FORM APPROVED
OMB NO.: 0920-0840
EXPIRATION DATE: 2/28/2016
NORC at the University of Chicago |
Injection Behaviors among Young Persons in Rural/Suburban Settings |
Formative Research Survey |
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(ID) Participant ID (System Generated sequential participation number)
SITE. Recruitment Site (Populated by Field Staff)
- Kenosha
- Racine
- Belleville (fixed site)
- Belleville (mobile)
CCODE. Coupon Code (Populated by Field Staff)
Text field
(Intdate) IC.4 Date of Interview
Self-Populate
INTRO_0.
Public reporting burden of this collection of information is estimated to average 45 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. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-0840).
INTRO_1.
Thank you for
joining our study. We are doing this study to understand how people
get infected with hepatitis C while injecting drugs. We hope to use
this information to help people who inject drugs stay safe in the
future. Our goal is to reduce the risk of infection associated with
injecting drugs.
Before you begin, we want to ask
you to help us with a problem we have in studies like this one. For a
lot of different reasons, people who take surveys about using drugs
sometimes feel uncomfortable telling us they did things that other
people might disapprove of. For example, it is pretty common for
people to say they haven't ever used somebody else's needle to inject
drugs even when they know they have. They don't tell the truth
because they are worried that people will disapprove or think less of
them or that they will get into trouble. Not everybody does this, but
some people do, and that makes the study results harder to
understand.
It would be very easy to fill out this
survey and not give fully honest responses. In fact, nothing would
happen to you if you did. However, this study will be so much more
useful and helpful for people who inject drugs if you give us the
best and most truthful information that you can. Remember, your name
is not connected to this survey in any way and no one will ever know
how you answered these questions. You will not get into trouble for
answering these questions truthfully. So, we would like to ask you to
help us with this study by trying to always give accurate responses
even if the questions are hard to think about. Thank you so much for
your time in helping us.
The survey will take 45
minutes and will now begin.
DSEX. What is your gender?
-Male
-Female
-Trans-gendered
DHORM. If Trans-gendered, do you inject hormones?
-Yes
-No
DZIP. What is your zipcode?
-Enter zipcode
DZIPUP. Do you currently live (sleep at night) in a state other than Wisconsin, Illinois, Minnesota, or Missouri?
-Yes
-No
DSTATE. Please enter state and zipcode
-State
DZIPOTH.
-Zipcode
-I do not have a zipcode
-I do not have a zipcode
DRACE. How do you define your race?
-White
-Black or African American
-American Indian, Alaska Native, or Pacific Islander
-Asian
-More than one race (please describe)
DHISP. How do you define your Hispanic ethnicity?
-Hispanic or Latino/a
-Non-Hispanic or Latino/a
DORIG. If Hispanic or Latino/a, what is your Hispanic ethnic origin?
-Mexican, Mexican American, Chicano
-Puerto Rican
-Cuban
-Other (Please describe)
DED. What is your highest level of education?
-Less than 9th grade
-9th – 12th grade, no diploma
-High school graduate
-GED
-Some college, no degree
-Associate’s degree
-Bachelor’s
degree
-Graduate or professional degree
DSLEEP. Over the last week, where did you usually sleep at night?
-At home, which I rent or own by myself or that are rented or owned by my spouse or family
-In a college dormitory
-At a group home or halfway house
-Staying with relatives other than spouse or children
-Staying with friends
-At a shelter
-In my car
-On the street/outside
-In a squat (abandoned/empty house or property)
-Other (please describe)
DMS. Are you married or romantically involved (boyfriend/girlfriend/spouse)?
-Yes, I have a spouse, boyfriend or girlfriend
-No, I am single
DLW. Who do you live with?
-I live alone
-I live with my romantic partner
-I live with friends/roommates
-I live with my parents and/or relatives
-Other (please describe)
DKIDS. Do you have kids?
-Yes
-No
DKIDLIVE. Do your kids live with you?
-Yes
-No
-Half-time (Greater than or equal to 50% of the time)
-Sometimes (Less than 50% of the time)
DJOB. In the past three months, where have you gotten money from? (Select ALL that apply)
-Regular job (employed at an hourly rate or salaried)
-Temporary work (odd jobs, day labor, babysitting/caretaker, bottle deposits)
-Unemployment Insurance
-Legal self-employment (own business)
-Panhandling
-Government programs (Supplemental Security Income, Temporary Assistance for Needy Families, Food Stamps)
-Hustling (Boosting, Stealing, Dealing)
-Sex for money, housing, drugs or transportation
-Spouse, partner, or friend
-Relative (parents, grandparents, etc.)
