Form NOMs Instruments NOMs Instruments NOMs Instruments

Form Approved

OMB No.: 09300230

     Expiration Date:  04/30/2012

Center for Substance Abuse Prevention

National Outcome Measures

Adult Community Survey Form

(Adults ages 18 and older)

Use this Adult Community Survey Form for surveys of communities in which data may be collected at a single point in time or at multiple time points, each time using different samples of individuals rather than a matched pretest/posttest design.

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 0930-0230. 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 for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

Center for Substance Abuse Prevention
National Outcome Measures

Adult Community Survey Form

This survey is voluntary. 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. No one will connect your answers with your name or other identifying information. To help us protect the privacy of your answers, 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.

Thank you for agreeing to participate in this survey.

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

Contract/Grant ID

Date Completed

	/		/
Month		Day		Year

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)
   American Indian or Alaska Native
   Asian
   Black or African American
   Native Hawaiian or Other Pacific Islander
   White

4. What is your date of birth?

	/		/
Month		Day		Year

MILITARY FAMILY AND DEPLOYMENT

5. Have you ever served in the Armed Forces, in the Reserves, or the National Guard?

No, (Skip to #6]

Yes, in the Armed Forces

Yes, in the Reserves

Yes, in the National Guard

5b.   Are you currently on active duty in the Armed Forces, in the Reserves, or the National Guard [select all that apply]?

Yes, in the Armed Forces

Yes, in the Reserves

Yes, in the National Guard

No, separated or retired from Armed Forces, Reserves, or National Guard

5c.   Have you ever been deployed to a combat zone?

Never deployed 
Iraq or Afghanistan (e.g., Operation Enduring Freedom/Operational Iraqi Freedom/Operation New Dawn)
Persian Gulf (Operation Desert Shield or Desert Storm)

Vietnam/Southeast Asia

Korea

WWII

Deployed to a combat zone not listed above (e.g., Somalia, Bosnia, Kosovo) 

6. Is anyone in your family or someone close to you on active duty in the Armed Forces, in the Reserves, or the National Guard, or separated or retired from Armed Forces, Reserves, or the National Guard?

Yes

Yes, more than one

No, (Skip to Next Section)

7. If yes (answer for up to six people):

7a. What is the relationship of that person (Service Member) to you:	Mother/Father  Brother/Sister  Spouse/Partner  Child  Other, Specify_____________
7b. Has the Service Member experienced any of the following (check all that apply):	Deployed in support of Combat Operations      (e.g. Iraq or Afghanistan) Was physically Injured during combat       Operations   Developed combat stress symptoms/difficulties adjusting following deployment, including PTSD,  Depression, or suicidal thoughts  Died or was killed

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

8. 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	8a.	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	8b.	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	8c.	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	8d.	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	8e.	During the past 30 days, on how many days did you use any other illegal drug?

9. 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:

			Check if NEVER	Fill in your age when you first used (in years)	Check if don’t know or can’t say
Cigarettes: Include menthol and regular cigarettes and loose tobacco rolled into cigarettes	9a.	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	9b.	Ever used any other tobacco product?
Alcoholic beverages: Include beer, wine, wine coolers, malt beverages, and liquor	9c.	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	9d.	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	9e.	Ever used any other illegal drug?

10. 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
10a.	When they smoke one or more packs of CIGARETTES per day?
10b.	When they smoke MARIJUANA once or twice a week?
10c.	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.

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

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

Form Approved OMB No.: 09300230

     Expiration Date:  04/30/2012

Center for Substance Abuse Prevention

National Outcome Measures

Youth Community Survey Form

(Youth ages 12-17)

Use this Youth Community Survey Form for surveys of communities in which data may be collected at a single point in time or at multiple time points, each time using different samples of individuals rather than a matched pretest/posttest design.

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 0930-0230. 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 for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

Center for Substance Abuse Prevention

National Outcome Measures

Youth Community Survey Form

This survey is voluntary. 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. 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.

Thank you for agreeing to participate in this survey.

