Form Instrument for Chi Instrument for Chi Instrument for Children

B1-1

ATTACHMENT B-1:

INSTRUMENT FOR CHILDREN

B-1.1

CRAFFT

B1-2

Attachment B-1.1

CRAFFT

B1-3

FEBRUARY 18, 2010 FORMAT
Readmit |__|
2 Phases |__|
Initial |__|__|
DATE:

Form Approved
OMB No. xxxx-xxxx
Expiration Date xx-xx-xxxx

2 0
|__|__| |__|__| |__|__|__|__|

START TIME: |__|__| : |__|__| a.m. |__|
p.m. |__|

MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

END TIME: |__|__| : |__|__|a.m. |__|
p.m. |__|

CHILD’S ID# |__|__|

2 0
MOTHER’S GPRA INTAKE DATE |__|__| |__|__| |__|__|__|__|
EVALUATION PHASE: Intake |__| 3-mos post-Int |__|

6-mos post-Int |__|

PERSON COMPLETING |_______________|

Discharge |__| 6-mos post-DC |__|

GRANT#

TI |__|__|__|__|__|__|

PPW CRAFFT
(AGES 11-17)

Please check a YES or NO response to each of the following questions.

C Have you ever ridden in a car driven by someone (including yourself)

Yes

No

who was “high” or had been using alcohol or drugs? ..............................

R Do you ever use alcohol or drugs to relax, feel better about yourself,

or fit in? .....................................................................................................

A Do you ever use alcohol or drugs while you are by yourself, alone? .......
F Do you ever forget things you did while using alcohol or drugs? .............
F Do your family or friends ever tell you that you should cut down on

your drinking or drug use? ........................................................................

T Have you ever gotten into trouble while you were using

alcohol or drugs? ......................................................................................

©Children’s Hospital Boston, 2001
Reproduced with permission from the Center for Adolescent Substance Abuse Research,
CeASAR, Children’s Hospital Boston,
For more information, contact [email protected] or visit www.crafft.org

Public reporting burden for this collection of information is estimated to average 5 minutes per response; 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 to SAMHSA Reports Clearance Officer, Room 7-1044, 1
Choke Cherry Road, Rockville, MD 20857. 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 control number for this project is 0930-0269