-Child Support/Alimony
-Other (please describe)
DJOB2. In the past three months, where has most of your money come from?
-Regular job (employed at an hourly rate or salaried)
-Temporary work (odd jobs, day labor, babysitting/caretaker, bottle deposits)
-Unemployment Insurance
-Legal self-employment (own business)
-Panhandling
-Government programs (Supplemental Security Income, Temporary Assistance for Needy Families, Food Stamps)
-Hustling (Boosting, Stealing, Dealing)
-Sex for money, housing, drugs or transportation
-Spouse, partner, or friend
-Relative (parents, grandparents, etc.)
-Child Support/Alimony
-Other (please describe)
DMONEY. About how much money do you usually make per week?
-Less than $100
-$100-$500
-$500-$1000
-More than $1000
DHI. What type of health insurance do you have?
-Private insurance (Humana, United, Blue Cross, etc.)
-Public insurance (BadgerCare, Medicaid, Medicare)
-I do not have insurance
DTRANSP. What do you use for transportation? (Select ALL that apply)
-My own car
-Someone else’s car (friend/spouse/family member)
-Take public transportation (bus and/or train)
-I hitch rides from other people
-I walk to where I need to go
-I bike to where I need to go
-Other (please describe)
DARST. Have you ever been arrested?
-Yes
-No
DJAIL1. Have you ever spent a night or more in jail or prison?
-Yes
-No
DJAIL2. While in jail/prison did you ever? (Select ALL that apply)
- Inject drugs
- Get a tattoo
- I did not inject drugs or get a tattoo in jail
DINJNUM. About how many times in your life have you injected drugs for recreational reasons?
-1 time only
-2 to 5 times
-6 to 10 times
-11 to 100 times
-More than 100 times
ISENTR1. People who use street drugs use different kinds of equipment when they shoot up (e.g., rigs, gear, points and works). This part of the survey asks questions about these different types of equipment and materials. When answering these questions, think about when you injected drugs over the last week or the last time you injected.
ISENTR2. Several of these questions are asked twice; first asking you to identify ALL that apply and the second time asking you to identify the ONE response that is most common.
ISENTR3. This section of questions will ask you about needles, meaning the syringe or needle set that you use to shoot drugs. Please click here, if you would like to see a picture of what a needle looks like.
IESYR1. How would you describe the needles you have used to inject drugs over the past week or the last time you injected? (Select ALL that apply)
- A brand new needle that has never been used before.
- A needle that only I had used before.
- A needle that someone I know had used before.
- A needle that someone I don’t know might have used before.
- A needle that someone I know or don’t know had used before but that was cleaned with bleach and water before I used it.
-Other, please describe.
IESYR2. How many shots do you usually get out of a single needle?
-Drop down menu with numbers (0-10+)
IESYR3. What type of needle have you mostly used to inject drugs over the past week or the last time you injected? (Select ONLY one)
- A brand new needle that has never been used before.
- A needle that I, but no one else had used before.
- A needle that someone I know had used before.
- A needle that someone I don’t know might have used before.
- A needle that someone I know or don’t know had used before but that was cleaned (with bleach; soap; or boiled).
IESYR4. Over the past week or the last time you injected, where did you get the needles that you used to inject drugs? (Select ALL that apply)
-A needle exchange program (sometimes known as a syringe service program)
-A drug store or other medical goods supplier
-Mail or internet order
-Borrowed from a friend
-Borrowed from a family member
-Purchased or rented from someone
-I found the needle
-Other, please describe
IESYR5. Over the past week or the last time you injected, where did you usually get the needle that you have used to inject drugs? (Select ONLY one)
- A needle exchange program (sometimes known as a syringe service program)
- A drug store or other medical goods supplier
- Mail or internet order
- Borrowed from a friend or family member
- Purchased or rented from someone
-I found the needle
-Other, describe
IESYR6. Of the needles that you used in the past week or the last time you injected, what were the barrel sizes? (Select ALL that apply)
-1/2 cc
-1 cc
-Greater than 1 cc
-Don’t know
-Other, please describe.
IESYR7. When you shoot up, what barrel size do you usually use? (Select ONLY one)
-1/2 cc
-1 cc
-Greater than 1 cc
-Don’t know
-Other, please describe.
IESYR8. What do you usually use to clean your needles (Select only one)?