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

Contract/Grant ID

Date Completed

	/		/
Month		Day		Year

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)
   American Indian or Alaska Native
   Asian
   Black or African American
   Native Hawaiian or Other Pacific Islander
   White

4. What is your date of birth?

	/		/
Month		Day		Year

Military Family and Deployment

5. Is anyone in your family or someone close to you on active duty in the Armed Forces, in the Reserves, or the National Guard, or separated or retired from Armed Forces, Reserves, or the National Guard?

Yes

Yes, more than one

No, (Skip to Next Section)

6. If yes (answer for up to six people):

6a. What is the relationship of that person (Service Member) to you:	Mother Father Brother/Sister Aunt/Uncle Grandparent Other, Specify_____________
6b. Has the Service Member experienced any of the following (check all that apply):	Deployed in support of Combat Operations      (e.g. Iraq or Afghanistan) Was physically Injured during combat       Operations   Developed combat stress symptoms/difficulties adjusting following deployment, including PTSD,  Depression, or suicidal thoughts  Died or was killed

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

7. 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	7a.	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	7b.	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	7c.	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	7d.	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	7e.	During the past 30 days, on how many days did you use any other illegal drug?

8. 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:

			Check if NEVER	Fill in your age when you first used (in years)	Check if don’t know or can’t say
Cigarettes: Include menthol and regular cigarettes and loose tobacco rolled into cigarettes	8a.	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	8b.	Ever used any other tobacco product?
Alcoholic beverages: Include beer, wine, wine coolers, malt beverages, and liquor	8c.	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	8d.	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	8e.	Ever used any other illegal drug?

9. 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
9a.	How do you feel about someone your age smoking one or more packs of cigarettes a day?
9b.	How do you think your close friends would feel about YOU smoking one or more packs of cigarettes a day?
9c.	How do you feel about someone your age trying marijuana or hashish once or twice?
9d.	How do you feel about someone your age using marijuana once a month or more?
9e.	How do you feel about someone your age having one or two drinks of an alcoholic beverage nearly every day?

10. 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
10a.	When they smoke one or more packs of CIGARETTES per day?
10b.	When they smoke MARIJUANA once or twice a week?
10c.	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.
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

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

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

Form Approved

OMB No.: 09300230

     Expiration Date:  04/30/2012

Center for Substance Abuse Prevention

National Outcome Measures

Adult Programs Survey Form

(Adult participants ages 18 and older)

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

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 0930-0230. 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 for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

Center for Substance Abuse Prevention

National Outcome Measures

Adult Programs Survey Form

This survey is voluntary. 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. No one will connect your answers with your name or other identifying information. To help us protect the privacy of your answers, 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.

Thank you for agreeing to participate in this survey.

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

Contract/Grant ID

Date Completed

	/		/
Month		Day		Year

Survey Type (Check one)

Baseline Exit First followup after exit Second followup

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)
   American Indian or Alaska Native
   Asian
   Black or African American
   Native Hawaiian or Other Pacific Islander
   White

4. What is your date of birth?

	/		/
Month		Day		Year

MILITARY FAMILY AND DEPLOYMENT

5. Have you ever served in the Armed Forces, in the Reserves, or the National Guard?

No, (Skip to #6]

Yes, in the Armed Forces

Yes, in the Reserves

Yes, in the National Guard

5b.   Are you currently on active duty in the Armed Forces, in the Reserves, or the National Guard [select all that apply]?

Yes, in the Armed Forces

Yes, in the Reserves

Yes, in the National Guard

No, separated or retired from Armed Forces, Reserves, or National Guard

5c.   Have you ever been deployed to a combat zone?

Never deployed 
Iraq or Afghanistan (e.g., Operation Enduring Freedom/Operational Iraqi Freedom/Operation New Dawn)
Persian Gulf (Operation Desert Shield or Desert Storm)

Vietnam/Southeast Asia

Korea

WWII

Deployed to a combat zone not listed above (e.g., Somalia, Bosnia, Kosovo) 

6. Is anyone in your family or someone close to you on active duty in the Armed Forces, in the Reserves, or the National Guard, or separated or retired from Armed Forces, Reserves, or the National Guard?

