summary,
5= Probable Cause, 6= OTHER [SPECIFY] WARRANT: 0=No, 1=Yes

b) OFFENSE

c) CODE

d) SEVERITY e) WARRANT

1
2
3
AR11.

Booking date

_________/___________/ 20___ ___

AR12.

Booking time

________________________ a.m. | p.m. | military [CIRCLE ONE]

AR13.

Sample source [1= STOCK, 2= FLOW, 3= OTHER]

__________________

AR14.

ADAM ID# (of person filling out this side of Facesheet)

__________________