-I clean my needles in water without boiling them.
-I boil my needles in water.
-I use water and bleach to clean my needles.
-I use straight bleach to clean my needles.
-I clean my needles in other ways, please describe.
-I don’t clean my needles.
IESYR9. In the past week or the last time you injected, did you at any time use someone else’s needle after they used it?
-Yes
-No
IESYR10 Did you or they clean the needle before you used it?
-I cleaned it.
-They cleaned it.
-No one cleaned it.
-I don’t know
IESYR11. In your lifetime, how many times have you used someone else’s needle after they used it?
-Never
-1 time
-2-5 times
-More than five times
IESYR12. In the past week or the last time you injected, did anyone ever use your needle after you used it?
- Yes
- No
-Don’t know
IEFILINT: Now we would like to ask you about filters, sometimes known as cottons. By filters or cottons, we mean a piece of cotton, a cigarette filter, or other material that people use to strain or filter the liquid as you draw or pull it into a needle. Please click here, if you would like to see a picture of a filter used for drug use.
IEFIL1. Over the past week or the last time you injected have you used filters in the process of injecting drugs?
-Yes
-No [If No, skip to 35]
IEFIL2. Over the past week or the last time you injected, where did you get the filters that you used or what were they made of? (Select ALL that apply)
- An “official” filter from a needle exchange program (sometimes known as a syringe service program)
- Material purchased from a store (cotton ball, gauze)
- A cigarette filter
- Pocket lint
- Other, please describe
IEFIL3. Over the past week or the last time you injected, what did you usually use for a filter? (Select ONLY one)
- An “official” filter from a needle exchange program (sometimes known as a syringe service program)
- Material purchased from a store (cotton ball, gauze)
- A cigarette filter
- Pocket lint
- Other, please describe
IEFIL4. Over the past week or the last time you injected, have you ever used a filter that someone else used before you?
-Yes
-No
-Don’t know
IEFIL5. Over the past week or the last time you injected, did anyone ever use your filter after you used it?
-Yes
-No
-Don’t know
IEFIL6. In the past week or the last time you injected, how did you save your filters? (Select ALL that apply)
- In a closed or covered container (tin foil, a plastic bag, or Tupperware).
-Uncovered
- Did not save filters
IEFIL7. In the past week or the last time you injected, what was the most common way you saved your filters? (Select ONLY one)
- In a closed or covered container (tin foil, a plastic bag, or Tupperware).
-Uncovered
- Did not save filters
IEFIL8. In the past week or the last time you injected, have you ever purchased, traded, or been given used filters from someone else?
- Yes
- No
IECOOKIN: The next section asks you about cookers. By cooker, we mean something that people use to dissolve drugs in water before injection, usually something like a spoon, a bottle cap, or the bottom of a pop can. Please click here, if you would like to see a picture of a cooker used for drug use.
IECOOK1. Over the past week or the last time you injected, have you used cookers when you injected drugs?
-Yes
-No [If No, Skip to 43]
IECOOK2. Over the past week or the last time you injected, what did you use for your cookers? (Select ALL that apply)
-An “official” cap obtained from a needle exchange program (sometimes known as a syringe service program)
-Spoon
-Pop can bottom
-Bottle cap
-Don’t use a cooker (cold shake)
-Other, please describe
IECOOK3. Over the past week or the last time you injected, what did you usually use for your cooker? (Select ONLY one)
-An “official” cap obtained from a needle exchange program (sometimes known as a syringe service program)
-Spoon
-Pop can bottom
-Bottle cap
-Don’t use a cooker (cold shake)
-Other, please describe
IECOOK4. Over the past week or the last time you injected, how many people including yourself usually used your cooker?
Number: Drop down myself-10+, I don’t use a cooker
IECOOK5. Over the past six months, how many days would your cooker usually last before you got a new one?
- I used a new cooker every time I inject drugs
- 1 day
- 2 days to a week
- Longer than a week
IECOOK6. In the past six months have you ever used a cooker that someone else used before you (even during the same injection session)?
- Yes
- No
IECOOK7. In the past six months how often have you used a cooker that someone else used before you (even during the same injection session)?
- Never
- 1 time
- 2-5 times
- More than 5 times
IECOOK8. Over the past week or the last time your shot, did anyone at any time use your cooker after you used it?
-Yes
-No
-I don’t know
IEH20INT. Now we would like to talk to you about mix water. Mix water is water that is used to turn drugs into a liquid that can be injected. Please click here, if you would like to see a picture of some items that others use for mix water.