Yes

Yes, more than one

No, (Skip to Next Section)

7. If yes (answer for up to six people):

7a. What is the relationship of that person (Service Member) to you:	Mother/Father  Brother/Sister  Spouse/Partner  Child  Other, Specify_____________
7b. Has the Service Member experienced any of the following (check all that apply):	Deployed in support of Combat Operations      (e.g. Iraq or Afghanistan) Was physically Injured during combat       Operations   Developed combat stress symptoms/difficulties adjusting following deployment, including PTSD,  Depression, or suicidal thoughts  Died or was killed

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

8. 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	8a.	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	8b.	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	8c.	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	8d.	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	8e.	During the past 30 days, on how many days did you use any other illegal drug?

9. 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:

			Check if NEVER	Fill in your age when you first used (in years )	Check if don’t know or can’t say
Cigarettes: Include menthol and regular cigarettes and loose tobacco rolled into cigarettes	9a.	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	9b.	Ever used any other tobacco product?
Alcoholic beverages: Include beer, wine, wine coolers, malt beverages, and liquor	9c.	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	9d.	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	9e.	Ever used any other illegal drug?

10. 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
10a.	When they smoke one or more packs of CIGARETTES per day?
10b.	When they smoke MARIJUANA once or twice a week?
10c.	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.

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
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

13. 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

Form Approved

OMB No.: 09300230

     Expiration Date: 04/30/2012

Center for Substance Abuse Prevention

National Outcome Measures

Youth Programs Survey Form

(Participants ages 12-17)

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

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 0930-0230. 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 for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

Center for Substance Abuse Prevention

National Outcome Measures

Youth Programs Survey Form

This survey is voluntary. 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. 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.

Thank you for agreeing to participate in this survey.

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

Contract/Grant ID

Date Completed

	/		/
Month		Day		Year

Survey Type (Check one)

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

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)
   American Indian or Alaska Native
   Asian
   Black or African American
   Native Hawaiian or Other Pacific Islander
   White
   
   

4. What is your date of birth?

	/		/
Month		Day		Year

Military Family and Deployment

5. Is anyone in your family or someone close to you on active duty in the Armed Forces, in the Reserves, or the National Guard, or separated or retired from Armed Forces, Reserves, or the National Guard?

Yes

Yes, more than one

No, (Skip to Next Section)

6. If yes (answer for up to six people above):

6a. What is the relationship of that person (Service Member) to you:	Mother Father Brother/Sister Aunt/Uncle Grandparent Other, Specify_____________
6b. Has the Service Member experienced any of the following (check all that apply):	Deployed in support of Combat Operations      (e.g. Iraq or Afghanistan) Was physically Injured during combat       Operations   Developed combat stress symptoms/difficulties adjusting following deployment, including PTSD,  Depression, or suicidal thoughts  Died or was killed

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

7. 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	7a.	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	7b.	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	7c.	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	7d.	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	7e.	During the past 30 days, on how many days did you use any other illegal drug?

8. 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:

			Check if NEVER	Fill in your age when you first used (in years)	Check if don’t know or can’t say
Cigarettes: Include menthol and regular cigarettes and loose tobacco rolled into cigarettes	8a.	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	8b.	Ever used any other tobacco product?
Alcoholic beverages: Include beer, wine, wine coolers, malt beverages, and liquor	8c.	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	8d.	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	8e.	Ever used any other illegal drug?

9. 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
9a.	How do you feel about someone your age smoking one or more packs of cigarettes a day?
9b.	How do you think your close friends would feel about YOU smoking one or more packs of cigarettes a day?
9c.	How do you feel about someone your age trying marijuana or hashish once or twice?
9d.	How do you feel about someone your age using marijuana once a month or more?
9e.	How do you feel about someone your age having one or two drinks of an alcoholic beverage nearly every day?

10. 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
10a.	When they smoke one or more packs of CIGARETTES per day?
10b.	When they smoke MARIJUANA once or twice a week?
10c.	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.

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

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

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
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

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