IEH201. Over the past week or the last time you injected, where did you get the mix water that you used to inject drugs? (Select ALL that apply)
- Tap water (from a faucet)
- Bottled water
- Tube (a tube is a container of prefilled water usually obtained from a needle exchange program. Click here to see a photo of a tube)
- Other, please describe
IEH202. Where did you usually get the mix water that you used to inject drugs? (Select ONLY one)
- Tap water (from a faucet)
- Bottled water
- Tube (a tube is a prefilled water container usually obtained from a needle exchange program. Click here to see a photo of a tube)
- Other, please describe
IEH203. If you used a tube in the past week or the last time you injected, how did you usually get the water from the tube into your needle?
- Tear the top off the tube and squirt its contents into the cooker or barrel
- Stick the needle through the plastic into the tube and draw out the water
- Tear the top off the tube and stick the needle in the opening (without puncturing the plastic with the needle)
- Other, please describe
IEH204. In the past week or the last time you injected, how often did someone else draw water from a container that you had already drawn from?
- Never
- 1 time
- More than once but not every time I shot up
- Every time I shot up
IEH205. In the past week or the last time you injected, how often did you draw water from a container that someone else had already drawn their water from?
- Never
- 1 time
- More than once but not every time I shot up
- Every time I shot up
-Other, please describe
IEBMEINT. Often people will bleed during the process of shooting up and will need to use something to manage and clean the bleeding.
IEBME1. In the past week or the last time you injected have you ever seen blood from other people on surfaces, filters, needles or other things that you come into contact when shooting up?
- Yes
- No
IEBME2. In the past week or the last time you injected, what did you use to manage any bleeding from you or others? (Select ALL that apply)
- Piece of cloth or a rag
-Finger
- Alcohol swab
- Tissue, toilet paper, paper towel, paper napkin
- Safety square (cotton gauze square usually obtained from a needle exchange or harm reduction program)
- Band Aid or Bandage
- Tongue
- I did not need to clean any blood
IEBME3. In the past week or the last time you injected, what did you usually use to manage any bleeding from you or others? (Select ONLY one)
- Piece of cloth or a rag
- Finger
- Alcohol swab
- Tissue, toilet paper, paper towel, paper napkin
- Safety square (cotton gauze square usually obtained from a needle exchange or harm reduction program)
- Band Aid or Bandage
- Tongue
- I did not need to clean any blood
-Other, please describe
SSDAINT. This section will ask you about how you get drugs and the people that you use drugs with. No identifying information about these individuals will be asked; rather, you will be asked about how often you see these people and in what situations you’ve seen them.
SSDA1. How do you usually get your drugs? (Select ONLY one)
- I get drugs just for me
- I get drugs for me and others
- I take turns with other people getting drugs that we all use
- Other people get my drugs for me
SSDA2. Who do you get your drugs from? (Select ALL that apply)
- A friend
-A friend of a friend
-A street dealer
-A street dealer who is also my friend
-A relative
-A romantic partner
- A paying sex partner
-Someone I pay for sex
-A doctor
- A stranger passing through
-Online/the Internet
-Other, please describe
SSDA2IN. Did you inject with any of them? (Select ALL that apply)
-List is generated based on selections from SSDA2
SSDA3. Who do you usually get your drugs from? (Select ONLY one)
- A friend
-A friend of a friend
-A street dealer
-A street dealer who is also my friend
-A relative
-A romantic partner
- A paying sex partner
-Someone I pay for sex
-A doctor
- A stranger passing through
-Other (please describe)
SSDA4. Do you ever inject with the people that you buy drugs from?
- Yes
- No
SSDA5. Have you ever injected with someone who had much more experience injecting than you?
- Yes
- No
SSDA6. If yes, who was this person or people? (Select ALL that apply)?
- A friend
-A friend of a friend
-A street dealer
-A street dealer who is also my friend
-A relative
-A romantic partner
- A paying sex partner
-Someone I pay for sex
-A doctor
- A stranger passing through
-Other, please describe
SSDA7. In the past week, or the last time you injected, how many people have you injected with? By injected with, we mean you injected drugs while the other person also injected drugs in the same room.
- No one
- 1 person
- 2 to 4 people
- 5 or more people
SSDA8. In the past week or the last time you injected, how many people have you injected with that you know (you know their name and they know yours)?
- No one
- 1 person
- 2 to 4 people
- 5 or more people
SSDA9. In the past week or the last time you injected, how many people have you injected with that you DID NOT know (you didn’t know their name or they didn’t know yours)?
- No one
- 1 person
- 2 to 4 people
- 5 or more people
SSDA10. Think of the people you have been shooting up with lately (like over the last week). How long have you known most of these people?
-Less than a year
- 1 to 5 years
-More than 5 years
SSDA11. How many times in your life has someone else injected you?
-0 (Never)
-1 time
-2 to 5 times
-6 to 10 times
-10 to 100 times
-More than 100 times
SSDA12. Think about the first time you injected, did you inject yourself or did someone else inject you?
-I injected myself
-Someone else injected me
SSDA13. If someone else injected you, who injected you?
- A friend
-A friend of a friend
-A street dealer
-A street dealer who is also my friend
-A relative
-A romantic partner
- A paying sex partner
-Someone I pay for sex
-A doctor
-A stranger passing through
-Other, please describe
SSDA14. How many times in your life have you injected someone else?
-0 (Never)
-1 time
-2 to 5 times
-6 to 10 times
-10 to 100 times
-More than 100 times
SSDA15 Have you ever injected someone else for the first time – that is, given this person their first hit?
-Yes
-No
SSDA16. How many people in town do you think are currently injecting drugs? By think, we mean take your best guess based on your knowledge of the scene in town. Give your best estimate.
- (Enter Number)
SSDA17. How many people in town do you know who are currently injecting drugs? By know, we mean you have either seen them inject, seen track marks or obvious signs that they were injecting, or they have personally told you that they inject drugs. This time, try to count and give an actual number instead of an estimate.
- (Enter Number)
SNSIZEIN: The next section asks questions about how many people with each first name that you know. By know, we mean you know them and they know you by sight or name, that you could contact them, that they live in the United States, that there has been some contact (in person, by phone, mail, or email) over the past two years. These questions might seem a little odd, but we are asking them in order to try to understand the size of your social network.
SNSIZE1.
Name Response Option
Stephanie Drop down (0 to 10+)
Jacqueline Drop down (0 to 10+)
Kimberly Drop down (0 to 10+)
Nicole Drop down (0 to 10+)
Christina Drop down (0 to 10+)
Jennifer Drop down (0 to 10+)
Christopher Drop down (0 to 10+)
David Drop down (0 to 10+)
Robert Drop down (0 to 10+)
Anthony Drop down (0 to 10+)
Robert Drop down (0 to 10+)
James Drop down (0 to 10+)
Michael Drop down (0 to 10+)
SNSIZE2. Can you tell me how many people you know that have had the following experiences in the last 2 years.
Experience Response Option
Diagnosed with Hepatitis C Drop down (0 to 10+)
Diagnosed with HIV/AIDS Drop down (0 to 10+)
Was the victim of a murder Drop down (0 to 10+)
Successfully killed themselves Drop down (0 to 10+)
Overdosed Drop down (0 to 10+)
Was in jail or prison Drop down (0 to 10+)
Was homeless Drop down (0 to 10+)
Was a victim of rape Drop down (0 to 10+)
Died in an auto accident Drop down (0 to 10+)
SSRRINT. The next section asks questions about how you heard about this study.
SSRR1. What is the main reason you participated in this study? (Select ONLY one)
-For the incentive payment
-For the HCV test results
-Someone asked me to
-The study seemed interesting to me or good for society
- To repay a debt to the person who gave me the coupon
-Other, please describe
SSRR2. Did you receive a coupon or code number to participate in this study?
-Yes
-No
SSRR3. How did you receive a coupon or code number to participate in this study?
-Someone handed me a paper coupon
-Someone called or texted me and gave me the code over the phone
-Someone emailed me the code
-I found the code posted on the internet
-Other, please describe
SSRR4. How would you best describe your relationship to the person who gave you the coupon for this survey?
-Someone you met for the first time
-An acquaintance or casual friend
-A friend
-A close friend
-A partner (boyfriend/girlfriend or wife/husband)
-A casual sex partner
-A family member or relative
-A dealer
-A customer
-Someone I know from online only
SSRR5. How many times in the last month did you see the person who gave you this coupon?
-Every day or almost every day (like every day at work)
-More than 5 times
-3 to 5 times
-2 times
-1 time
-I did not see the person
SSRR6. How long have you known the person who gave you the coupon?
-I know the person from online only
-Less than a year
- 1 to 5 years
-More than 5 years
SSRR7. How many times last month did you inject drugs with the person who gave you this coupon?
-More than 5 times
-3 to 5 times
-Twice
-Once
-I did not inject drugs with this person
ICILINT. The next section asks questions about where and how you use drugs.
ICIL1. Over the past week or the last time you injected where did you shoot up? (Select ALL that apply)
- Your own private and secure place (your apartment or dorm room)
- Someone else’s private and secure place (their apartment or dorm room)
- A public indoor space (bar or club bathroom, stairwell)
-A public, outdoor space (an alley or a park)
- Other, please describe
ICIL2. Where did you mostly shoot up? (Select ONLY one)
- Your own private and secure place (your apartment or dorm room)
- Someone else’s private and secure place (their apartment or dorm room)
- A public indoor space (bar or club bathroom, stairwell)
- A public, outdoor space (an alley or a park)
- Other, please describe
ICIL3. Over the past week or the last time you injected, who usually picked when and where to inject? (Select ONLY one)
- I did
- Someone close to me did (a close friend, a romantic partner, or a family member)
- Someone I didn’t know very well (a stranger, or someone who’s not close to me)
ICIL4. Thinking about the last time you injected, how many people were injecting drugs with you?
-Drop down (1-10+)
ICIL5. Again thinking about the last time you injected, how many other people shared the same surface as you did to fix up their shot? By surface, we mean the same general flat space that you used to fix up your own shot.
-Drop down (1-10+)
ICIL6. Over the past week or the last time you injected, how often did you feel as if you needed to hurry when you were preparing and giving yourself an injection?
- Never
- Sometimes
- Always
ICIL7. What was the most common reason you felt like you had to hurry?
To get back to work/family/etc.
To keep someone from seeing me (like a friend or acquaintance, not the police)
To keep from getting caught by the police
So I wouldn’t have to share my drugs
To get some drugs that someone else had
Other, please describe
ICDP1. Over the past week or the last time you injected, how did you clean your hands prior to injecting? (Select ALL that apply)
- Soap and water
- Hand sanitizer
- Rinsed hands under water without soap
- Moist towelette/sanitary square
- Cleaned hands some other way (wiped on pants or a towel)
- Did not clean my hands (SKIP TO 78)
ICDP2. Over the past week or the last time you injected how did you usually clean your hands prior to injecting? (Select ONLY one)
- Soap and water
- Hand sanitizer
- Rinsed hands under water without soap
- Moist towelette/sanitary square
- Cleaned hands some other way (wiped on pants or a towel)
- Did not clean my hands
ICDP3. Over the last week or the last time you injected how did you divide your drugs with other people? (Select ALL that apply)
- I did not divide any drugs with anyone else [If selected, Skip to 80]
- Split the drugs before cooking [If selected, Skip to 80]
- Dissolved into solution and then divided the solution with each person using a syringe
- Loaded the drugs into a syringe and then shot into each person’s syringe with a syringe (Backloading or frontloading)
ICDP4. When you divided drugs using syringes, were you certain that ALL the syringes used were clean/sterile?
-Yes
-No
-I don’t know
ICDP5. Over the last week or the last time you injected how did you usually divide your drugs with other people? (Select ONLY one)
- I did not divide any drugs with anyone else
- Split the drugs before cooking
- Dissolved into liquid and then divided the liquid with each person using a neutral syringe
- Loaded the drugs into a syringe and then shot into each person’s syringe using a neutral syringe (Backloading or frontloading)
ICDP6. When you divided drugs using syringes, were you certain that all the syringes used were clean/sterile?
-Yes
-No
-I don’t know
ICIS1. How do you usually find a vein to shoot your drugs?
- I find it just by looking for it
- I push on my veins and find one that pushes back
- I fish for a vein in a spot where I have gotten off (high) before
- Someone else injects me
- Skin popping
- I take muscle shots (don’t look for a vein)
- Other, please describe
ICIS2. Over the past week or the last time you injected, how many times did you stick yourself before you got a hit?
- 1 time
- 2 times
- 3 to 4 times
- 5 or more times
ICIS3. Over the past week or the last time you injected, how many times did you stick yourself before you got a hit? This time instead of giving a range, just try to estimate the number.
Drop down (1-10+)
ICIS4. Of the X [pre-populate X with ICIS3] times that you stuck yourself the last time you injected, how many times did you leave the needle in and search around for a vein?
Drop down (1-10+)
ICIS5. If you stuck yourself more than one time, how did you stop the bleeding before moving on to your next stick?
-I didn’t, I just let it bleed
-With my finger or hand
- With my mouth or tongue
- With a safety square, fabric, paper towel
-Other, please describe
OMFPSCR. The questions in the next section are about injecting drugs, and some might even seem silly to some people. We can tell you that we are asking them to help support or reject previous statements or beliefs that people may have about people who inject drugs. Please give them the same level of attention and honest response as you have given the previous questions. Thanks.
PCSE1. I can always manage to solve difficult problems if I try hard enough.
-All of the time
-Most of the time
-Some of the time
-Seldom
-Never
PCSE2. If someone opposed me, I can find the means and ways to get what I want.
-All of the time
-Most of the time
-Some of the time
-Seldom
-Never
PCSE3. It is easy for me to stick to my aims and accomplish my goals.
-All of the time
-Most of the time
-Some of the time
-Seldom
-Never
PCSE4. I am confident that I could deal efficiently with unexpected events.
-All of the time
-Most of the time
-Some of the time
-Seldom
-Never
PCSE5. I can remain calm when facing difficulties because I can rely on my coping abilities.
-All of the time
-Most of the time
-Some of the time
-Seldom
-Never
PCSE6. If I am in trouble, I can usually think of a solution.
-All of the time
-Most of the time
-Some of the time
-Seldom
-Never
PCMC1. When carpet is selling at $10 a foot, how many feet can you buy for sixty dollars?
- 10 feet
- 6 feet
- 60 feet
- 16 feet
PCMC2. How many of the five pairs of items listed below are exact duplicates (check ALL that apply)?
-Nieman, K.M. Neiman, K.M.
-Thomas, G.K. Thomas, C. K.
-Hoff, J.P. Hoff, J.P.
-Pino, L.R. Pina, L.R.
-Warner, T.S. Wanner, T.S.
-No pairs are exact duplicates
PCMC3. Consider the following three statements:
The boy plays baseball. All baseball players wear hats. The boy wears a hat.
Assume the first two statements are true. Is the final one…?
-True
-False
-Uncertain
PCE1. I have a wide range of friends and know lots of people.
-True
-False
PCE2. I prefer to know just a few people well.
-True
-False
PCE3. After attending a large social event, I feel like I need time alone to recharge.
-This is mostly true.
-This is mostly false.
-This is sometimes true / I don’t know
PCE4. How do you feel about being in the spotlight?
-I crave attention
-It doesn’t bother me
-I hate it
PCPA1. Do you ever use drugs when you are by yourself?
-Yes
-No
PCPA2. Have you ever had trouble completely stopping using drugs for a period of time when you wanted or needed to (for example when visiting family or to get ready for a drug test)?
-Yes
-No
PCPA3. Have you ever done illegal things to get drugs (other than buy and take them)?
-Yes
-No
PCPA4. Have you ever experienced withdrawal symptoms (felt dope sick) when you stopped taking drugs?
-Yes
-No
PCPA5. Have you ever overdosed?
-Yes
-No
PCPA6. Have you ever been to drug treatment?
-Yes
-No
PCPA7. Have you ever lost a job because of your drug use?
-Yes
-No
PCPA8. Have you ever lost a romantic partner or a very close friend because of your drug use?
-Yes
-No
PCISS. Please evaluate the following statements.
PCISS1. I like to have new and exciting experiences and sensations even if they are a little frightening.
-True
-False
PCISS2. I enjoy getting into new situations where you can’t predict how things will turn out.
-True
-False
PCISS3. I prefer friends who are excitingly unpredictable.
-True
-False
PCISS4. I tend to change interests frequently.
-True
-False
PCAA. Please select how important these statements are to you based on the following options: Very important; Important; Somewhat Important; Of Little Importance; and Not important.
PCAA1. Having or getting a college degree is
-Very important
-Important
-Somewhat Important
-Of Little Importance
-Not important
PCAA2. Making more money than I do now is
-Very important
-Important
-Somewhat Important
-Of Little Importance
-Not important
PCAA3. Owning my own home now or in the future is
-Very important
-Important
-Somewhat Important
-Of Little Importance
-Not important
PCAA4. Being in love and/or having a stable romantic partner is
-Very important
-Important
-Somewhat Important
-Of Little Importance
-Not important
PCAA5. Having a career is
-Very important
-Important
-Somewhat Important
-Of Little Importance
-Not important
PCAA6. Raising children now or in the future is
-Very important
-Important
-Somewhat Important
-Of Little Importance
-Not important
DHINTRO. The next series of questions switches back to drug use and asks about the types of drugs that you’ve used in the past or currently.
DH1. What types of drugs have you ever used? (Check ALL that apply)
-Alcohol
-Marijuana (Weed/Pot/Cannabis)
-Cocaine
-Crack
-Heroin
-Heroin and cocaine together
-Heroin and crack together
-Methadone
-Prescription opiates (Dilaudid/Demeral/Opana/Oxycontin/Vicodin, etc.)
-Prescription amphetamines (Adderall, Concerta, Dexadrine, Ritalin, etc.)
-Prescription benzodiazepine (Ativan, Klonapin, Valium, Xanax)
-Prescription barbiturates (Phenolbarbitol, Seconal, Thuinal)
-Methamphetamine (Speed/Crystal/Crank/Ice/Tina)
-Bathsalts
-Hallucinogens (LSD/Mushrooms/Mescaline)
-Ecstasy (Molly)
-Inhalants (Whippets, huffing, glue, etc.)
-Other, please describe
DH1INJEC. What types of drugs have you ever injected? (Check ALL that apply)
-Prepopulated with DH1 Response (with the exception of marijuana, inhalants)
DH2. You mentioned you had injected prescription opioids:
Do you need more water to prepare prescription opioid pills for injection than you do with regular opioid pills?
-Yes
-No
-I don’t know
DH3. Do you need more water to prepare these kinds of pills than you do for injecting heroin?
-Yes
-No
DH4. In the last week or the last time you injected, which of these drugs did you use, and how many times did you inject it?
-[List all drugs selected in DH1INJEC with a check box to check if used in column one and a dropdown menu from 0 to 10+ in column 2 for how many times did you inject it]
DH5. Right now, which drug do you most like to inject if it’s available (i.e. your drug of choice)?
[Populate with list from DH1INJEC, allow the selection of only one]
DH6. Have you ever regularly (a few times a week) injected a drug other than the drug that you are mostly using now?
-Yes
-No
DH7. If yes, which drugs have you every regularly shot up with?
-Provide applicable drug list
DH8. Like in the example below, please tell us, in order, your favorite drug and favorite way to take them over time from the first to the last drug you have used?
Example table
Drug |
Order |
Method of use |
Age at first use |
Alcohol |
1 |
Drank |
12 |
Marijuana |
2 |
Smoked |
12 |
Prescription Opiates |
3 |
Ate |
15 |
Prescription Opiates |
4 |
Injected |
15 |
Heroin |
5 |
Snorted |
17 |
Cocaine |
6 |
Snorted |
17 |
Heroin |
7 |
Injected |
18 |
Methamphetamine |
8 |
Snorted |
19 |
Heroin and Cocaine |
9 |
Injected |
20 |
Prescription Opiates |
10 |
Injected |
21 |
-Input screen [for programming]
Drug |
Order |
Method of use |
Age at first use |
(Populate with drop down list from DH1) |
Drop down list 1 to 10 |
Drop down options
|
Drop down menu 8 to 29 |
DH9. Think back to the very first time you injected any drugs, other than those prescribed to you. How old were you when you first injected drugs?
-Drop down (ages 8-30, other)
DH9OTH. Please enter age.
-Text box to enter age
DH10. In your lifetime, how many times have you used a needle to shoot drugs?
-1 time
-2 to 5 times
-6 to 10 times
-10 to 100 times
-Between 100 and 1,000 times (Between a month and a year at 3 injections a day)
-More than 1,000 times (More than a year at 3 injections a day)
-Other (please describe)
DH11. In the last 6 months, how many times did you shoot up?
-1 time
-2 to 5 times
-6 to 10 times
-10 to 100 times
-More than 100 times
DH12. In the last month how many days did you shoot up?
-Drop down (0-30)
DH13. In the last week, how many days did you shoot up?
-Drop down (0-7)
DH14. On the average day that you shoot up, how many times per day do you inject?
-Drop down (1-10+)
Thank you for completing the survey. Please notify the staff that you have finished to obtain your Hepatitis C results (if you would like to know your result).
Field Staff Enter Password to proceed
-Text box
HEPCTST. Field Staff Enter Hepatitis C Result (Required Entry)
Positive
Negative
END SURVEY
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Injection Behaviors among Young Persons in Rural/Suburban Settings |
| Subject | Formative Research Survey |
| Author | Prepared by: David Rein, Katherine Meyer |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |