Other Documents

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment B – CI Recruitment Flyers

Recruitment Advertisements (print or online)
Adolescents
*Ages 12 to 17 Needed for Study*
RTI International, a not-for-profit research organization, is looking for adolescents aged 12 to 17 to provide
input on questions for a national study on alcohol use, drug use, and other health-related issues. All
responses will be kept confidential under federal law. No medical tests or examinations are involved.
Requires about 60 minutes. A parent or guardian must accompany the adolescent to the interview. Parents
will not observe the interview or find out answers to any questions. The private interview will be conducted
at our offices in Research Triangle Park, NC. Eligible participants who complete the interview will
receive $40.
For eligibility, call:
XXXX
or
1-800-334-8571 ext. XXXX

*Persons 12 to 17 needed for research study*
RTI International, a not-for-profit research organization, is looking for adolescents aged 12 to 17 to provide
input on questions for a national study on alcohol use, drug use, and other health-related issues. All
responses will be kept confidential under federal law. No medical tests or examinations are involved.
Requires about 60 minutes. Parents should plan to accompany the adolescent to the interview. The private
interview will be conducted at our offices in Washington, DC. Eligible participants who complete the
interview will be given $40.
To learn more, call:
1-800-334-8571 ext. XXX
*Persons 12 to 17 needed for research study*
RTI International, a not-for-profit research organization, is looking for adolescents aged 12 to 17 to provide
input on questions for a national study on alcohol use, drug use, and other health-related issues. All
responses will be kept confidential under federal law. No medical tests or examinations are involved.
Requires about 60 minutes. Parents should plan to accompany the adolescent to the interview. The private
interview will be conducted at our offices in Chicago, IL. Eligible participants who complete the interview
will be given $40.
To learn more, call:
1-800-334-8571 ext. XXX

Ages 65+
*Ages 65 and Older Needed for Study*
RTI International, a not-for-profit research organization, is looking for persons aged 65 and older to
provide input on questions for a national study on alcohol use, drug use, and other health-related issues.
All responses will be kept confidential under federal law. No medical tests or examinations are involved.
Requires about 60 minutes. The private interview will be conducted at our offices in Research Triangle
Park, NC. Eligible participants who complete the interview will receive $40.
For eligibility, call:
XXXX
or
1-800-334-8571 ext. XXXX
*Persons 65 and older needed for research study*
RTI International, a not-for-profit research organization, is looking for persons aged 65 and older to
provide input on questions for a national study on alcohol use, drug use, and other health-related issues. All
responses will be kept confidential under federal law. No medical tests or examinations are involved.
Requires about 90 minutes. The private interview will be conducted at our offices in Washington, DC.
Eligible participants who complete the interview will be given $40.
To learn more, call:
1-800-334-8571 ext. XXXX
*Persons 65 and older needed for research study*
RTI International, a not-for-profit research organization, is looking for persons aged 65 and older to
provide input on questions for a national study on alcohol use, drug use, and other health-related issues. All
responses will be kept confidential under federal law. No medical tests or examinations are involved.
Requires about 90 minutes. The private interview will be conducted at our offices in Chicago, IL. Eligible
participants who complete the interview will be given $40.

Non-native English Speakers
*Research Opportunity for Non-native English Speakers*
RTI International, a not-for-profit research organization, is looking for adults who speak English as a
second lanaguge to provide input on questions for a national study on alcohol use, drug use, and other
health-related issues. All responses will be kept confidential under federal law. No medical tests or
examinations are involved. Requires about 60 minutes. The private interview will be conducted at our
offices in Research Triangle Park, NC. Eligible participants who complete the interview will receive $40.
For eligibility, call:
XXXX
or
1-800-334-8571 ext. XXXX

*Research Opportunity for Non-native English Speakers*
RTI International, a not-for-profit research organization, is looking for adults who speak English as a
second lanaguge to provide input on questions for a national study on alcohol use, drug use, and other
health-related issues. All responses will be kept confidential under federal law. No medical tests or
examinations are involved. Requires about 60 minutes. The private interview will be conducted at our
offices in Washington, DC. Eligible participants who complete the interview will be given $40.
To learn more, call:
1-800-334-8571 ext. XXX
*Research Opportunity for Non-native English Speakers*
RTI International, a not-for-profit research organization, is looking for adults who speak English as a
second lanaguge to provide input on questions for a national study on alcohol use, drug use, and other
health-related issues. All responses will be kept confidential under federal law. No medical tests or
examinations are involved. Requires about 60 minutes. The private interview will be conducted at our
offices in Chicago, IL. Eligible participants who complete the interview will be given $40.
To learn more, call:
1-800-334-8571 ext. XXX

Master Advertistment (Print or Online)
*Research Opportunity for Qualified Participants*
RTI International, a not-for-profit research organization, is looking for respondents to provide input on
questions for a national study on alcohol use, drug use, and other health-related issues. We are interested in
interviewing adults who are over 65 years old or speak English as a second language. We are also
interested in interviewing adolescents aged 12 to 17. All responses will be kept confidential under federal
law. No medical tests or examinations are involved. Requires about 60 minutes. The private interview will
be conducted at our offices in Research Triangle Park, NC. Eligible participants who complete the
interview will receive $40.
For eligibility, call:
XXXX
or
1-800-334-8571 ext. XXXX

*Research Opportunity for Non-native English Speakers*
RTI International, a not-for-profit research organization, is looking for respondents to provide input on
questions for a national study on alcohol use, drug use, and other health-related issues. We are interested in
interviewing adults who are over 65 years old or speak English as a second language. We are also
interested in interviewing adolescents aged 12 to 17. All responses will be kept confidential under federal
law. No medical tests or examinations are involved. Requires about 60 minutes. The private interview will
be conducted at our offices in Washington, DC. Eligible participants who complete the interview will be
given $40.
To learn more, call:
1-800-334-8571 ext. XXX
*Research Opportunity for Non-native English Speakers*
RTI International, a not-for-profit research organization, is looking for respondents to provide input on
questions for a national study on alcohol use, drug use, and other health-related issues. We are interested in
interviewing adults who are over 65 years old or speak English as a second language. We are also
interested in interviewing adolescents aged 12 to 17. All responses will be kept confidential under federal
law. No medical tests or examinations are involved. Requires about 60 minutes. The private interview will
be conducted at our offices in Chicago, IL. Eligible participants who complete the interview will be given
$40.
To learn more, call:
1-800-334-8571 ext. XXX

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment C – CI Recruitment Screening
Scripts

Text-to-Speech Testing
Screening Script to Identify Cognitive Interview Participants
Date/Time of Call ___________________
[NOTE: DO NOT READ TEXT OR RESPONSE CATEGORIES IN ALL CAPS.]
[IF RESPONDING TO A MESSAGE:]
Hello, this is [NAME] calling from RTI International. Thank you for contacting us about our
study that will test questions about alcohol use, drug use, and health care coverage. I understand
that you're interested in participating in an upcoming interview. Is that correct?
[IF ANSWERING AN INCOMING CALL]
Thank you for contacting us about our study that will test questions about alcohol use, drug use,
and health care coverage. I understand that you're calling about participation in an upcoming
study. Is that correct?
IF NO ADDITIONAL INTERVIEWS NEED TO BE SCHEDULED, OFFER TO PUT THE
CALLER ON A WAIT LIST. COLLECT FIRST NAME AND TELEPHONE NUMBER.
Let me ask you a few questions about you to see if you are eligible.
1.

How did you hear about this study?

2.

How old are you? [IF ANY CONCERNS, ASSURE THAT THIS IS ONLY FOR US TO
KNOW ABOUT THE FINAL COMPOSITION OF THE PARTICIPANTS.]
(AGE IN YEARS)
PLEASE READ THE FOLLOWING IF THE PERSON IS UNDER 12:
Since you are [AGE], we cannot interview you for this study. Thank you for your time
and interest. [CONCLUDE THE CALL.]

IF CALLER IS 18 OR OLDER:
2a. Are you calling about your own participation in this study or to enroll your child?
1
SELF – GO TO ADULT SCREENER ON PAGE 7
2
CHILD – CONTINUE WITH 2F

1

3

BOTH – SCREEN ADULT FIRST, THEN RETURN TO 2F TO ASK
PERMISSION FOR CHILD

IF CALLER IS 12-17 YEARS OLD AND:
o IF WE DO NOT CURRENTLY NEED PARTICIPANTS FOR THIS AGE GROUP,
PUT HIM/HER ON A WILL CALL LIST, THANK HIM/HER AND TERMINATE
CALL.
o WE STILL NEED PARTICIPANTS FOR THIS AGE GROUP, CONTINUE WITH 2b.
2b.

Since you are under 18, I will need to talk with a parent or guardian and ask them
if it is okay for you to participate. I will describe the study to your parent or
guardian, including the types of questions that we will ask and what you will need
to do to participate. Your parent or guardian will need to tell us if it is okay for
you to participate in the study.
May I speak with your parent or guardian now to ask if it is okay for you to
participate?
1
2

YES – PARENT/GUARDIAN AVAILABLE [GO TO 2F]
NO – PARENT/GUARDIAN NOT AVAILABLE [GO TO 2C]

2c.

When would be a good time for me to call back to talk with them? ________

2d.

Thank you. If I can't get in touch with your (parent/guardian), I may need to leave
a message for them to call me back. If that happens, I will only say that I'm
calling about a health study, and will not tell anything more about the study until I
have them on the phone. Likewise, when I call you back, if I can't get in touch
with you, I may need to leave a message, but I'll only say that I'm calling about a
health study. We won't ask you anything further for the study until I have a
chance to talk with a (parent/guardian).

2e.

What phone number should I call to reach your parents? _______________

-----------------------------------------------------------------------------------------------------------2f.

TO PARENT/GUARDIAN, IF CHILD CALLED: My name is _______ from
RTI International. Your child responded to an advertisement we placed for
research participants between the ages of 12 and 17 for a study that will help us
see how well young people understand questions about alcohol use, drug use and
health care coverage. We would like to talk with you further about [his/her]
participation in this study. Am I speaking with an adult who is responsible for
[him/her]?

2

YES
NO
TO PARENT/GUARDIAN, IF PARENT/GUARDIAN CALLED: This study will
help us see how well young people understand questions about alcohol use, drug
use and health care coverage. We would like to talk with you further about your
child’s participation in this study. Am I speaking with an adult who is responsible
for [him/her]?
YES
NO
Before I explain more about the study, does your child have any physical
problems that would prevent your child from hearing questions during the
interview?
1

YES
Please describe:
_________________________________________________________________
_________________________________________________________________
2

NO [CONTINUE WITH 2G]

PLEASE READ THE FOLLOWING IF THE PARENT/GUARDIAN REPORTS
VISUAL OR HEARING LIMITATIONS THAT WOULD PREVENT THE
ADOLESCENT FROM DOING THE INTERVIEW:
Since [he/she] is not able to hear the questions, we cannot interview
[him/her] for this study. Thank you for your time and interest.
[CONCLUDE THE CALL.]
2g.

We’re interested in interviewing your child at [RTI’s office in Research
Triangle Park/Chicago/Washington, DC]. His/Her interview will take
about 60 minutes in total. Your child will use a laptop computer to answer
questions about alcohol use, drug use, and other health issues. The
interviewer will ask how well your child understands the questions in the
interview. So that your child can feel comfortable answering the questions
in the interview, you will not be able to observe your child’s interview. If
your child would like to take part, your child will receive $40 in cash.
Your child can skip any question he/she does not want to answer. The
interview will be conducted in private, and the answers will be kept
private and confidential.

3

[ASK IF PARENT HAS ANY QUESTIONS AND IF WE HAVE
INITIAL PERMISSION FOR THE CHILD TO PARTICIPATE AS
WELL.]
THANK

[IF PERMISSION GIVEN] Thank you very much.

----------------------------------------------------------------------------------------------------------3.

OK, great! Let me ask you a few additional questions to determine if your child is
eligible to participate.
CHILD'S SEX [CONFIRM IF NECESSARY]
1
2

MALE
FEMALE

4.

In what city do you live? [TO DETERMINE GEOGRAPHIC DIVERSITY OF
PARTICIPANTS]

5.

How old is the child who will be taking part in the interview?

6.

Has In the past 12 months, how many research studies has your child participated in?
• 0
• 1-2
• 3-5
• 5 OR MORE
IF 1 OR MORE STUDIES, PROBE TO DETERMINE TYPE OF STUDY AND
WHETHER THE CALLER/CHILD HAS PARTICIPATED IN AN RTI STUDY IN
THE PAST 12 MONTHS. THANK CALLER FOR HIS/HER TIME IF
PARTICIPATED IN ANY RTI STUDY IN THE PAST 12 MONTHS OR SURVEY OR
OTHER SOCIAL SCIENCE RESEARCH IN THE PAST 12 MONTHS, SUCH AS
PUBLIC OPINION RESEARCH, PSYCHOLOGY EXPERIMENTS, MARKET
RESEARCH, ETC. (IF UNSURE ABOUT THE TYPE OF PRIOR STUDY
PARTICIPATION, GO TO WAITING LIST INSTRUCTIONS AND CONTACT THE
RTI STUDY LEADER ABOUT ELIGIBILITY.)

GROUP SAMPLE TARGETS TO BE ASSESSED FOLLOWING SCREENING
INTERVIEW (relax as needed in the order indicated):
•

Total: 24 people; 6 adolescents, 6 respondents age 65+, 6 with low levels of literacy, and 6
non-native English speakers.

•

Gender: aim for a 50/50 split of boys and girls
4

[THANK THE PERSON FOR HIS/HER TIME IF THE PERSON MEETS THE GENERAL
ELIGIBILITY CRITERIA BUT A TARGET FOR THE GROUP HAS BEEN MET.
OTHERWISE, CONTINUE.]
IF CHILD IS ELIGIBLE:
Your child is eligible to participate in our interview. Let me tell you a little about the study. The
purpose of the study is to get feedback on how easy or difficult different questions about alcohol
use, drug use, and health care coverage are to understand. These questions will be presented on a
laptop computer. We are doing this research to improve the questions about use of prescription
drugs in a large national survey, called the National Survey on Drug Use and Health, which is
given to about 70,000 people every year. The survey is conducted by RTI International, and is
funded by the Substance Abuse and Mental Health Services Administration or SAMHSA. We
will interview about 18 adults and six adolescents, and the interview will take about 60 minutes.
We are trying to schedule interviews to start in July. If your child takes part in the interviews,
he/she will receive $40 in cash for completing the interviews.
Taking part in the study is voluntary.
Interviews will be conducted at our office in (Research Triangle Park/Chicago/DC).
What your child says during the interview will remain private and confidential. As such, we will
not share information he/she gives us with anyone other than project staff.
Would you allow your child to participate in this study?
1

YES [GET AVAILABILITY DATES/TIMES AND SCHEDULE A
CALLBACK TO CONFIRM. THEN ASK TO SPEAK TO THE CHILD TO
GAIN ASSENT. INFORM THE PARENT THAT WE WILL HANG UP AFTER
SPEAKING WITH THE CHILD, BUT THAT WE WILL SPEAK TO THEM
AGAIN DURING THE CALL BACK.]

2

NO
[IF NO] If you'd like to tell us, we'd be interested in knowing why you decided
that you don't want your child to take part in this study. [USE AVAILABLE
SPACE FOR RESPONSES. THEN THANK THE R FOR HIS/HER TIME.]

WHEN SPEAKING TO CHILD AFTER PARENTAL PERMISSION HAS BEEN OBTAINED:
Hello. Your (mom/dad/guardian) has mentioned that you might be interested in helping us out
with a study. Let me tell you a little about the study. The purpose of the study is to get feedback
on how easy or difficult different questions about alcohol use, drug use, and health care coverage
are to understand. These questions will be presented on a laptop computer. Your parent will not

5

find out your answers to these questions. We are doing this research to improve the questions
about use of prescription drugs in a large national survey, called the National Survey on Drug
Use and Health, which is given to about 70,000 people every year. The survey is conducted by
RTI International, and is funded by the Substance Abuse and Mental Health Services
Administration or SAMHSA. We will interview about 18 adults and six adolescents, and the
interview will take about 60 minutes. Your (mom/dad/guardian) will bring you to our offices so
that you can do the interview. When you have completed the interview, you will receive $40 in
cash.
Taking part in the study is voluntary. Would you like to participate in the interview?
1 YES - - THANK R.
2 NO - - If you'd like to tell us, we'd be interested in knowing why you decided that
you don't want to take part in this study. [USE AVAILABLE SPACE FOR
RESPONSES. THEN THANK THE R FOR HIS/HER TIME.]

6

IF ADULT CALLING FOR AN ADULT ONLY INTERVIEW:
IF WE DO NOT CURRENTLY NEED PARTICIPANTS FOR THIS AGE GROUP, PUT
HIM/HER ON A WILL CALL LIST, THANK HIM/HER AND TERMINATE CALL
As I said, I work with RTI International, which is conducting the National Survey on
Drug Use and Health. RTI is doing this study for the Substance Abuse and Mental Health
Services Administration, which is an agency of the U.S. government.
We’re interested in testing some questions on alcohol use, drug use and health care
coverage. We want to see how well people understand these questions. We plan to
interview about 24 people. Six will be aged 12 to 17, while the rest will be adults. Are
you interested in participating?
1
YES [CONTINUE WITH 3]
2
NO [Thank you for your time and interest. CONCLUDE THE
CALL.]
1.

Before I explain more about the study, do you have any physical problems
that would prevent you from hearing questions during the interview?
YES
Please describe:
_________________________________________________________________
_________________________________________________________________
NO [CONTINUE WITH 4]
PLEASE READ THE FOLLOWING IF THE R REPORTS VISUAL OR
HEARING LIMITATIONS THAT WOULD PREVENT HIM FROM
DOING THE INTERVIEW:
Since you are not able to [read/hear] the questions, we cannot
interview you for this study. Thank you for your time and interest.
[CONCLUDE THE CALL.]

We’re interested in interviewing you at [RTI’s office in Research Triangle
Park/Chicago/Washington, DC]. This interview will take about 60 minutes in total. You
will be asked to answer questions alcohol use, drug use, and other health issues. The
interviewer will ask how well you understand the questions in the interview. If you take
part in the interview and, you will receive $40 in cash.

7

You can skip any question you do not want to answer. The interview will be conducted in
private, and the answers will be kept private and confidential.
[ASK IF R HAS ANY QUESTIONS.]
THANK
2.

[IF PERMISSION GIVEN] Thank you very much.
OK, great! Let me ask you a few additional questions to determine if you are eligible
to participate.
R’S SEX [CONFIRM IF NECESSARY]
MALE
FEMALE

3.

In what city do you live? [TO DETERMINE GEOGRAPHIC DIVERSITY OF
PARTICIPANTS]

4.

What is the highest grade or year of school you have completed? (CIRCLE ONE)
•
•
•
•
•
•

7.

LESS THAN HIGH SCHOOL
HIGH SCHOOL DIPLOMA OR GED
SOME COLLEGE
ASSOCIATE'S DEGREE/DEGREE FROM TECHNICAL OR
COMMUNITY COLLEGE
4-YEAR COLLEGE DEGREE
GRADUATE DEGREE

Is English your native language?
YES
NO [GO TO 7a]

7a.
8.

What is your native language?
In the past 12 months, how many research studies have you participated in?
• 0
• 1-2
• 3-5
• 5 OR MORE
IF 1 OR MORE STUDIES, PROBE TO DETERMINE TYPE OF STUDY AND
WHETHER THE CALLER HAS PARTICIPATED IN AN RTI STUDY IN THE PAST
12 MONTHS. THANK CALLER FOR HIS/HER TIME IF PARTICIPATED IN ANY
8

RTI STUDY IN THE PAST 12 MONTHS OR SURVEY OR OTHER SOCIAL
SCIENCE RESEARCH IN THE PAST 12 MONTHS, SUCH AS PUBLIC OPINION
RESEARCH, PSYCHOLOGY EXPERIMENTS, MARKET RESEARCH, ETC. (IF
UNSURE ABOUT THE TYPE OF PRIOR STUDY PARTICIPATION, GO TO
WAITING LIST INSTRUCTIONS AND CONTACT THE RTI STUDY LEADER
ABOUT ELIGIBILITY.)
GROUP SAMPLE TARGETS TO BE ASSESSED FOLLOWING SCREENING
INTERVIEW (relax as needed in the order indicated):
•

Total: 40 people; 20 adolescents and 20 parent pairs

•

Native Language: aim for six non-native English speakers

•

Literacy: aim for six indicating low literacy. Low literacy will be defined as Education =
LESS THAN HS and recruited from a literacy center

•

Gender: aim for a 50/50 mix of men and women

[THANK THE PERSON FOR HIS/HER TIME IF THE PERSON MEETS THE GENERAL
ELIGIBILITY CRITERIA BUT A TARGET FOR THE GROUP HAS BEEN MET.
OTHERWISE, CONTINUE.]
IF R IS ELIGIBLE:
You are eligible to participate in our interview. Let me tell you a little about the study. The
purpose of the study is to get feedback on how easy or difficult different questions about alcohol
use, drug use, and health care coverage are to understand. These questions will be presented on a
laptop computer. We are doing this research to improve the questions about use of prescription
drugs in a large national survey, called the National Survey on Drug Use and Health, which is
given to about 70,000 people every year. The survey is conducted by RTI International, and is
funded by the Substance Abuse and Mental Health Services Administration or SAMHSA. We
will interview about 24 adults and six adolescents, and the interview will take about 60 minutes.
We are trying to schedule interviews to start in July. If you take part in the interviews, you will
receive $40 in cash for completing the interviews.
Taking part in the study is voluntary.
Interviews will be conducted at our office in (Research Triangle Park/Chicago/DC).
What you say during the interview will remain private and confidential. As such, we will not
share information you give us with anyone other than project staff.
Are you available to participate in this study?

9

1

YES [GET AVAILABILITY DATES/TIMES AND SCHEDULE A
CALLBACK TO CONFIRM.]

2

NO
[IF NO] If you'd like to tell us, we'd be interested in knowing why you decided
that you don't want to take part in this study. [USE AVAILABLE SPACE FOR
RESPONSES. THEN THANK THE R FOR HIS/HER TIME.]

10

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment D – CI Parental Permission Forms

Parental Permission and Informed Consent
The National Survey on Drug Use and Health is a large survey given to about
70,000 people across the country every year. RTI International conducts the National
Survey on Drug Use and Health. It collects information on many health-related issues.
We ask about a lot of health issues, so that we can better help everyone in the United
States. Right now we’re interested in testing a new computerized voice that will reading
some questions in the study. Before we do this, we want to see how well people
understand these questions and how they might go about answering them. We are under
contract with the Substance Abuse and Mental Health Services Administration to carry
out this survey. You or your child responded to an advertisement that we placed for
research subjects. At present, we are seeking the help of young people like your child to
see how our new questions work.
Your child is one of six adolescent respondents in Washington, DC, and Research
Triangle Park, NC who are participating in this study. Taking part in the interview is
strictly voluntary. Your child can skip any portion of the interview he/she does not wish
to be involved with. There is no penalty if he/she chooses to skip any part of the
interview. The interview will be conducted in private to ensure nobody else overhears
his/her answers. All answers will be kept private and confidential. We will not share the
information given to us with any person outside the project staff, and your child's name
will never be connected to the answers he/she provides. Federal law requires us to keep
your child’s answers confidential and to use his/her answers only for statistical purposes
(the Confidential Information Protection and Statistical Efficiency Act of 2002). The
only exception to this promise of confidentiality is if your child tells me that he/she
intends to seriously harm him/herself or someone else or if he/she has been abused or if
your child identifies a person who has given him/her drugs; in this situation I may need to
notify a mental health professional or other authorities.
The interview will take about one hour. During the interview, your will listen to
survey questions being played using different voices. The survey includes questions
about the use of tobacco, alcohol, drugs such as marijuana, and other health issues.
However, we will not be asking your child to answer these questions. Instead, we will ask
follow up items about the survey questions to determine whether the voice used to read
the questions was clear and easy to understand. For example, we may ask your child to
repeat the question in his or her own words.
He/She will receive $40 in cash in appreciation for the interview.
We would like to audio record the interactions between your child and the interviewer.
The recording will be heard only by members of the research team to help us make sure
we have all the information from your child about how these questions work. To protect
his/her privacy, the recording will remain on the laptop computer, which will be
protected by a password. The recording will be destroyed soon after the study ends.
However, having the interactions recorded is voluntary and you can decline for your
child.

If you have any questions about this study, you can contact Emily Geisen at RTI at 1800-334-8571 X. 26566). If you have any questions about your rights as a parent or legal
guardian or your child's rights as a study participant, you can call RTI's Office of
Research Protection at 1-866-214-2043 (a toll-free number).
Do we have your permission for [CHILD’S NAME] to participate?
As Parent/Guardian, I give my permission for my child to participate in this interview.
____Yes

____No

As Parent/Guardian, I give my permission for my child’s interview to be audio recorded:
____Yes

____No

Signature of Interviewer:______________________________

Date:__________________

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment E – CI Participant Informed
Consent Forms

Text to Speech Testing
Adult Cognitive Interview Participant Informed Consent Form
National Survey on Drug Use and Health (NSDUH)
Introduction
I am going to explain this study to you. You can stop me at any time if you have questions about anything I tell
you.
The purpose of this study is to test some questions that will be used in the National Survey on Drug Use and
Health, or NSDUH. The NSDUH is a large survey given to about 70,000 people across the country each year. It
collects information on many health-related issues. The aim is to better serve all people throughout the United
States. Right now, we're interested in evaluating the voice that will read some questions in the study. We want
to see how well people understand these questions and how they might go about answering them. RTI is
carrying out this research study for the Substance Abuse and Mental Health Services Administration, or
SAMHSA, which is part of the US Department of Health and Human Services. You are one of 30 participants
at least 12 years old (including about 24 adults) who will review the survey questions for this study.
Description of the Interview
Your participation in this interview will involve listening to survey questions being played using different
voices. The survey includes questions about the use tobacco, alcohol, drugs such as marijuana, and other health
issues. However, I will not be asking you to answer these questions. Instead, I will ask you follow up questions
to determine whether the voices used to read the questions were clear and easy for you to understand. For some
questions, I may ask you to put the questions in your own words. The interview will last approximately 60
minutes. Your participation in this study will end after you finish the interview.
We also would like to audio record what you say during the interview. Only the people who work on this study
will hear the recording. It will help us make sure we have understood your answers. If you don't want us to
audio record you, that's okay.
Confidentiality/Your Rights
Taking part in the interview is completely voluntary. You can skip any interview questions you do not wish to
answer. Your personal information will not be connected to your answers in any way. Federal law requires us to
keep your answers confidential and to use these answers only for statistical purposes (the Confidential
Information Protection and Statistical Efficiency Act of 2002). With your agreement, we will audio record your
interview. You can ask us to pause or stop the recording at any time. Only RTI and SAMHSA research team
members will be able to listen to the recordings. The recordings will be destroyed within 60 days of the end of
this study. Comments from all interviews will be combined in a report that will not identify who made the
comments.
[Read only if observer is present: A member of the RTI research team or representative(s) of SAMHSA is here
with us today and would like to observe this interview from a separate observation room. If you do not want
anyone else to observe your interview, we will simply ask this person (these people) to leave the observation
room and then do the interview.]
Possible Risks and Benefits
You can ask me to stop the interview at any time. If you want to take a break at any time during the interview,
please tell me. It is possible some of the survey questions may make you feel uncomfortable or upset. If this
happens, I can tell you how to contact a counselor.
1

There are no direct benefits to you from participating in this interview. However the answers you give will help
us to improve the quality of questions for the NSDUH.
Payment for Participation
You will be given $40 in cash for completing the interview.
Your Questions
If you have any other questions about the study, you can call Ms. Emily Geisen at 1-800-334-8571 ext. 26566.
If you have any questions about your rights as a study participant, you can call RTI's Office of Research
Protection at 1-866-214-2043 (a toll-free number).
I will sign my name here to indicate that I have explained this information to you and that you have agreed to be
interviewed.
___________________________
Signature of Interviewer

_________________________
Date

Read only if observer is present: I also will sign my name here to indicate that you have given your consent for
a member of the RTI research team or representative of SAMHSA to observe the interview. [INTERVIEWER,
PLEASE WRITE "NA" ON THE SIGNATURE LINE IF THE INTERVIEW IS NOT BEING OBSERVED.]
___________________________
Signature of Interviewer

_________________________
Date

Finally, I will sign my name here to indicate that you have agreed for the interview to be audio recorded.
___________________________
Signature of Interviewer

_________________________
Date

2

Participant Informed Assent (ADOLESCENT)
Introduction
I am going to explain this study to you. You can stop me at any time if you have questions about anything I tell
you.
The purpose of this study is to test some questions that will be used in the National Survey on Drug Use and
Health, or NSDUH. The NSDUH is a large survey given to about 70,000 people across the country each year. It
collects information on many health-related issues, to better help everyone in the United States. We're interested
in evaluating the voice that will read some questions in the study. We want to see how well people understand
these questions. We also want to know how people go about answering the questions. RTI is doing this study
for the Substance Abuse and Mental Health Services Administration, or SAMHSA. You are one of six
participants between the ages of 12 to 17 who will help us test these questions.
Description of the Interview
Your participation in this interview will involve listening to survey questions being played using different
voices. The survey includes questions about the use tobacco, alcohol, drugs such as marijuana, and other health
issues. However, I will not be asking you to answer these questions. Instead, I will ask you follow up questions
to determine whether the voices used to read the questions were clear and easy for you to understand. For some
questions, I may ask you to put the questions in your own words. The interview will last approximately 60
minutes. Your participation in this study will end after you finish the interview.
We also would like to audio record what you say during the interview. Only the people who work on this study
will hear the recording. It will help us make sure we have understood your answers. If you don't want us to
audio record you, that's okay.
Confidentiality/Your Rights
You don't have to answer a question if you don't want to. If you want to take a break at any time, just tell me.
Your name will be kept private. No one else will see your answers to these questions. Your parents will not
find out about your answers to questions. The only exceptions to this promise of confidentiality are if you tell
me that you intend to seriously harm yourself or someone else or if you have been abused or if you identify an
adult who has given you drugs; in these situations I may need to notify a mental health professional or other
authorities.
Possible Risks and Benefits
Some of the the questions we ask may make you feel uncomfortable or upset. If this happens, let me know right
away, and we can either take a break or I can give you information about talking with a counselor.
We are required by law to keep your answers private. The law also requires the study to use your answers only
to learn how the questions work. The name of this law is the Confidential Information Protection and Statistical
Efficiency Act of 2002.
There are no direct benefits to you from doing this interview. Your involvement in this study will help us
improve the questions for the NSDUH.
When we finish, I will give you $40 in cash to thank you for taking time to talk to me.
If you or your parent/guardian have any other questions about the study, you can call Ms. Emily Geisen at 1800-334-8571 ext. 26566. If you or your parent/guardian have any questions about your rights as a participant
in this study, you can call RTI's Office of Research Protection at 1-866-214-2043.
1

I will sign my name here to indicate that I have explained this information to you and that you have agreed to be
interviewed. You will be given a copy of this form.
___________________________
Signature of Interviewer

_________________________
Date

I will sign my name here to indicate that you have agreed for the interview to be audio recorded.
___________________________
Signature of Interviewer

_________________________
Date

2

Participant Assent to Be Observed (ADOLESCENT)
[Another person who works on the study/A person or people who work(s) with the sponsor of this study] also is
here with us today. This person (These people) would like to watch your interview in a separate observation
room. We have already talked with your parent or guardian about this, and they have said it is okay to have this
person (these people) watch the interview. What you say will still be kept private. It's okay if you don't want
this person (these people) to watch your interview. We will simply ask that person(them) to leave the
observation room.
Is it OK for this person (them) to watch your interview?
CHECK ONE OF THE BOXES BELOW. SIGN AND DATE FORM
____Other study team member or sponsor representative may observe the interview.
____Other study team member or sponsor representative may not observe the interview.

___________________________
Signature of Interviewer

_______________________
Date

3

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment F – CI Receipt for Participation

Receipt for Participation
The participant has voluntarily taken part in a study to improve the questions asked in a national
survey on alcohol and drug use. This study is being conducted by RTI International for the
Substance Abuse and Mental Health Services Administration (SAMHSA). By my signature
below, I confirm that I have given the participant $40.00 in appreciation for his/her participation
in this project.

RTI Staff Signature

Date

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment U – Cognitive Interview Debriefing
Questions

NSDUH TTS Pretesting Debriefing Questions 
Cognitive Interview Phase 

The next few questions ask for your opinions about the voice that read the questions you just heard. 
Please think carefully about this voice as you answer these questions. 

1. How would you rate the speed or pace of the voice that read the interview questions? Would you 
say the pace of the voice was much too slow, a little too slow, just right, a little too fast, or much 
too fast?  
☐  MUCH TOO SLOW 
☐  A LITTLE TOO SLOW 
☐  JUST RIGHT (NEITHER TOO FAST NOR TOO SLOW) 
☐  A LITTLE TOO FAST 
☐  MUCH TOO FAST 

2. Cadence is the way a voice changes by gently rising and falling when speaking. How would you 
rate the cadence of the voice? Would you say the cadence of the voice was excellent, very good, 
good, fair, poor, or very poor? 

☐  EXCELLENT 
☐  GOOD 
☐  FAIR 
☐  POOR 
☐  VERY POOR 

3. How would you rate the pronunciation of the questions read by the voice? Would you say the 
pronunciation of the voice was excellent, good, fair, poor, or very poor? 

☐  EXCELLENT 
☐  GOOD 
☐  FAIR 
☐  POOR 
☐  VERY POOR 

4. How difficult was it to understand the voice?  Would you say not at all difficult, slightly difficult, 
moderately difficult, very difficult or extremely difficult?  

☐  NOT AT ALL DIFFICULT 
☐  SLIGHTLY DIFFICULT 
☐  MODERATELY DIFFICULT 
☐  VERY DIFFICULT 
☐  EXTREMELY DIFFICULT 

5. How pleasant was the voice? Would you say not at all pleasant, somewhat pleasant, moderately 
pleasant, very pleasant or extremely pleasant? 

☐  NOT AT ALL PLEASANT 
☐  SOMEWHAT PLEASANT 
☐  MODERATELY PLEASANT 
☐  VERY PLEASANT 
☐  EXTREMELY PLEASANT 

6. How do you rate the overall quality of the voice? Would you say the quality of the voice was 
excellent, good, fair, poor, or very poor? 

☐  EXCELLENT 
☐  GOOD 
☐  FAIR 
☐  POOR 
☐  VERY POOR 

7. This voice might be used in an interview for about 30 minutes. How comfortable would you be 
listening to that voice for 30 minutes? Would you say not at all comfortable, slightly comfortable, 
moderately comfortable, very comfortable or completely comfortable? 

☐  NOT AT ALL COMFORTABLE 
☐  SLIGHTLY COMFORTABLE 
☐  MODERATELY COMFORTABLE 
☐  VERY COMFORTABLE 
☐  EXTREMELY COMFORTABLE 

8. You said [ANSWER FROM Q7].Tell me more about how you chose your answer. 

Click here to enter text. 

9. Was there anything else about the voice that you liked or disliked? 

Click here to enter text. 

FINAL DEBRIEFING (TO BE READ AFTER ALL THREE VOICES) 

10. Of the three voices you heard, which voice did you prefer most? 

☐  HUMAN VOICE (VOICE ___) 
☐  SLOWER COMPUTERIZED VOICE (VOICE ___) 
☐  FASTER COMPUTERIZED VOICE   (VOICE ___) 
☐  NO PREFERENCE   

11. Tell me more about why you prefer that voice. 

Click here to enter text. 

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment H – Lead Letter

UNITED STATES DEPARTMENT OF HEALTH & HUMAN SERVICES
ROCKVILLE, MD 20857

[NAME County/Parish/District] Resident at:
1234 Main Street
Anywhere, XX 12345

Dear [NAME County/Parish/District] Resident:
The U.S. Department of Health and Human Services is conducting a study called the National
Survey on Drug Use and Health. This study asks questions about use or non-use of alcohol,
tobacco and other substances. The study also asks about mental health and other health-related
topics relevant for all people. Since 1971, this information has been used by local, state and
national agencies for planning and providing treatment and prevention programs.
Your address was randomly chosen, through scientific methods, along with almost 200,000
others across the country. RTI International, a nonprofit organization, was selected to conduct
this study. Soon, an RTI interviewer will be in your neighborhood to give you more information.
The interviewer will carry an identification card like the example shown below.
First, the interviewer will ask a few general questions. Then the interviewer may ask one or two
members of your household to complete the full interview. It is possible no one will be chosen
to be interviewed. If anyone is chosen and completes the full interview, he or she will
receive $30 in cash.
By Federal law*, the answers you give will be kept confidential and will be used only for
statistical purposes.
Please share this information with any others in your household. Feel free to ask the interviewer
any questions you have about this study. More information is also available on the study website
at: http://nsduhweb.rti.org or you may contact us at 1-800-848-4079.
Your help is very important to this study’s success. Thank you for your cooperation.
Sincerely,

Joel Kennet, Ph.D.
National Study Director, DHHS

Ilona S. Johnson
National Field Director, RTI
You will be contacted by: ___________________________________________
Interviewer Name
*Confidentiality protected by the Confidential Information Protection and Statistical Efficiency Act of 2002 (PL 107-347)
Authorized by the U.S. Congress as part of Section 505 of the Public Health Service Act (42 USC 290aa4)
Approved by Office of Management and Budget (OMB Approval No. XXXX-XXXX)

UNITED STATES DEPARTMENT OF HEALTH & HUMAN SERVICES
ROCKVILLE, MD 20857

Residente de: [NAME County/Parish/District]
1234 Main Street
Anywhere, XX 12345
Estimado(a) residente de [NAME County/Parish/District]:
El Departamento de Salud y Servicios Humanos de los Estados Unidos está realizando un estudio
llamado Encuesta Nacional de la Salud y el Consumo de Drogas. Este estudio hace preguntas
acerca del uso o no uso de alcohol, tabaco y otras sustancias. El estudio también hace preguntas
sobre la salud mental y otros aspectos relacionados con la salud que son de importancia para todas
las personas. Desde 1971, esta información ha sido utilizada por agencias locales, estatales y
nacionales para planear y proporcionar tratamiento y programas de prevención.
La dirección de usted fue seleccionada al azar, a través de métodos científicos, junto con casi
otras 200,000 direcciones en todo el país. RTI International, una organización sin fines de lucro,
fue elegida para realizar este estudio. Dentro de poco, un entrevistador de RTI estará en su
comunidad para darle más información. El entrevistador llevará consigo una tarjeta de
identificación similar a la que se muestra más abajo.
Primero, el entrevistador le hará unas pocas preguntas generales. Luego, es posible que el
entrevistador le pida a una o a dos personas en su hogar que completen una entrevista en su
totalidad. Es posible que nadie sea seleccionado para la entrevista. Si alguien es seleccionado y
completa toda la entrevista, él o ella recibirá $30 dólares en efectivo.
Según la ley federal*, las respuestas que nos dé se mantendrán confidenciales y sólo se utilizarán
con propósitos estadísticos.
Por favor, comparta esta información con las otras personas en su hogar. Si tiene preguntas sobre
este estudio, por favor no dude en hacérselas al entrevistador. También puede encontrar más
información en el sitio de Internet del estudio en: http://nsduhweb.rti.org (disponible solamente
en inglés), o puede llamarnos al 1-800-848-4079.
Su ayuda es muy importante para el éxito de este estudio. Gracias por su cooperación.
Atentamente,

Dr. Joel Kennet
Director Nacional de Estudios, Departamento
de Salud y Servicios Humanos

Ilona S. Johnson
Directora Nacional del Estudio, RTI
Entrevistador(a) que se comunicará con usted: _____________________________________________
Nombre del/de la entrevistador(a)
*La confidencialidad está protegida por la Ley de Protección de la Información Confidencial y Eficiencia Estadística del año 2002
(PL 107-347). El estudio está autorizado por la sección 505 de la Ley del Servicio de Salud Pública (42 USC 290aa4). El estudio está
aprobado por la Oficina de Administración y Presupuesto (OMB, siglas en inglés), Número de aprobación XXXX-XXXX.

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment I – Contact Cards – Sorry I Missed
You and Appointment Cards

Sorry I
Missed You…

Sorry I
Missed You…

Dear Resident:

Dear Resident:

I stopped by today to talk to you about an
important research study being conducted by RTI.

I stopped by today to talk to you about an
important research study being conducted by RTI.

I am sorry that I did not find you at home. I will
return to talk with you in the next few days.

I am sorry that I did not find you at home. I will
return to talk with you in the next few days.

Thank you in advance for your participation.

Thank you in advance for your participation.

Sincerely,__________________________________

Sincerely,__________________________________

Date: ________________ Time: ______________

Date: ________________ Time: ______________

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment J – Study Description

Study
Description
Your address is one of several in this area randomly chosen for the 2014 National
Survey on Drug Use and Health. This study, sponsored by the U.S. Department of
Health and Human Services, collects information for research and program planning by
asking about:
 tobacco, alcohol, and drug use or non-use,
 knowledge and attitudes about drugs, 
 mental health, and
 other health issues. 
You cannot be identified through any information you give us. Your name and address
will never be connected to your answers. Also, federal law requires us to keep all of
your answers confidential. Any data that you provide will only be used by authorized
personnel for statistical purposes according to the Confidential Information Protection
and Statistical Efficiency Act of 2002.
The screening questions take just a few minutes. If anyone is chosen, the interview will
take about an hour. You can refuse to answer any questions, and you can quit at any
time. Each person who is chosen and completes the interview will receive $30
in cash.
If you have questions about the study, call the Project Representative at 1-800-8484079. If you have questions about your rights as a study participant, call RTI’s Office of
Research Protection at 1-866-214-2043 (a toll-free number). You can also visit our
project website: http://nsduhweb.rti.org/ for more information.
Thank you for your cooperation and time.

Peter Tice, Ph.D.
Project Officer
Center for Behavioral Health Statistics and Quality
Substance Abuse and Mental Health Services Administration (SAMHSA)
U.S. Department of Health and Human Services
Your confidentiality is protected by the Confidential Information Protection and Statistical Efficiency Act of 2002
(CIPSEA, PL 107-347). Any project staff or authorized data user who violates CIPSEA may be subject to a jail
term of up to 5 years, a fine of up to $250,000, or both.

NOTICE: Public reporting burden for this collection of information is estimated to average 60 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, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, Paperwork Reduction Project (09300110); Room 2-1057; 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 OMB control number for this project is XXXX-XXXX, expiration date XX/XX/XX.

Descripción
del estudio
Su dirección es una de varias en esta zona que fue seleccionada al azar para participar en
la Encuesta Nacional sobre la Salud y el Consumo de Drogas del año 2014. Este estudio
está bajo el patrocinio del Departamento de Salud y Servicios Humanos de los Estados
Unidos y tiene como fin recopilar información para planificar estudios y programas
relacionados con la salud al preguntar acerca de lo siguiente:
 el uso o no uso de tabaco, alcohol y drogas,
 el conocimiento y actitudes hacia las drogas, 
 la salud mental, y
 otros asuntos relacionados con la salud. 
A usted no se le podrá identificar a través de ninguna información que nos proporcione. Sus
respuestas nunca se relacionarán con su nombre y dirección. Además, la ley federal
requiere que mantengamos todas sus respuestas en forma confidencial. Cualquier
información que usted proporcione será utilizada solamente por el personal autorizado con
propósitos estadísticos, de acuerdo a la ley de Protección de la Información Confidencial y
Eficiencia Estadística del año 2002.
Las preguntas iniciales de selección duran solo unos minutos. Si alguien es seleccionado(a),
la entrevista durará aproximadamente una hora y media. Usted puede rehusarse a
contestar cualquier pregunta y puede dejar de participar en cualquier momento. Cada
persona seleccionada que complete la entrevista recibirá $30 dólares en efectivo.
Si tiene alguna pregunta acerca del estudio, sírvase llamar al representante del proyecto al
1-800-848-4079. Si tiene alguna pregunta acerca de sus derechos como participante del
estudio, sírvase llamar a la Oficina de RTI para la Protección de Participantes en Estudios al
1-866-214-2043 (número gratuito). También le invitamos a visitar nuestro sitio en el
Internet: http://nsduhweb.rti.org/ si desea mayor información.
Le agradecemos su tiempo y colaboración.

Dr. Peter Tice
Administrador del Proyecto
Centro para las Estadísticas y la Calidad de la Salud Conductual
Administración de Servicios para el Abuso de Drogas y la Salud Mental (SAMHSA)
Departamento de la Salud Pública de los Estados Unidos
Departamento de Salud y Servicios Humanos
Su confidencialidad está protegida por la ley de Protección de la Información Confidencial y Eficiencia Estadística
del año 2002 (CIPSEA, por sus siglas en inglés, Ley Pública 107-347). Cualquier miembro del personal del
proyecto o cualquier empleado autorizado a usar los datos que viole esta ley, puede estar sujeto a pasar tiempo
en prisión hasta por 5 años, puede ser multado hasta por $250,000 dólares, o ambos.
NOTA: Se calcula que el tiempo aproximado que le tomará a cada participante en dar esta información será 90 minutos por cada entrevista, incluyendo el tiempo para repasar
las instrucciones, buscar las fuentes de información existentes, juntar y mantener los datos requeridos, así como completar y revisar la recopilación de datos. Envíe sus
comentarios acerca de este cálculo de tiempo o acerca de cualquier otro aspecto relacionado con esta recolección de datos, incluyendo sugerencias respecto a la reducción del
tiempo, a SAMHSA Reports Clearance Officer, Paperwork Reduction Project (0930-0110); Room 2-1057; 1 Choke Cherry Road; Rockville, MD 20857. Ninguna agencia está
autorizada a realizar o a patrocinar ninguna recopilación de datos o información sin presentar un número de control OMB válido, ni está obligada ninguna persona a participar en
una recopilación de datos si no existe dicho número. El número de control OMB para este proyecto es XXXX-XXXX, con fecha de vencimiento XX/XX/XX.

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment O – Federalwide Assurance

http://ohrp.cit.nih.gov/search/IOrgDtl.aspx

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment T – Quality Control Form

QUALITY CONTROL FORM
NOTICE: Public reporting burden (or time) for this collection of information is estimated to average 2 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, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer,
Paperwork Reduction Project (0930-0110); Room 2-1057; 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 OMB control number for this project is xxxx-xxxx.

OMB No.: xxxx-xxxx
OMB Expiration Date:
xx/xx/xx

VERSIÓN EN ESPAÑOL AL REVERSO
As part of our quality control program, we plan to contact a portion of the survey participants to
make sure that the interviewer has followed the study procedures. We only ask general
questions—no specific information is required. We sincerely appreciate your cooperation.
Please fill in the boxes below. (PLEASE PRINT CLEARLY.) Thank you.

[Your phone number will be kept confidential and will not be released to anyone other than our
quality control representatives.]
TELEPHONE
NUMBER

_

_

(Area Code)

(Telephone Number)

YOUR
ADDRESS
CITY

ZIP
CODE

STATE

BOXES BELOW MUST FIRST BE COMPLETED [IN INK] BY INTERVIEWER.
TODAY’S
DATE

M

M

_

D

D

_

1

FI
NAME
CASE
ID #

4

TIME

.
.

AM
PM

FI
ID #
_

_

_

Include
A or B!

IF respondent is 12 - 17 years old, which
adult granted permission for the interview? 
(Examples: father, mother, etc.)

[Print Parent/Guardian’s relationship to the child in this box.]

FORMULARIO DE CONTROL DE CALIDAD
NOTA: Se calcula que el tiempo que le tomará a cada participante para dar esta información será 2 minutos, incluyendo el tiempo
para repasar las instrucciones, buscar las fuentes de información existentes, reunir y mantener los datos requeridos, así como
completar y revisar la recopilación de información. Envíe sus comentarios acerca de este cálculo de tiempo o cualquier otro aspecto
relacionado con esta recolección de información, incluyendo sugerencias para reducir el tiempo a: SAMHSA Reports Clearance Officer,
Paperwork Reduction Project (0930-0110); Room 2-1057; 1 Choke Cherry Road, Rockville, MD 20857. Ninguna agencia está
autorizada a realizar o patrocinar ninguna recopilación de información sin presentar un número de control válido de la Oficina de
Administración y Presupuesto (OMB, por sus siglas en inglés), ni tampoco está obligada ninguna persona a participar en una
recopilación de información si no existe dicho número. El número de control OMB para este proyecto es xxxx-xxxx.

No. de control OMB:
xxxx-xxxx
Fecha de vencimiento:
xx de month de 20xx

ENGLISH VERSION ON OTHER SIDE
Como parte de nuestro programa de control de calidad, pensamos comunicarnos con un grupo de
participantes de esta encuesta para asegurarnos que el (la) entrevistador(a) ha cumplido con los
procedimientos apropiados del estudio. Solo haremos preguntas en general y no solicitaremos
ninguna información específica. Le agradecemos sinceramente su colaboración.
Por favor llene los espacios en blanco a continuación. (FAVOR DE ESCRIBIR CLARAMENTE.)
Gracias.

[Su número de teléfono se mantendrá confidencial y solo se dará esta información a nuestro
personal encargado del control de calidad.]
_

NÚMERO DE
TELÉFONO

_

(Código de área)

(Número de teléfono)

SU
DIRECCIÓN

CIUDAD

CÓDIGO
POSTAL

ESTADO

BOXES BELOW MUST FIRST BE COMPLETED [IN INK] BY INTERVIEWER.
TODAY’S
DATE

M

M

_

D

D

_

1

FI
NAME
CASE
ID #

4

TIME

.
.

AM
PM

FI
ID #
_

_

_

Include
A or B!

IF respondent is 12 - 17 years old, which
adult granted permission for the interview? 
(Examples: father, mother, etc.)

[Print Parent/Guardian’s relationship to the child in this box.]

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment K – Introduction and Informed
Consent Scripts

INTRODUCTION AND INFORMED CONSENT FOR
INTERVIEW RESPONDENTS AGE 18+

INTRODUCE YOURSELF AND STUDY AS NECESSARY: Hello, I’m ________,
and I’m working on a nationwide study sponsored by the U.S. Department of
Health and Human Services. You should have received a letter about this study.
(SHOW LEAD LETTER, IF NECESSARY.)
READ THE BOXED INFORMATION BELOW
BEFORE STARTING EVERY INTERVIEW

This year, we are interviewing about 70,000 people across the nation. You have
been randomly chosen to take part. You may choose not to take part in this study,
but no one else can take your place. We will give you $30 when you finish the
interview.
GIVE STUDY DESCRIPTION TO R IF YOU HAVE NOT ALREADY DONE SO.
This study asks about tobacco, alcohol, and drug use or non-use, knowledge and
attitudes about drugs, mental health, and other health issues. It takes about an
hour. You will answer most of the questions on the computer, so I will not see your
answers. We are only interested in the combined responses from all 70,000 people,
not just one person’s answers. This is why we do not ask for your name and we
keep your answers separate from your address. RTI may contact you by phone or
mail to ask a few questions about the quality of my work. This is why we ask for
your phone number and current address at the end of the interview.
While the interview has some personal questions, federal law keeps your answers
private. We hope that protecting your privacy will help you to give accurate
answers. You can quit the interview at any time and you can refuse to answer any
questions.
If it is all right with you, let’s get started.
(Can we find a private place to complete the interview?)

INTRODUCTION AND INFORMED CONSENT FOR
INTERVIEW RESPONDENTS AGE 12-17
READ THE SCRIPT BELOW AND OBTAIN PERMISSION FROM THE PARENT/GUARDIAN

Your (AGE) year-old child has been selected to be in this study. Your child’s participation is
voluntary. This interview asks about tobacco, alcohol, and drug use or non-use, knowledge
and attitudes about drugs, mental health, and other health related issues. All of your child’s
answers will be confidential and used only for statistical purposes. Since your child will answer
most of the questions on the computer, I will never see the answers, and you are not allowed
to see them either. If it is all right with you, we’ll get started.
(Can we find a private place to complete the interview?)

ONCE PARENTAL PERMISSION HAS BEEN GIVEN, CONFIRM THE PARENT/GUARDIAN OR
ANOTHER ADULT WILL BE PRESENT FOR THE DURATION OF THE INTERVIEW
THEN, READ THE BOXED INFORMATION BELOW BEFORE STARTING EVERY INTERVIEW
WITH A 12-17 YEAR OLD

This year, we are interviewing about 70,000 people across the nation. You have been
randomly chosen to take part. You may choose not to take part in this study, but no one else
can take your place. We will give you $30 when you finish the interview.
GIVE STUDY DESCRIPTION TO R IF YOU HAVE NOT ALREADY DONE SO.
This study asks about tobacco, alcohol, and drug use or non-use, knowledge and attitudes
about drugs, mental health, and other health issues. It takes about an hour. You will answer
most of the questions on the computer, so I will not see your answers. Your answers will
never be seen by either your parents or your school. We are only interested in the combined
responses from all 70,000 people, not just one person’s answers. This is why we do not ask
for your name and we keep your answers separate from your address. RTI may contact you
by phone or mail to ask a few questions about the quality of my work. This is why we ask for
your phone number and current address at the end of the interview.
While the interview has some personal questions, federal law keeps your answers private. We
hope that protecting your privacy will help you to give accurate answers. You can quit the
interview at any time and you can refuse to answer any questions.
If it is all right with you, let’s get started.

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment W – Tablet Screening Video Script

TABLET SCREENING VIDEO SCRIPT
To serve people across the United States, the National Survey on Drug Use and Health collects data on
substance use, mental health and other health-related issues that are used by local, state, and national
agencies to support education, treatment and prevention programs.
For this survey, households nationwide just like yours are scientifically selected at random and then
visited by a professional interviewer.
During this visit, the interviewer asks a few general questions to determine if anyone in your household
will complete an interview. Those completing the full interview will receive $30 cash.
To protect your privacy, you record most of your answers into a computer. The interviewer never sees
or hears them. Your answers are combined with those from thousands of others, and are reported only
as overall statistics.
You cannot be replaced so your participation is very important.
Feel free to ask the interviewer any questions you have or visit nsduhweb.rti.org for more information.
(Approx. run time: 50 seconds)

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment Q – Parental Introductory Script

PARENT IS THE SCREENING RESPONDENT
ONE YOUTH IS SELECTED:
Your (AGE) year-old child has been selected for an
interview. I would like to talk with him/her to see if
he/she is interested in participating in this study
which asks about tobacco, alcohol, and drug use or
non-use and other health related issues.
If your child is interested, I will give both of you more
information and ask for permission to complete the
interview. Is he/she available?
TWO YOUTHS ARE SELECTED:
Your (AGE) year-old and (AGE) year-old children
have been selected for an interview. I would like to
talk with them to see if they are interested in
participating in this study which asks about tobacco,
alcohol, and drug use or non-use and other health
related issues.
If they are interested, I will give all of you more
information and ask for permission to complete the
interview. Are they available?

PARENT IS NOT THE SCREENING RESPONDENT
INTRODUCE YOURSELF/STUDY AS NECESSARY:
Hello, I’m ________with RTI International. We are conducting a
nationwide study sponsored by the U.S. Department of Health
and Human Services. You should have received a letter about
this study. (SHOW LEAD LETTER, IF NECESSARY.)

ONE YOUTH IS SELECTED:
Your (AGE) year-old child has been selected for an interview.
I would like to talk with him/her to see if he/she is interested in
participating in this study which asks about tobacco, alcohol,
and drug use or non-use and other health related issues.
If your child is interested, I will give both of you more
information and ask for permission to complete the interview.
Is he/she available?

TWO YOUTHS ARE SELECTED:
Your (AGE) year-old and (AGE) year-old children have been
selected for an interview. I would like to talk with them to see if
they are interested in participating in this study which asks
about tobacco, alcohol, and drug use or non-use and other
health related issues.
If they are interested, I will give all of you more information
and ask for permission to complete the interview.
Are they available?

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment L – Pilot Test Screening Questions

2015 NATIONAL SURVEY ON DRUG
USE AND HEALTH (NSDUH):
SCREENER SPECIFICATIONS FOR
PROGRAMMING (ENGLISH VERSION)

Substance Abuse and Mental Health Services Administration
Center for Behavioral Health Statistics and Quality
Rockville, Maryland 20857
April 2014

2015 NATIONAL SURVEY ON DRUG
USE AND HEALTH (NSDUH):
SCREENER SPECIFICATIONS FOR
PROGRAMMING (ENGLISH VERSION)
Contract No. HHSS283201300001C
RTI Project No. 0213984.002.102.001
RTI Authors:

RTI Project Director:
David Hunter

Patricia LeBaron
Gretchen McHenry
Tennyson Chen

SAMHSA Project Officer:
Peter Tice

For questions about this report, please email [email protected].
Prepared for Substance Abuse and Mental Health Services Administration,
Rockville, Maryland
Prepared by RTI International, Research Triangle Park, North Carolina
April 2014
Recommended Citation: Center for Behavioral Health Statistics and Quality.
(2014). 2015 National Survey on Drug Use and Health (NSDUH): Screener
Specifications for Programming (English Version). Substance Abuse and
Mental Health Services Administration, Rockville, MD.

Acknowledgments

2015 NATIONAL SURVEY ON DRUG USE AND HEALTH
SCREENING APPLICATION UPDATES
The following updates have been made to the 2015 NSDUH Screening Application:
•
•
•

As necessary, dates were updated in the screening program.
Response options in the Spanish screener have been translated into
Spanish.
Interviewer Debriefing items were edited.

Table of Contents
Screening Application Updates........................................................................................................ i
Section

Page

1.

HU Screening, English ....................................................................................................... 1-1

2.

HU Screening, Spanish ...................................................................................................... 2-1

3.

GQU Screening, English .................................................................................................... 3-1

4.

GQU Screening, Spanish.................................................................................................... 4-1

5.

Select Case Screen Options ................................................................................................ 5-1

6.

Record of Calls ................................................................................................................... 6-1

7.

Screening and Interview Refusals ...................................................................................... 7-1

8.

Verification......................................................................................................................... 8-1

9.

FI Debriefing Questions ..................................................................................................... 9-1

NSDUH DR Screening Application Specifications
Section 1
HU Screening - English
Document Format:
• Screen names bolded
• Screen/question/instructional text designated by black and red text and non-italicized text in
parenthesis (Upper-lower black text to be read, red text is instructions to FI)
• Fills designated by parenthesis and italics
• Logic designated by brackets
• Text of instructional message boxes provided in bracketed logic
• Response categories underlined

The line number and address are located at the top of each screen. Touch the address to see DU
ADDRESS box, an enlarged display of the line number and address. If a case is an Added DU, the DU
ADDRESS box displays the link line number.

STUDY INTRODUCTION
Hello, my name is (FI NAME) with RTI International in North Carolina. We are conducting a
nationwide study sponsored by the U.S. Department of Health and Human Services.
[IF NOT ADDED DU] You should have received a letter explaining the study.
[IF NOT ADDED DU] HAND R COPY OF LETTER IF NEEDED
[IF ADDED DU] HAND R LEAD LETTER, ALLOW TIME TO READ
Next [IDENTIFY SR]

IDENTIFY SR [IF STUDY INTRODUCTION = NEXT]
First, just let me verify: do you live here?
IF NOT OBVIOUS:
And are you 18 or older?
IF NO TO EITHER, ASK FOR AN ADULT RESIDENT, TOUCH “PREVIOUS,” AND BEGIN
AGAIN.
SR Available [ADDRESS VERIFICATION]
SR Not Available [EXIT SCREENING: “ARE YOU SURE YOU WANT TO EXIT
SCREENING?” IF Yes, RECORD OF CALLS. IF No, IDENTIFY SR.]

ADDRESS VERIFICATION [IF IDENTIFY SR = SR AVAILABLE]
1-1

I just need to verify -- is this
STREET: (NUMBER AND STREET)
CITY: (CITY)
STATE: (STATE)
ZIP: (ZIP)
Address Is Correct [INFORMED CONSENT]
Need to Edit Address [EDIT ADDRESS]
FI At Wrong Address [SELECT CASE]

EDIT ADDRESS [IF ADDRESS VERIFICATION = NEED TO EDIT ADDRESS]
TOUCH THE ITEM YOU NEED TO EDIT
STREET # (NUMBER)
STREET: (STREET)
CITY: (CITY)
STATE: (STATE)
ZIP: (ZIP)
Update [SAVE UPDATED ADDRESS, THEN INFORMED CONSENT]

INFORMED CONSENT [IF ADDRESS VERIFICATION = ADDRESS IS CORRECTCONTINUE OR EDIT ADDRESS = UPDATE]
GIVE PERSON STUDY DESCRIPTION AND SAY
Please read this statement. It describes the survey and the legislation that assures the
confidentiality of any information you provide. It also explains that your answers are used for
statistical purposes only and that your participation is voluntary. If anyone is selected for the full
interview, that person will receive $30 in cash after the interview is completed.
Next [MISSED DUs]

MISSED DUs [IF INFORMED CONSENT = CONTINUE]
FOR REGULAR HUs SUCH AS INDIVIDUAL HOUSES, TOWNHOUSES, DUPLEXES,
TRAILERS, COTTAGES
Are there any other living quarters within this structure or on this property, such as a separate
apartment with a separate entrance?
Yes [MISSED DU ADDRESS]
[IF MISSED DU: CANNOT ADD UNIT
“YOU CANNOT ADD A MISSED DU
FROM A DU THAT HAS BEEN ADDED”
MISSED DUs]

1-2

No [OCCUPANCY]

FOR APARTMENT/CONDO HUs: DON'T ASK, JUST TOUCH "APT/CONDO" (BELOW)
TO CONTINUE.
APT/CONDO [OCCUPANCY]

MISSED DU ADDRESS [IF MISSED DUs = YES]
RECORD STREET ADDRESS OR DESCRIPTION OF UNIT
STREET #:
STREET:
Update [OCCUPANCY]

Cancel [CANCEL DU: “ARE YOU SURE
YOU WANT TO CANCEL ADDITION OF THIS DU?
IF Yes, OCCUPANCY. IF No, MISSED DU
ADDRESS.]

OCCUPANCY [IF MISSED DUs = NO OR MISSED DU ADDRESS = UPDATE OR
CANCEL MISSED DU = YES]
(Have/Will) you or anyone else in this household (lived/live) here for most of the time during the
months of (CURRENT QUARTER)?
Yes [TOTAL SDU MEMBERS]

No [OCCUPANCY – CONFIRMATION: YOUR
‘NO’ RESPONSE WILL CONCLUDE THIS
SCREENING AND FINALIZE THIS CASE. DO YOU
WANT TO CHANGE YOUR ANSWER? (‘YES’
WILL CONTINUE SCREENING. ‘NO’ WILL
FINALIZE THE CASE.) IF Yes, TOTAL SDU
MEMBERS. IF No, VERIFICATION.]

TOTAL SDU MEMBERS [IF OCCUPANCY= YES]
(Including yourself), how many people in this household (lived/will live) here for most of the time
during the months of (CURRENT QUARTER)? (Do not include anyone who (lived/will live) at
school or somewhere else for most of the time during the months of (CURRENT QUARTER).)
ENTER NUMBER 1-20 [MEMBERS 12 OR OLDER]
[IF 1 TOTAL SDU MEMBERS = 1, ONLY HOUSEHOLD MEMBER: “CONFIRM
RESPONSE: IS THERE ONLY 1 PERSON IN THIS HOUSEHOLD?” IF No, TOTAL
SDU MEMBERS. IF Yes, ONLY ELIGIBLE HH MEMBER: “Is that you?” IS
THIS SCREENING RESPONDENT THE ONE ELIGIBLE RESIDENT OF THE DU?
IF No, HOUSEHOLDER AGE USING ‘THIS PERSON’ FILL. IF Yes,
HOUSEHOLDER AGE USING ‘YOUR’ FILL.]

1-3

MEMBERS 12 OR OLDER [IF TOTAL SDU MEMBERS NE BLANK AND >1]
Of these (TOTAL SDU MEMBERS) people, how many are now age 12 or older?
ENTER SUBSET OF TOTAL SDU MEMBERS [ROSTER INTRO]
[IF MEMBERS 12 OR OLDER = 1, ONLY ELIGIBLE MEMBER: “CONFIRM
RESPONSE: IS THERE ONLY 1 PERSON AGE 12 OR OLDER IN THIS
HOUSEHOLD?” IF No, MEMBERS 12 OR OLDER. IF Yes, ROSTER: “IS THIS
SCREENING RESPONDENT THE ONE ELIGIBLE RESIDENT OF THE DU?”
IF No, HOUSEHOLDER AGE USING ‘THIS PERSON’ FILL. IF Yes,
HOUSEHOLDER AGE USING ‘YOUR’ FILL.]

ROSTER INTRO [IF MEMBERS 12 OR OLDER NE 1 OR BLANK]
Next I'll ask a few questions about the people who live here. Let's start with the person or one of
the persons living here who owns or rents this home. We'll refer to this person as the
householder.
Next [HOUSEHOLDER AGE]

HOUSEHOLDER AGE [IF ROSTER INTRO NE BLANK OR ROSTER NE BLANK OR
CONFIRM ROSTER FOR HOUSEHOLDER = NO]
Please tell me the age of this person on his or her last birthday.
IF SR IS HOUSEHOLDER:
Please tell me your age on your last birthday.
ENTER AGE [SCREENING RESPONDENT]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, HOUSEHOLDER AGE. IF Yes, THIS PERSON: IS THIS
PERSON THE SR? IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM RESPONSE.
IS THIS PERSON THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE
CONFIRM RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE
AND = No, PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT
CHANGE AND = Yes, PERSON = SCREENING RESPONDENT.]

SCREENING RESPONDENT [IF HOUSEHOLDER AGE NE BLANK OR IF
AGE NE BLANK AND SCREENING RESPONDENT NE YES]
IS THIS (HOUSEHOLDER AGE/AGE) YEAR OLD PERSON THE SCREENING
RESPONDENT? IF UNSURE ASK: “Is that you?”
Yes [SETS LANGUAGE FOR SUBSEQUENT ROSTER QUESTIONS USING
‘YOU/YOUR’]
No [SETS LANGUAGE FOR SUBSEQUENT ROSTER QUESTIONS USING
‘THIS PERSON.’]

1-4

[IF HOUSEHOLDER, HOUSEHOLDER GENDER OTHERWISE, RELATION]

HOUSEHOLDER GENDER [IF SCREENING RESPONDENT NE BLANK FOR
HOUSEHOLDER]
ASK ONLY IF NOT OBVIOUS
Is this person male or female?
Male
Female
[HOUSEHOLDER HISPANIC]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, HOUSEHOLDER GENDER. IF Yes, THIS PERSON: IS THIS
PERSON THE SR? IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM RESPONSE.
IS THIS PERSON THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE
CONFIRM RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE
AND = No, PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT
CHANGE AND = Yes, PERSON = SCREENING RESPONDENT.]

HOUSEHOLDER HISPANIC [IF HOUSEHOLDER GENDER NE BLANK]
(Are you/Is he/Is she/Is this person) of Hispanic, Latino or Spanish origin?
(That is, do any of these groups describe (your/his/her/their) national origin or ancestry – Puerto
Rican, Cuban, Cuban-American, Mexican, Mexican-American, Chicano, Central or South
American, or origin in some other Spanish-speaking country?)
Yes
No
[HOUSEHOLD RACE]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, HOUSEHOLDER HISPANIC. IF Yes, THIS PERSON: IS THIS
PERSON THE SR? IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM RESPONSE.
IS THIS PERSON THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE
CONFIRM RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE
AND = No, PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT
CHANGE AND = Yes, PERSON = SCREENING RESPONDENT.]

HOUSEHOLDER RACE [IF HOUSEHOLDER HISPANIC NE BLANK]
(Are you/Is he/Is she/Is this person) White, Black or African American, American Indian or
Alaska Native, Native Hawaiian or other Pacific Islander, or Asian?
White
Black or African American
American Indian or Alaska Native
Native Hawaiian/other Pacific Islander

1-5

Asian
Other
(CHECK ALL THAT APPLY)
[HOUSEHOLDER MILITARY OR IF HOUSEHOLDER AGE NE 17-65 CONFIRM
ROSTER]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, HOUSEHOLDER RACE. IF Yes, THIS PERSON: IS THIS
PERSON THE SR? IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM RESPONSE.
IS THIS PERSON THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE
CONFIRM RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE
AND = No, PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT
CHANGE AND = Yes, PERSON = SCREENING RESPONDENT.]

HOUSEHOLDER MILITARY [IF HOUSEHOLDER RACE NE BLANK AND
HOUSEHOLDER AGE = 17-65 AND SCREENING
RESPONDENT = NO FOR THIS MEMBER]
(Are you/Is he/Is she/Is this person) currently on active duty in the United States military?
Yes
No
Unknown
Refused
[CONFIRM ROSTER]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, HOUSEHOLDER MILITARY. IF Yes, THIS PERSON: IS
THIS PERSON THE SR? IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM
RESPONSE. IS THIS PERSON THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE:
PLEASE CONFIRM RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT
CHANGE AND = No, PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES
NOT CHANGE AND = Yes, PERSON = SCREENING RESPONDENT.]

HOUSEHOLDER MILITARY [IF HOUSEHOLDER RACE NE BLANK AND
HOUSEHOLDER AGE = 17-65 AND SCREENING
RESPONDENT = YES FOR THIS MEMBER]
(Are you/Is he/Is she/Is this person) currently on active duty in the United States military?
Yes
No
Refused
[CONFIRM ROSTER]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, HOUSEHOLDER MILITARY. IF Yes, THIS PERSON: IS

1-6

THIS PERSON THE SR? IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM
RESPONSE. IS THIS PERSON THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE:
PLEASE CONFIRM RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT
CHANGE AND = No, PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES
NOT CHANGE AND = Yes, PERSON = SCREENING RESPONDENT.]

CONFIRM ROSTER [IF HOUSEHOLDER MILITARY NE BLANK OR IF
HOUSEHOLDER AGE NE 17-65 AND HOUSEHOLDER RACE NE BLANK]
[IF RACE, HISPANIC, AND/OR MILITARY IS ‘OTHER’, ‘DK’, OR ‘REF’ OMIT
RESPECTIVE FILLS FROM CONFIRM ROSTER SCREEN.]
I have listed (a, IF SR: you as a) (AGE) year old (GENDER) householder. (She is/He is/IF SR:
You are (RACE), (HISPANIC), and (is/is not/IF SR: are/are not) on active duty in the United
States military.
Is that correct?
Yes [OTHER MEMBERS] [IF ROSTER NE BLANK , THEN VERIFY ROSTER DATA]
No [HOUSEHOLDER AGE]

OTHER MEMBERS [IF CONFIRM ROSTER = YES AND MEMBERS 12 OR OLDER ≥ 2]
READ TO RESPONDENT:
Now I need some general information about (the other person/all of the other people) in this
household who (is/are) 12 years old or older. [IF MEMBERS 12 OR OLDER >2] Let's start with
the oldest and work down to the youngest.
Next [AGE]

AGE [IF OTHER MEMBERS NE BLANK OR CONFIRM ROSTER = NO]
[IF MEMBERS 12 OR OLDER = 2] Please tell me the age of this person on his or her last
birthday.
[IF MEMBERS 12 OR OLDER > 2 HH MEMBERS] Please tell me the age of the (oldest/next
oldest) person on his or her last birthday.
ENTER AGE [IF ANY SCREENING RESPONDENT = YES, RELATION. IF ALL
SCREENING RESPONDENT = BLANK OR NO, SCREENING
RESPONDENT]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, AGE. IF Yes, THIS PERSON: IS THIS PERSON THE SR?
IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM RESPONSE. IS THIS PERSON
THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE CONFIRM
RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE AND = No,
PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT CHANGE AND
= Yes, PERSON = SCREENING RESPONDENT.]

1-7

RELATION [IF AGE NE BLANK AND ANY SCREENING RESPONDENT =YES]
[IF SCREENING RESPONDENT = YES FOR THIS MEMBER] How are you related to the
householder?
[IF SCREENING RESPONDENT = YES FOR HOUSEHOLDER] How is this person related to
you, the householder?
[IF SCREENING RESPONDENT = NO FOR THIS MEMBER AND SCREENING
RESPONDENT = NO FOR HOUSEHOLDER] How is this person related to the householder?
Husband
Wife
Son (includes step)
Daughter (includes step)
Son-in-law/Daughter-in-law
Brother (includes step)
Sister (includes step)
Brother-in-law/Sister-in-law
Parent/Guardian (incl. step)
Parent-in-law (incl. step)
Aunt/Uncle
Nephew/Niece
Grandparent
Grandchild
Cousin
Ex-Spouse
Live-in Partner
Friend/Roommate
Tenant/Boarder/Exch Student
Other relative
Other Non-relative
Relationship Unspecified
[IF RELATION = HUSBAND, WIFE, SON, DAUGHTER, BROTHER OR SISTER
HISPANIC, OTHERWISE GENDER]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, RELATION. IF Yes, THIS PERSON: IS THIS PERSON THE
SR? IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM RESPONSE. IS THIS
PERSON THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE CONFIRM
RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE AND = No,
PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT CHANGE AND
= Yes, PERSON = SCREENING RESPONDENT.]

GENDER [IF RELATION NE HUSBAND, WIFE, SON, DAUGHTER, BROTHER OR SISTER]
ASK ONLY IF NOT OBVIOUS
Is this person male or female?
Male
Female
Refused

1-8

[HISPANIC]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, GENDER. IF Yes, THIS PERSON: IS THIS PERSON THE SR?
IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM RESPONSE. IS THIS PERSON
THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE CONFIRM
RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE AND = No,
PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT CHANGE AND
= Yes, PERSON = SCREENING RESPONDENT.

HISPANIC [IF GENDER NE BLANK]
(Are you/Is he/Is she/Is this person) of Hispanic, Latino or Spanish origin?
(That is, do any of these groups describe (your/his/her/their) national origin or ancestry – Puerto
Rican, Cuban, Cuban-American, Mexican, Mexican-American, Chicano, Central or South
American, or origin in some other Spanish-speaking country?)
Yes
No
Unknown
Refused
[RACE]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, HISPANIC. IF Yes, THIS PERSON: IS THIS PERSON THE SR?
IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM RESPONSE. IS THIS PERSON
THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE CONFIRM
RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE AND = No,
PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT CHANGE AND
= Yes, PERSON = SCREENING RESPONDENT.]

RACE [IF HISPANIC NE BLANK]
(Are you/Is he/Is she/Is this person) White, Black or African American, American Indian or
Alaska Native, Native Hawaiian or other Pacific Islander, or Asian?
White
Black or African American
American Indian or Alaska Native
Native Hawaiian/other Pacific Islander
Asian
Other
Unknown
Refused
(CHECK ALL THAT APPLY)
[IF AGE 17-65, MILITARY, OTHERWISE CONFIRM ROSTER]

1-9

[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, RACE. IF Yes, THIS PERSON: IS THIS PERSON THE SR?
IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM RESPONSE. IS THIS PERSON
THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE CONFIRM
RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE AND = No,
PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT CHANGE AND
= Yes, PERSON = SCREENING RESPONDENT.]

MILITARY [IF RACE NE BLANK AND AGE 17-65 AND SCREENING RESPONDENT = NO
FOR THIS MEMBER]
(Are you/Is he/Is she/Is this person) currently on active duty in the United States military?
Yes
No
Unknown
Refused
[CONFIRM ROSTER]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, MILITARY. IF Yes, THIS PERSON: IS THIS PERSON THE
SR? IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM RESPONSE. IS THIS
PERSON THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE CONFIRM
RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE AND = No,
PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT CHANGE AND
= Yes, PERSON = SCREENING RESPONDENT.

HOUSEHOLDER MILITARY [IF HOUSEHOLDER RACE NE BLANK AND HOUSEHOLDER
AGE = 17-65 AND SCREENING RESPONDENT = YES FOR THIS MEMBER]
(Are you/Is he/Is she/Is this person) currently on active duty in the United States military?
Yes
No
Refused
[CONFIRM ROSTER]
[TO CHANGE THE SR, TOUCH FUNCTIONS MENU, CHANGE SR: DO YOU WANT TO
CHANGE THE SR, IF No, HOUSEHOLDER MILITARY. IF Yes, THIS PERSON: IS
THIS PERSON THE SR? IF Yes OR No, CONFIRM CHANGE: PLEASE CONFIRM
RESPONSE. IS THIS PERSON THE SR? IF RESPONSE CHANGES, CONFIRM CHANGE:
PLEASE CONFIRM RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT
CHANGE AND = No, PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES
NOT CHANGE AND = Yes, PERSON = SCREENING RESPONDENT.]

CONFIRM ROSTER [IF AGE 17-65 AND MILITARY IS NE BLANK, OTHERWISE
RACE NE BLANK]

1-10

[IF RACE, HISPANIC, AND/OR MILITARY IS ‘OTHER’, ‘DK’, OR ‘REF’ OMIT
RESPECTIVE FILLS FROM CONFIRM ROSTER SCREEN.]
I have listed a (AGE) year old (RELATIONSHIP). (He/She) is (RACE), (HISPANIC) [IF AGE
17-65] and (is/is not) on active duty the United States military.
Is that correct?
Yes [AGE FOR NEXT HH MEMBER, OTHERWISE VERIFY ROSTER DATA]
No [AGE]

VERIFY ROSTER DATA [IF CONFIRM ROSTER = YES ]
Relation (Relationship)
A (Age)
SR (Y for Screening Respondent)
[UPON TOUCHING ON ANY ROSTER LINE, SELECT SHOW DETAILS, SHOW ALL ROSTER
INFORMATION]
G (Gender: M, F, R)
H (Hispanic: Y, N, U, R)
R (Race: W, B, I, P, A, O)
M (Military: Y, N, U, R)
E (Eligibility: E, I)
[IF CONFIRM ROSTER = YES AND MEMBERS 12 OR OLDER=1]
DO NOT READ TO RESPONDENT. WHEN READY, TOUCH NEXT TO MAKE
SELECTION.
TO MAKE CORRECTIONS: TOUCH AND HOLD THE ROSTER LINE THAT YOU WANT
TO EDIT, THEN TOUCH 'EDIT' FROM THE POP-UP MENU.
[IF CONFIRM ROSTER = YES AND MEMBERS 12 OR OLDER>=2]
I need to make sure this list is accurate. I have listed...
[READ AGES AND RELATIONSHIPS ROSTERED].
TO MAKE CORRECTIONS: TOUCH AND HOLD THE ROSTER LINE THAT YOU WANT
TO EDIT, THEN TOUCH 'EDIT’ FROM THE POP-UP MENU.
[FUNCTIONS TO ADD ROSTER MEMBERS AND/OR EDIT ROSTER DATA]
Next [START SELECTION]

START SELECTION
THE PROGRAM WILL START THE SELECTION PROCESS. ARE YOU SURE YOU ARE
READY TO MAKE THE SELECTIONS?

1-11

Yes [RESPONDENT SELECTION]
No [VERIFY ROSTER DATA]

RESPONDENT SELECTION [START SELECTION = YES]
Interview A
Roster #: (Roster # of selected member, None)
QuestID: (7-digit Questionnaire ID, BLANK)
Relation: (Relationship to householder, BLANK)
Age: (AGE, BLANK)
Race: (W, B, I, P, A, O, BLANK)

Sex: (M, F, BLANK)
Hispanic: (Y, N, BLANK)

Interview B
Roster #: (Roster # of selected member, None)
QuestID: (7-digit Questionnaire ID, BLANK)
Relation: (Relationship to householder, BLANK)
Age: (AGE, BLANK)
Race: (W, B, I, P, A, O, BLANK)

Sex: (M, F, BLANK)
Hispanic: (Y, N, BLANK)

1-12

NSDUH DR Screening Application Specifications
Section 2
HU Screening - Spanish
Document Format:
• Screen names bolded
• Screen/question/instructional text designated by black and red text and non-italicized text in
parenthesis (Upper-lower black text to be read, red upper case text is instructions to FI)
• Fills designated by parenthesis and italics
• Logic designated by brackets
• Text of instructional message boxes provided in bracketed logic
• Response categories underlined

The line number and address are located at the top of each screen. Tap the address to see DU ADDRESS
box, an enlarged display of the line number and address. If a case is an Added DU, the DU ADDRESS
box displays the link line number.

STUDY INTRODUCTION
(Buenas noches/Buenas tardes/Buenos días). Mi nombre es (FI NAME) y trabajo para RTI
International en Carolina del Norte. Estamos llevando a cabo un estudio nacional patrocinado por
el Departamento de Salud y Servicios Humanos de los Estados Unidos.
[IF NOT ADDED DU] Usted ha de debe haber recibido una carta explicándole el estudio.
[IF NOT ADDED DU] HAND R COPY OF LETTER IF NEEDED
[IF ADDED DU] HAND R LEAD LETTER, ALLOW TIME TO READ
Continue [IDENTIFY SR]

IDENTIFY SR [IF STUDY INTRODUCTION = CONTINUE]
Primero, déjeme verificar: ¿vive usted aquí?
IF NOT OBVIOUS:
Y ¿tiene 18 años de edad o más?
IF NO TO EITHER, ASK FOR AN ADULT RESIDENT, TAP BACK ARROW, AND BEGIN
AGAIN.
SR Available [ADDRESS VERIFICATION]
SR Not Available [EXIT SCREENING: “ARE YOU SURE YOU WANT TO EXIT
SCREENING?” IF Yes, RECORD OF CALLS. IF No, IDENTIFY SR.]

2-1

ADDRESS VERIFICATION [IF IDENTIFY SR = SR AVAILABLE]
Solamente necesito confirmar que ésta es
STREET: (NUMBER AND STREET)
CITY: (CITY)
STATE: (STATE)
ZIP: (ZIP)
Address Is Correct – Continue [INFORMED CONSENT]
Need to Edit Address [EDIT ADDRESS]
FI At Wrong Address [SELECT CASE]

EDIT ADDRESS [IF ADDRESS VERIFICATION = NEED TO EDIT ADDRESS]
TAP THE ITEM YOU NEED TO EDIT
ST. # (NUMBER)
STREET: (STREET)
CITY: (CITY)
STATE: (STATE) ZIP: (ZIP)
Update [SAVE UPDATED ADDRESS, THEN INFORMED CONSENT]

INFORMED CONSENT [IF ADDRESS VERIFICATION = ADDRESS IS CORRECTCONTINUE OR EDIT ADDRESS = UPDATE]
GIVE PERSON STUDY DESCRIPTION AND SAY:
Por favor lea esta declaración, la cual describe la encuesta y la legislación que asegura la
confidencialidad de cualquier información que usted nos dé. También explica que sus respuestas
son usadas con propósitos estadísticos únicamente y que su participación es voluntaria. Si
alguien es seleccionado(a) para participar en la entrevista en su totalidad, dicha persona recibirá
$30 dólares en efectivo después de haber completado la entrevista.
Continue [MISSED DUs]

2-2

MISSED DUs [IF INFORMED CONSENT = CONTINUE]
FOR REGULAR HUs SUCH AS INDIVIDUAL HOUSES, TOWNHOUSES, DUPLEXES,
TRAILERS, COTTAGES
¿Hay alguna otra vivienda dentro de esta casa o propiedad, tal como un apartamento separado con
entrada aparte?
Yes Sí [MISSED DU ADDRESS]
[IF MISSED DU: CANNOT
ADD UNIT “YOU CANNOT
ADD A MISSED DU FROM
A DU THAT HAS BEEN ADDED”
MISSED DUs]

No [OCCUPANCY]

FOR APARTMENT/CONDO HUs: DON'T ASK, JUST TAP "APT/CONDO" (BELOW) TO
CONTINUE.
APT/CONDO [OCCUPANCY]

MISSED DU ADDRESS [IF MISSED DUs = YES]
RECORD STREET ADDRESS OR DESCRIPTION OF UNIT
STREET
NUMBER:
STREET
NAME:
Update [OCCUPANCY]

Cancel [CANCEL DU: “ARE YOU SURE
YOU WANT TO CANCEL
ADDITION OF THIS DU? IF Yes,
OCCUPANCY. IF No MISSED DU
ADDRESS.]

2-3

OCCUPANCY [IF MISSED DUs = NO OR MISSED DU ADDRESS = UPDATE OR
CANCEL MISSED DU = YES]
(¿Vivió /¿Vivirá) usted o alguna otra persona en esta vivienda la mayor parte del tiempo durante
los meses de (CURRENT QUARTER)?
Yes Sí [TOTAL SDU MEMBERS]

No [OCCUPANCY – CONFIRMATION:
YOUR ‘NO’ RESPONSE WILL
CONCLUDE THIS SCREENING
AND FINALIZE THIS CASE. DO
YOU WANT TO CHANGE YOUR
ANSWER? (‘YES’ WILL CONTINUE
SCREENING. ‘NO’ WILL FINALIZE THE
CASE.) IF Yes, TOTAL SDU MEMBERS. IF No,
VERIFICATION.]

TOTAL SDU MEMBERS [IF OCCUPANCY= YES]
(Incluyéndose a sí mismo), ¿cuántas personas (vivieron/vivirán) en esta vivienda la mayor parte
del tiempo durante los meses de (CURRENT QUARTER)? (No incluya a nadie que (vivió/vivirá)
en la escuela o en otro lugar la mayor parte del tiempo durante los meses de (CURRENT
QUARTER).)

ENTER NUMBER 1-20 [MEMBERS 12 OR OLDER]
[IF 1 TOTAL SDU MEMBERS = 1, ONLY HOUSEHOLD MEMBER: “CONFIRM
RESPONSE: IS THERE ONLY 1 PERSON IN THIS HOUSEHOLD?” IF No, TOTAL
SDU MEMBERS. IF Yes, ROSTER: “IS THIS SCREENING RESPONDENT THE
ONE ELIGIBLE RESIDENT OF THE DU?” IF No, HOUSEHOLDER AGE USING
‘THIS PERSON’ FILL. IF Yes, HOUSEHOLDER AGE USING ‘YOUR’ FILL.]

MEMBERS 12 OR OLDER [IF TOTAL SDU MEMBERS NE BLANK AND >1]
De estas (TOTAL SDU MEMBERS) personas, ¿cuántas tienen 12 años o más actualmente?
ENTER SUBSET OF TOTAL SDU MEMBERS [ROSTER INTRO]
[IF MEMBERS 12 OR OLDER = 1, ONLY ELIGIBLE MEMBER: “CONFIRM
RESPONSE: IS THERE ONLY 1 PERSON AGE 12 OR OLDER IN THIS
HOUSEHOLD?” IF No, MEMBERS 12 OR OLDER. IF Yes, ROSTER: “IS THIS
SCREENING RESPONDENT THE ONE ELIGIBLE RESIDENT OF THE DU?”
IF No, HOUSEHOLDER AGE USING ‘THIS PERSON’ FILL. IF Yes,
HOUSEHOLDER AGE USING ‘YOUR’ FILL.]

2-4

ROSTER INTRO [IF MEMBERS 12 OR OLDER NE 1 OR BLANK]
Ahora le haré unas cuantas preguntas acerca de las personas que viven aquí. Empecemos con la
persona o una de las personas que vive aquí, quien es el dueño o la dueña de la casa o que paga
por el alquiler de la misma. Nos referiremos a esta persona como la cabeza de la familia.
Continue [HOUSEHOLDER AGE]

HOUSEHOLDER AGE [IF ROSTER INTRO NE BLANK OR ROSTER NE BLANK OR
CONFIRM ROSTER FOR HOUSEHOLDER = NO]
Por favor dígame la edad de esta persona en su último cumpleaños.
IF SR IS HOUSEHOLDER:
Por favor dígame su edad en su último cumpleaños.
ENTER AGE [SCREENING RESPONDENT]

SCREENING RESPONDENT [IF HOUSEHOLDER AGE NE BLANK OR IF
AGE NE BLANK AND SCREENING RESPONDENT NE YES]
IS THIS (HOUSEHOLDER AGE/AGE) YEAR OLD PERSON THE SCREENING
RESPONDENT?
Yes [SETS LANGUAGE FOR SUBSEQUENT ROSTER QUESTIONS USING
‘YOU/YOUR’]
No [SETS LANGUAGE FOR SUBSEQUENT ROSTER QUESTIONS USING
‘THIS PERSON.’]
[IF HOUSEHOLDER, HOUSEHOLDER GENDER OTHERWISE, RELATION]

HOUSEHOLDER GENDER [IF SCREENING RESPONDENT NE BLANK FOR
HOUSEHOLDER]
ASK ONLY IF NOT OBVIOUS
¿Es esta persona hombre o mujer?
Male Hombre
Female Mujer
[HOUSEHOLDER HISPANIC]

2-5

HOUSEHOLDER HISPANIC [IF HOUSEHOLDER GENDER NE BLANK]
¿Es (usted/él/ella/esta persona) de origen hispano, latino o español?
(Es decir que su origen nacional o descendencia se puede describir como puertorriqueño, cubano,
cubano-americano, mexicano, mexicano-americano, chicano, centro o sudamericano, o es
nativo(a) de otro país donde se habla español?)
Yes Sí
No
[HOUSEHOLD RACE]

HOUSEHOLDER RACE [IF HOUSEHOLDER HISPANIC NE BLANK]
¿Es (usted/él/ella/esta persona) de raza blanca, negra o afro-americana, indígena americana o
nativo(a) de Alaska, nativo(a) de Hawaii o de otra isla del pacífico, o asiática?
White Blanca
Black or African American Negra o afro-americana
American Indian or Alaska Native Indígena americana o nativo(a) de Alaska
Native Hawaiian/other Pacific Islander Nativo(a) de Hawaii o de otra isla del pacífico
Asian Asiática
Other Otra raza
(CHECK ALL THAT APPLY)
[HOUSEHOLDER MILITARY OR IF HOUSEHOLDER AGE NE 17-65 CONFIRM
ROSTER]

HOUSEHOLDER MILITARY [IF HOUSEHOLDER RACE NE BLANK AND
HOUSEHOLDER AGE = 17-65 AND SCREENING RESPONDENT = NO FOR THIS
MEMBER]
¿Está (usted/él/ella/esta persona) actualmente en servicio activo en las fuerzas armadas de los
Estados Unidos?
Yes Sí
No
Unknown No sabe
Refused Se rehúsa
[CONFIRM ROSTER]

2-6

HOUSEHOLDER MILITARY [IF HOUSEHOLDER RACE NE BLANK AND
HOUSEHOLDER AGE = 17-65 AND SCREENING RESPONDENT = YES FOR THIS
MEMBER]
¿Está (usted/él/ella/esta persona) actualmente en servicio activo en las fuerzas armadas de los
Estados Unidos?
Yes Sí
No
Refused Se rehúsa
[CONFIRM ROSTER]

CONFIRM ROSTER [IF HOUSEHOLDER MILITARY NE BLANK OR IF
HOUSEHOLDER AGE NE 17-65 AND HOUSEHOLDER RACE NE BLANK]
There are four translation variations. English is also provided here for clarification.
1. SCREENING RESPONDENT AGE 17- 65
ENGLISH:
I have listed you as a (AGE) year old (GENDER) resident. You are (RACE),
(HISPANIC), and (are/are not) on active duty in the United States military.
SPANISH:
(MALE:Lo)(FEMALE: La) he anotado a usted, (GENDER: una joven/una mujer/un
joven/un hombre/una persona) de (AGE) años de edad. (Usted) es de raza (RACE:
blanca, negra o afro-americana, indígena americana o nativo(a) de Alaska, nativo(a) de
Hawaii o de otra isla del pacífico, asiática). (HISPANIC: Usted es hispana / Usted es
hispano/ Usted no es hispana / Usted no es hispano) (MILITARY: y está en servicio
activo en las fuerzas armadas de los Estados Unidos. / y no está en servicio activo en las
fuerzas armadas de los Estados Unidos.).
2. SCREENING RESPONDENT UNDER AGE 17 OR OVER AGE 65
ENGLISH:
I have listed you as a (AGE) year old (GENDER) resident. You are (RACE), and (not)
(HISPANIC).
SPANISH:
(MALE:Lo)(FEMALE: La) he anotado a usted, (GENDER: una joven/una mujer/un
joven/un hombre/una persona) de (AGE) años de edad. (Usted) es de raza (RACE:
blanca, negra o afro-americana, indígena americana o nativo(a) de Alaska, nativo(a) de
Hawaii o de otra isla del pacífico, asiática). (HISPANIC: Usted es hispana / Usted es
hispano/ Usted no es hispana / Usted no es hispano).

3. OTHER MEMBERS AGES 17- 65
ENGLISH:

2-7

I have listed a (AGE) year old (GENDER) resident. (She/He) is (RACE), (HISPANIC)
and (is/is not) on active duty in the United States military.
SPANISH:
He anotado (GENDER) de (AGE) años de edad. (Ella/Él) es de raza (RACE). (Ella/Él)
(es/no es) (HISPANIC) y (está/no está) en servicio activo en las fuerzas armadas de los
Estados Unidos.
SPANISH GENDER/RELATIONSHIP DESCRIPTIONS:
He anotado (GENDER: una joven/una mujer/un joven/un hombre/una persona) de
(AGE) años de edad. (Ella /Él /Esta persona) es de raza (RACE: blanca, negra o afroamericana, indígena americana o nativo(a) de Alaska, nativo(a) de Hawaii o de otra isla
del pacífico, asiática). (HISPANIC: Ella es hispana / Él es hispano/Esta persona es
hispana / Ella no es hispana / Él no es hispano/Esta persona no es hispana)
(MILITARY: y está en servicio activo en las fuerzas armadas de los Estados Unidos. / y
no está en servicio activo en las fuerzas armadas de los Estados Unidos.).
4. OTHER MEMBERS UNDER AGE 17- OR OVER AGE 65
ENGLISH:
I have listed a (AGE) year old (GENDER) resident. (She/He) is (RACE), and (not)
(HISPANIC).
SPANISH:
He anotado (GENDER: una joven/una mujer/un joven/un hombre/una persona) de
(AGE) años de edad. (Ella/Él) es de raza (RACE: blanca, negra o afro-americana,
indígena americana o nativo(a) de Alaska, nativo(a) de Hawaii o de otra isla del
pacífico, asiática). (HISPANIC: Ella es hispana / Él es hispano/ Ella no es hispana / Él
no es hispano).
¿Es esto correcto?
Yes Sí [OTHER MEMBERS] [IF ROSTER NE BLANK , VERIFY ROSTER DATA]
No [HOUSEHOLDER AGE]

2-8

OTHER MEMBERS [IF CONFIRM ROSTER = YES AND MEMBERS 12 OR OLDER ≥ 2]
READ TO RESPONDENT:
[IF MEMBERS 12 OR OLDER =2] Ahora necesito información general sobre la otra persona en
este hogar que tenga 12 años de edad o más.
[IF MEMBERS 12 OR OLDER >2] Ahora necesito información general sobre todas las otras
personas en este hogar que tengan 12 años de edad o más. Empecemos con la persona mayor
hasta llegar a la persona menor.
CONTINUE [AGE]

AGE [IF OTHER MEMBERS NE BLANK OR CONFIRM ROSTER = NO]
[IF MEMBERS 12 OR OLDER = 2] Por favor dígame la edad de esta persona en su último
cumpleaños.
[IF MEMBERS 12 OR OLDER > 2 HH MEMBERS] Por favor dígame la edad de la (persona
mayor/siguiente persona) en su último cumpleaños.
ENTER AGE [IF ANY SCREENING RESPONDENT = YES, RELATION. IF ALL
SCREENING RESPONDENT = BLANK OR NO, SCREENING RESPONDENT]

2-9

RELATION [IF AGE NE BLANK AND ANY SCREENING RESPONDENT =YES]
[IF SCREENING RESPONDENT = YES FOR THIS MEMBER] ¿Cuál es su parentesco con la
cabeza de la familia?
[IF SCREENING RESPONDENT = YES FOR HOUSEHOLDER] ¿Qué parentesco tiene esta
persona con usted, la cabeza de la familia?
[IF SCREENING RESPONDENT = NO FOR THIS MEMBER] ¿Qué parentesco tiene esta
persona con la cabeza de la familia?
Husband Esposo
Wife Esposa
Son (includes step) Hijo (incluye hijo adoptivo)
Daughter (includes step) Hija (incluye hija adoptiva)
Son-in-law/Daughter-in-law Yerno/Nuera
Brother (includes step) Hermano (incluye hermano adoptivo)
Sister (includes step) Hermana (incluye hermana adoptiva)
Brother-in-law/Sister-in-law Cuñado(a)
Parent/Guardian (incl. step) Padre o madre/Tutor(a) (incluye padrastro/madrastra)
Parent-in-law (incl. step) Suegro(a)
Aunt/Uncle Tía(o)
Nephew/Niece Sobrino(a)
Grandparent Abuelo(a)
Grandchild Nieto(a)
Cousin Primo(a)
Ex-Spouse Ex-esposo(a)
Live-in Partner Pareja conviviente
Friend/Roommate Amigo(a)/Compañero(a) de casa o de cuarto
Tenant/Boarder/Exch Student Inquilino(a)/Pensionista/Intercambio estudiantil
Other relative Otro pariente
Other Non-relative Otra persona que no es pariente
Relationship Unspecified No se especificó la relación
[IF RELATION = HUSBAND, WIFE, SON, DAUGHTER, BROTHER OR SISTER
HISPANIC, OTHERWISE GENDER]
ChangeSR [CHANGE SR: DO YOU WANT TO CHANGE THE SR, IF No,
RELATION. IF Yes, THIS PERSON: IS THIS PERSON THE SR? IF Yes OR No,
CONFIRM CHANGE: PLEASE CONFIRM RESPONSE. IS THIS PERSON THE
SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE CONFIRM
RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE AND
= No, PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT
CHANGE AND = Yes, PERSON = SCREENING RESPONDENT.]

2-10

GENDER [IF RELATION NE HUSBAND, WIFE, SON, DAUGHTER, BROTHER OR SISTER]
ASK ONLY IF NOT OBVIOUS
¿Es esta persona hombre o mujer?
Male Hombre
Female Mujer
Refused Se rehúsa
[HISPANIC]
ChangeSR [CHANGE SR: DO YOU WANT TO CHANGE THE SR, IF No,
GENDER. IF Yes, THIS PERSON: IS THIS PERSON THE SR? IF Yes OR No,
CONFIRM CHANGE: PLEASE CONFIRM RESPONSE. IS THIS PERSON THE
SR? IF RESPONSE CHANGES, CONFIRM CHANGE: PLEASE CONFIRM
RESPONSE. IS THIS PERSON THE SR? IF RESPONSE DOES NOT CHANGE AND
= No, PERSON NE SCREENING RESPONDENT. IF RESPONSE DOES NOT
CHANGE AND = Yes, PERSON = SCREENING RESPONDENT.

HISPANIC [IF GENDER NE BLANK]
¿Es (usted/él/ella/esta persona) de origen hispano, latino o español?
(Es decir que su origen nacional o descendencia se puede describir como puertorriqueño, cubano,
cubano-americano, mexicano, mexicano-americano, chicano, centro o sudamericano, o es
nativo(a) de otro país donde se habla español?)
Yes Sí
No
Refused Se rehúsa
[RACE]

RACE [IF HISPANIC NE BLANK]
¿Es (usted/él/ella/esta persona) de raza blanca, negra o afro-americana, indígena americana o
nativo(a) de Alaska, nativo(a) de Hawaii o de otra isla del pacífico, o asiática?
White Blanca
Black or African American Negra o afro-americana
American Indian or Alaska Native Indígena americana o nativo(a) de Alaska
Native Hawaiian/other Pacific Islander Nativo(a) de Hawaii o de otra isla del pacífico
Asian Asiática
Other Otra raza
Unknown No sabe
Refused Se rehúsa
(CHECK ALL THAT APPLY)

2-11

[IF AGE 17-65, MILITARY, OTHERWISE CONFIRM ROSTER]

MILITARY [IF RACE NE BLANK AND AGE 17-65 AND SCREENING RESPONDENT =
NO FOR THIS MEMBER]
¿Está (usted/él/ella/esta persona) actualmente en servicio activo en las fuerzas armadas de los
Estados Unidos?
Yes Sí
No
Unknown No sabe
Refused Se rehúsa
[CONFIRM ROSTER]

HOUSEHOLDER MILITARY [IF HOUSEHOLDER RACE NE BLANK AND
HOUSEHOLDER AGE = 17-65 AND SCREENING RESPONDENT = YES FOR THIS
MEMBER]
¿Está (usted/él/ella/esta persona) actualmente en servicio activo en las fuerzas armadas de los
Estados Unidos?
Yes Sí
No
Refused Se rehúsa
[CONFIRM ROSTER]

CONFIRM ROSTER [IF AGE 17-65 AND MILITARY IS NE BLANK, OTHERWISE
RACE NE BLANK]
There are four translation variations. English is also provided here for clarification.
1. SCREENING RESPONDENT AGE 17- 65
ENGLISH:
I have listed you as a (AGE) year old (GENDER) resident. You are (RACE),
(HISPANIC), and (are/are not) on active duty in the United States military.
SPANISH:
(MALE:Lo)(FEMALE: La) he anotado a usted, (GENDER: una joven/una mujer/un
joven/un hombre/una persona) de (AGE) años de edad. (Usted) es de raza (RACE:
blanca, negra o afro-americana, indígena americana o nativo(a) de Alaska, nativo(a) de
Hawaii o de otra isla del pacífico, asiática). (HISPANIC: Usted es hispana / Usted es
hispano/ Usted no es hispana / Usted no es hispano) (MILITARY: y está en servicio
activo en las fuerzas armadas de los Estados Unidos. / y no está en servicio activo en las
fuerzas armadas de los Estados Unidos).

2-12

2. SCREENING RESPONDENT UNDER AGE 17 OR OVER AGE 65
ENGLISH:
I have listed you as a (AGE) year old (GENDER) resident. You are (RACE), and (not)
(HISPANIC).
SPANISH:
(MALE:Lo)(FEMALE: La) he anotado a usted, (GENDER: una joven/una mujer/un
joven/un hombre/una persona) de (AGE) años de edad. (Usted) es de raza (RACE:
blanca, negra o afro-americana, indígena americana o nativo(a) de Alaska, nativo(a) de
Hawaii o de otra isla del pacífico, asiática). (HISPANIC: Usted es hispana / Usted es
hispano/ Usted no es hispana / Usted no es hispano).
3. OTHER MEMBERS AGES 17- 65
ENGLISH:
I have listed a (AGE) year old (GENDER) resident. (She/He) is (RACE), (HISPANIC)
and (is/is not) on active duty in the United States military.
SPANISH:
He anotado (GENDER) de (AGE) años de edad. (Ella/Él) es de raza (RACE). (Ella/Él)
(es/no es) (HISPANIC) y (está/no está) en servicio activo en las fuerzas armadas de los
Estados Unidos.
SPANISH GENDER/RELATIONSHIP DESCRIPTIONS:
He anotado (GENDER: una joven/una mujer/un joven/un hombre/una persona) de
(AGE) años de edad. (Ella /Él /Esta persona) es de raza (RACE: blanca, negra o afroamericana, indígena americana o nativo(a) de Alaska, nativo(a) de Hawaii o de otra isla
del pacífico, asiática). (HISPANIC: Ella es hispana / Él es hispano/Esta persona es
hispana / Ella no es hispana / Él no es hispano/Esta persona no es hispana)
(MILITARY: y está en servicio activo en las fuerzas armadas de los Estados Unidos. / y
no está en servicio activo en las fuerzas armadas de los Estados Unidos).

2-13

4. OTHER MEMBERS UNDER AGE 17- OR OVER AGE 65
ENGLISH:
I have listed a (AGE) year old (GENDER) resident. (She/He) is (RACE), and (not)
(HISPANIC).
SPANISH:
He anotado (GENDER: una joven/una mujer/un joven/un hombre/una persona) de
(AGE) años de edad. (Ella/Él) es de raza (RACE: blanca, negra o afro-americana,
indígena americana o nativo(a) de Alaska, nativo(a) de Hawaii o de otra isla del
pacífico, asiática). (HISPANIC: Ella es hispana / Él es hispano/ Ella no es hispana / Él
no es hispano).
¿Es esto correcto?
Yes Sí [AGE FOR NEXT HH MEMBER, OTHERWISE VERIFY ROSTER DATA]
No [AGE]

VERIFY ROSTER DATA [IF CONFIRM ROSTER = YES]
Rel (Relationship)
SR (Y for Screening Respondent)
A (Age)
[UPON TAPPING ON ANY ROSTER LINE, SHOW REMAINING COLUMNS]
G (Gender: M, F, R)
H (Hispanic: Y, N, U, R)
R (Race: W, B, I, P, A, O)
M (Military: Y, N, U, R)
E (Eligibility: E, I)
[IF CONFIRM ROSTER = YES AND MEMBERS 12 OR OLDER=1]
DO NOT READ TO RESPONDENT. WHEN READY, TAP CONTINUE TO MAKE
SELECTION.
TO MAKE CORRECTIONS: TAP THE ROSTER LINE THAT YOU WANT TO EDIT, THEN
TAP 'FUNCTIONS' AND 'EDIT.'
[IF CONFIRM ROSTER = YES AND MEMBERS 12 OR OLDER>=2]
Necesito asegurarme que la lista está correcta. He anotado...
[READ AGES AND RELATIONSHIPS ROSTERED].
TO MAKE CORRECTIONS: TAP THE ROSTER LINE THAT YOU WANT TO EDIT, THEN
TAP 'FUNCTIONS' AND 'EDIT.'
Continue [START SELECTION]

START SELECTION
2-14

THE PROGRAM WILL START THE SELECTION PROCESS. ARE YOU SURE YOU ARE
READY TO MAKE THE SELECTIONS?
Yes [RESPONDENT SELECTION]
No [VERIFY ROSTER DATA]

RESPONDENT SELECTION [START SELECTION = YES]
Interview A
Roster #: (Roster # of selected member, None)
QuestID: (7-digit Questionnaire ID, BLANK)
Relation: (Relationship to householder, BLANK)
Age: (AGE, BLANK)
Race: (W, B, I, P, A, O, BLANK)

Sex: (M, F, BLANK)
Hispanic: (Y, N, BLANK)

Interview B
Roster #: (Roster # of selected member, None)
QuestID: (7-digit Questionnaire ID, BLANK)
Relation: (Relationship to householder, BLANK)
Age: (AGE, BLANK)
Race: (W, B, I, P, A, O, BLANK)

Sex: (M, F, BLANK)
Hispanic: (Y, N, BLANK)

2-15

NSDUH DR Screening Application Specifications
Section 3
GQU Screening - English
Document Format:
• Screen names bolded
• Screen/question/instructional text designated by black and red text and non-italicized text in
parenthesis (Upper-lower black text to be read, red text is instructions to FI)
• Fills designated by parenthesis and italics
• Logic designated by brackets
• Text of instructional message boxes provided in bracketed logic
• Response categories underlined

STUDY INTRODUCTION
Hello, my name is (FI NAME) with RTI International in North Carolina. We are conducting a
nationwide study sponsored by the U.S. Department of Health and Human Services.
You should have received a letter explaining the study.
Next [IDENTIFY SR]

IDENTIFY SR [IF STUDY INTRODUCTION = NEXT]
First, just let me verify: do you live here?
IF NOT OBVIOUS:
And are you 18 or older?
IF NO TO EITHER, ASK FOR AN ADULT RESIDENT, TOUCH “PREVIOUS”, AND BEGIN
AGAIN.
SR Available [ADDRESS VERIFICATION]
SR Not Available [EXIT SCREENING: “ARE YOU SURE YOU WANT TO EXIT
SCREENING?” IF Yes, RECORD OF CALLS. IF No,
IDENTIFY SR.]

3-1

ADDRESS VERIFICATION [IF IDENTIFY SR = SR AVAILABLE]
I just need to verify -- is this
STREET: (NUMBER AND STREET)
CITY: (CITY)
STATE: (STATE)
ZIP: (ZIP)
Address Is Correct [INFORMED CONSENT]
Need to Edit Address [EDIT ADDRESS]
FI At Wrong Address [SELECT CASE]

EDIT ADDRESS [IF ADDRESS VERIFICATION = NEED TO EDIT ADDRESS]
TOUCH THE ITEM YOU NEED TO EDIT
STREET #: (NUMBER)
STREET: (STREET)
CITY: (CITY)
STATE: (STATE)
ZIP: (ZIP)
Update [SAVE UPDATED ADDRESS, THEN INFORMED CONSENT]

INFORMED CONSENT [IF ADDRESS VERIFICATION = ADDRESS IS CORRECTCONTINUE OR EDIT ADDRESS = UPDATE]
GIVE PERSON STUDY DESCRIPTION AND SAY
Please read this statement. It describes the survey and the legislation that assures the
confidentiality of any information you provide. It also explains that your answers are used for
statistical purposes only and that your participation is voluntary. If anyone is selected for the full
interview, that person will receive $30 in cash after the interview is completed.
Next [TRANSIENT]

TRANSIENT [IF INFORMED CONSENT = CONTINUE]
INTERVIEWER: IS THIS GQU A TRANSIENT SHELTER?
Yes [UNIT TYPE]
No [OCCUPANCY]

3-2

UNIT TYPE [IF TRANSIENT = YES]
ARE THE LISTED UNITS…
ROOMS [TOTAL GQU MEMBERS]
BEDS, OR [ROSTER #1]
PERSONS? [ROSTER #1]

OCCUPANCY [IF TRANSIENT = NO]
(Did/Will) you or anyone else in this room live here for most of the time during the
months of (CURRENT QUARTER)?
Yes [TOTAL GQU MEMBERS]

No [OCCUPANCY – CONFIRMATION:
YOUR ‘NO’ RESPONSE WILL
CONCLUDE THIS SCREENING
AND FINALIZE THIS CASE. DO
YOU WANT TO CHANGE YOUR
ANSWER? (‘YES’ WILL CONTINUE
SCREENING. ‘NO’ WILL FINALIZE THE
CASE.) IF Yes, TOTAL GQU MEMBERS.
IF No, VERIFICATION.]

TOTAL GQU MEMBERS [IF OCCUPANCY = YES OR IF UNIT TYPE = ROOMS]
[IF TRANSIENT = YES AND UNIT TYPE = ROOMS] (Including yourself) How many people
are staying in this room?
[IF TRANSIENT = NO] (Including yourself) How many people (lived/will live) in this room for
most of the time during the months of (CURRENT QUARTER)?
ENTER NUMBER 1-20 [MEMBERS 12 OR OLDER]
[IF TOTAL GQU MEMBERS = 1, ONLY MEMBER: CONFIRM RESPONSE: IS
THERE ONLY 1 PERSON LIVING HERE? IF No, TOTAL GQU MEMBERS.
IF Yes AND UNIT TYPE = ROOMS, ROSTER #1 AGE. IF Yes AND TRANSIENT =
NO, ROSTER: IS THIS SCREENING RESPONDENT THE ONE ELIGIBLE
RESIDENT OF THE DU? IF Yes, ROSTER #1 AGE USING ‘YOUR’ FILL. IF No,
ROSTER #1 AGE USING ‘THIS PERSON’ FILL].

MEMBERS 12 OR OLDER [IF TOTAL GQU MEMBERS NE BLANK AND >1]
[IF TRANSIENT = YES] How many of these [TOTAL GQU MEMBERS] people are now age 12
or older.
[IF TRANSIENT = NO] Of these [TOTAL GQU MEMBERS] people, how many are now age 12
or older?
ENTER SUBSET OF TOTAL GQU MEMBERS ROSTER # AGE

3-3

[IF MEMBERS 12 OR OLDER = 1, ONLY ELIGIBLE MEMBER: “CONFIRM
RESPONSE: IS THERE ONLY 1 PERSON AGE 12 OR OLDER IN THIS UNIT?”
IF No, MEMBERS 12 OR OLDER. IF Yes AND UNIT TYPE = ROOMS ROSTER #
1 AGE. IF Yes AND TRANSIENT = NO, ROSTER: IS THIS SCREENING
RESPONDENT THE ONE ELIGIBLE RESIDENT OF THE DU? IF Yes, ROSTER #1
AGE USING ‘YOUR’ FILL. IF No, ROSTER #1 AGE USING ‘THIS PERSON’
FILL].

ROSTER #1 AGE [IF MEMBERS 12 OR OLDER NE BLANK OR TOTAL GQU MEMBERS = 1
OR IF UNIT TYPE = BEDS OR PERSONS]
Please tell me your age on your last birthday.
ENTER AGE [ROSTER #1 NAME]

ROSTER #1 NAME [IF ROSTER #1 AGE NE BLANK]
What is your first name?
ENTER FIRST NAME [ROSTER #1 GENDER]

ROSTER #1 GENDER [IF ROSTER #1 NAME NE BLANK]
ASK ONLY IF NOT OBVIOUS
Is this person male or female?
Male
Female
[ROSTER #1 HISPANIC]

ROSTER #1 HISPANIC [IF ROSTER #1 GENDER NE BLANK]
Are you of Hispanic, Latino or Spanish origin?
(That is, do any of these groups describe your national origin or ancestry – Puerto Rican, Cuban,
Cuban-American, Mexican, Mexican-American, Chicano, Central or South American, or origin
in some other Spanish-speaking country?)
Yes
No
[ROSTER #1 RACE]

3-4

ROSTER #1 RACE [IF ROSTER #1 HISPANIC NE BLANK]
Are you White, Black or African American, American Indian or Alaska Native, Native Hawaiian
or other Pacific Islander, or Asian?
White
Black or African American
American Indian or Alaska Native
Native Hawaiian/other Pacific Islander
Asian
Other
(CHECK ALL THAT APPLY)

[ROSTER #1 MILITARY OR IF ROSTER #1 AGE NE 17-65 CONFIRM ROSTER]

ROSTER #1 MILITARY [IF ROSTER #1 RACE NE BLANK AND ROSTER #1 AGE = 17-65]
Are you currently on active duty in the United States military?
Yes
No
Refused
[CONFIRM ROSTER]

CONFIRM ROSTER [IF ROSTER #1 MILITARY NE BLANK OR IF
ROSTER #1 AGE NE 17-65 AND ROSTER #1 RACE NE
BLANK]
[IF RACE, HISPANIC, AND/OR MILITARY IS ‘OTHER’, ‘DK’, OR ‘REF’ OMIT
RESPECTIVE FILLS FROM CONFIRM ROSTER SCREEN.]
I have listed you as a (AGE) year old (GENDER) resident. You are (RACE), (HISPANIC) [IF
AGE =17-65] and (are/are not) on active duty in the United States military.
Is that correct?
Yes [IF MEMBERS 12 OR OLDER ≥ 2 OTHER MEMBERS. IF UNIT TYPE = BEDS OR
PERSONS OR UNIT TYPE = ROOMS AND TOTAL GQU MEMBERS OR MEMBERS
12 OR OLDER =1 VERIFY ROSTER DATA]
No [ROSTER #1 AGE]

3-5

OTHER MEMBERS [IF CONFIRM ROSTER = YES AND MEMBERS 12 OR OLDER ≥ 2]
READ TO RESPONDENT:
Now I need some general information about (the other person/all of the other people) who
(is/are) 12 years old or older. [IF MEMBERS 12 OR OLDER >2] Let's start with the oldest and
work down to the youngest.
Next [AGE]

AGE [IF OTHER MEMBERS NE BLANK OR CONFIRM ROSTER = NO]
[IF MEMBERS 12 OR OLDER = 2] Please tell me the age of this person on his or her last
birthday.
[IF MEMBERS 12 OR OLDER > 2 HH MEMBERS] Please tell me the age of the (oldest/next
oldest) person on his or her last birthday.
ENTER AGE [NAME]

NAME [IF AGE NE BLANK]
What is this person’s first name?
ENTER FIRST NAME [GENDER]

GENDER [IF NAME NE BLANK]
ASK ONLY IF NOT OBVIOUS
Is this person male or female?
Male
Female
Refused
[HISPANIC]

3-6

HISPANIC [IF GENDER NE BLANK]
(Is he/Is she/Is this person) of Hispanic, Latino or Spanish origin?
(That is, do any of these groups describe (his/her/their) national origin or ancestry – Puerto
Rican, Cuban, Cuban-American, Mexican, Mexican-American, Chicano, Central or South
American, or origin in some other Spanish-speaking country?)
Yes
No
Unknown
Refused
[RACE]

RACE [IF HISPANIC NE BLANK]
(Is he/Is she/Is this person) White, Black or African American, American Indian or Alaska
Native, Native Hawaiian or other Pacific Islander, or Asian?
White
Black or African American
American Indian or Alaska Native
Native Hawaiian/other Pacific Islander
Asian
Other
Unknown
Refused
(CHECK ALL THAT APPLY)
[IF AGE 17-65, MILITARY, OTHERWISE CONFIRM ROSTER]

MILITARY [IF RACE NE BLANK AND AGE 17-65]
(Is he/Is she/Is this person) currently on active duty in the United States military?
Yes
No
Unknown
Refused
[CONFIRM ROSTER]

3-7

CONFIRM ROSTER [IF AGE 17-65 AND MILITARY IS NE BLANK, OTHERWISE
RACE NE BLANK]
[IF RACE, HISPANIC, AND/OR MILITARY IS ‘OTHER’, ‘DK’, OR ‘REF’ OMIT
RESPECTIVE FILLS FROM CONFIRM ROSTER SCREEN.]
I have listed a (AGE) year old (GENDER) resident. (He/She) is (RACE), (HISPANIC) [IF AGE
17-65] and (is/is not) on active duty in the United States military.
Is that correct?
Yes [AGE FOR NEXT GQU MEMBER, OTHERWISE VERIFY ROSTER DATA]
No [AGE]

VERIFY ROSTER DATA [IF CONFIRM ROSTER = YES]
Name (First Name)
A (Age)
SR (Y for Screening Respondent)
[UPON TOUCHING ON ANY ROSTER LINE, SHOW SELECT SHOW DETAILS, ALL ROSTER
INFORMATION]
G (Gender: M, F, R)
H (Hispanic: Y, N, U, R)
R (Race: W, B, I, P, A, O)
M (Military: Y, N, U, R)
E (Eligibility: E, I)
[IF CONFIRM ROSTER = YES AND MEMBERS 12 OR OLDER=1]
DO NOT READ TO RESPONDENT. WHEN READY, TOUCH NEXT TO MAKE
SELECTION.
TO MAKE CORRECTIONS: TOUCH AND HOLD THE ROSTER LINE THAT YOU WANT
TO EDIT, THEN TOUCH 'EDIT' FROM THE POP-UP MENU.
[IF CONFIRM ROSTER = YES AND MEMBERS 12 OR OLDER>=2]
I need to make sure this list is accurate. I have listed...
[READ LIST OF OCCUPANTS’ AGES AND NAMES].
TO MAKE CORRECTIONS: TOUCH AND HOLD THE ROSTER LINE THAT YOU WANT
TO EDIT, THEN TOUCH 'EDIT' FROM THE POP-UP MENU.
[FUNCTIONS TO ADD ROSTER MEMBERS AND/OR EDIT ROSTER DATA]
Next [START SELECTION]

3-8

START SELECTION
THE PROGRAM WILL START THE SELECTION PROCESS. ARE YOU SURE YOU ARE
READY TO MAKE THE SELECTIONS?
Yes [RESPONDENT SELECTION]
No [VERIFY ROSTER DATA]

RESPONDENT SELECTION [START SELECTION = YES]
Interview A
Roster #: (Roster # of selected member, None)
QuestID: (7-digit Questionnaire ID, BLANK)
Name: (First Name, BLANK)
Age: (AGE, BLANK)
Race: (W, B, I, P, A, O, BLANK)

Sex: (M, F, BLANK)
Hispanic: (Y, N, BLANK)

Interview B
Roster #: (Roster # of selected member, None)
QuestID: (7-digit Questionnaire ID, BLANK)
Name: (First Name, BLANK)
Age: (AGE, BLANK)
Race: (W, B, I, P, A, O, BLANK)

Sex: (M, F, BLANK)
Hispanic: (Y, N, BLANK)

3-9

NSDUH DR Screening Application Specifications
Section 4
GQU Screening - Spanish
Document Format:
• Screen names bolded
• Screen/question/instructional text designated by black and red text and non-italicized text in
parenthesis (Upper-lower black text to be read, red upper case text is instructions to FI)
• Fills designated by parenthesis and italics
• Logic designated by brackets
• Text of instructional message boxes provided in bracketed logic
• Response categories underlined

STUDY INTRODUCTION
(Buenas noches/ Buenas tardes/Buenos días). Mi nombre es (FI NAME) " y trabajo para RTI
International en Carolina del Norte. Estamos llevando a cabo un estudio nacional patrocinado por
el Departamento de Salud y Servicios Humanos de los Estados Unidos.
Usted ha de haber recibido una carta explicándole el estudio.
Continue [IDENTIFY SR]

IDENTIFY SR [IF STUDY INTRODUCTION = CONTINUE]
Primero, déjeme verificar: ¿vive usted aquí?
IF NOT OBVIOUS:
Y ¿tiene 18 años de edad o más?
IF NO TO EITHER, ASK FOR AN ADULT RESIDENT, TAP BACK ARROW, AND BEGIN
AGAIN.
SR Available [ADDRESS VERIFICATION]
SR Not Available [EXIT SCREENING: “ARE YOU SURE YOU WANT TO EXIT
SCREENING?” IF Yes, RECORD OF CALLS. IF No, IDENTIFY SR.]

4-1

ADDRESS VERIFICATION [IF IDENTIFY SR = SR AVAILABLE]
Solamente necesito confirmar que ésta es
STREET: (NUMBER AND STREET)
CITY: (CITY)
STATE: (STATE)
ZIP: (ZIP)
Address Is Correct – Continue [INFORMED CONSENT]
Need to Edit Address [EDIT ADDRESS]
FI At Wrong Address [SELECT CASE]

EDIT ADDRESS [IF ADDRESS VERIFICATION = NEED TO EDIT ADDRESS]
TAP THE ITEM YOU NEED TO EDIT
ST. # (NUMBER)
STREET: (STREET)
CITY: (CITY)
STATE: (STATE) ZIP: (ZIP)
Update [SAVE UPDATED ADDRESS, THEN INFORMED CONSENT]

INFORMED CONSENT [IF ADDRESS VERIFICATION = ADDRESS IS CORRECTCONTINUE OR EDIT ADDRESS = UPDATE]
GIVE PERSON STUDY DESCRIPTION AND SAY:
Por favor lea esta declaración, la cual describe la encuesta y la legislación que asegura la
confidencialidad de cualquier información que usted nos dé. También explica que sus respuestas
son usadas con propósitos estadísticos únicamente y que su participación es voluntaria. Si
alguien es seleccionado(a) para participar en la entrevista en su totalidad, dicha persona recibirá
$30 dólares en efectivo después de haber completado la entrevista.
Continue [TRANSIENT]

TRANSIENT [IF INFORMED CONSENT = CONTINUE]
INTERVIEWER: IS THIS GQU A TRANSIENT SHELTER?
Yes [UNIT TYPE]
No [OCCUPANCY]

4-2

UNIT TYPE [IF TRANSIENT = YES]
ARE THE LISTED UNIT…
ROOMS [TOTAL GQU MEMBERS]
BEDS, OR [ROSTER #1]
PERSONS? [ROSTER #1]

OCCUPANCY [IF TRANSIENT = NO]
(¿Vivió/ ¿Vivirá) usted o alguna otra persona en este cuarto la mayor parte del tiempo durante los
meses de (CURRENT QUARTER)?
Yes Sí [TOTAL GQU MEMBERS]

No [OCCUPANCY – CONFIRMATION:
YOUR ‘NO’ RESPONSE WILL
CONCLUDE THIS SCREENING
AND FINALIZE THIS CASE. DO
YOU WANT TO CHANGE YOUR
ANSWER? (‘YES’ WILL CONTINUE
SCREENING. ‘NO’ WILL FINALIZE THE
CASE.) IF YES, TOTAL GQU MEMBERS.
IF NO, VERIFICATION.]

TOTAL GQU MEMBERS [IF OCCUPANCY = YES OR IF UNIT TYPE = ROOMS]
[IF TRANSIENT = YES AND UNIT TYPE = ROOMS] (Incluyéndose a sí mismo), ¿cuántas
personas viven en este cuarto?
[IF TRANSIENT = NO] (Incluyendose a sí mismo), ¿cuántas personas (vivieron/vivirán) en este
cuarto la mayor parte del tiempo entre los meses de (CURRENT QUARTER)?
ENTER NUMBER 1-20 [MEMBERS 12 OR OLDER]
[IF TOTAL GQU MEMBERS = 1, ONLY MEMBER: CONFIRM RESPONSE: IS
THERE ONLY 1 PERSON LIVING HERE? IF NO, TOTAL GQU MEMBERS.
IF YES AND UNIT TYPE = ROOMS, ROSTER #1 AGE. IF YES AND TRANSIENT
= NO, ROSTER: IS THIS SCREENING RESPONDENT THE ONE ELIGIBLE
RESIDENT OF THE DU? IF YES, ROSTER #1 AGE USING ‘YOUR’ FILL. IF NO,
ROSTER #1 AGE USING ‘THIS PERSON’ FILL].

4-3

MEMBERS 12 OR OLDER [IF TOTAL GQU MEMBERS NE BLANK AND >1]
[IF TRANSIENT = YES] ¿Cuántas de estas [TOTAL GQU MEMBERS] personas tienen 12 años
o más de edad actualmente?"
[IF TRANSIENT = NO] De estas [TOTAL GQU MEMBERS] personas, ¿cuántas tienen 12 años o
más actualmente?
ENTER SUBSET OF TOTAL GQU MEMBERS ROSTER # 1 AGE
[IF MEMBERS 12 OR OLDER = 1, ONLY ELIGIBLE MEMBER: “CONFIRM
RESPONSE: IS THERE ONLY 1 PERSON AGE 12 OR OLDER IN THIS UNIT?”
IF NO, MEMBERS 12 OR OLDER. IF YES AND UNIT TYPE = ROOMS ROSTER
# 1 AGE. IF YES AND TRANSIENT = NO, “ROSTER: IS THIS SCREENING
RESPONDENT THE ONE ELIGIBLE RESIDENT OF THE DU?” IF YES, ROSTER
#1 AGE USING ‘YOUR’ FILL. IF NO, ROSTER #1 AGE USING ‘THIS PERSON’
FILL].

ROSTER #1 AGE [IF MEMBERS 12 OR OLDER NE BLANK OR TOTAL GQU MEMBERS = 1
OR IF UNIT TYPE = BEDS OR PERSONS]
Por favor dígame su edad en su último cumpleaños.
ENTER AGE [ROSTER #1 NAME]

ROSTER #1 NAME [IF ROSTER #1 AGE NE BLANK]
¿Cuál es su nombre (sin apellido)?
ENTER FIRST NAME [ROSTER #1 GENDER]

ROSTER #1 GENDER [IF ROSTER #1 NAME NE BLANK]
ASK ONLY IF NOT OBVIOUS
¿Es esta persona hombre o mujer?
Male Hombre
Female Mujer
[ROSTER #1 HISPANIC]

4-4

ROSTER #1 HISPANIC [IF ROSTER #1 GENDER NE BLANK]
¿Es usted de origen hispano, latino o español?
(Es decir que su origen nacional o descendencia se puede describir como puertorriqueño, cubano,
cubano-americano, mexicano, mexicano-americano, chicano, centro o sudamericano, o es
nativo(a) de otro país donde se habla español?)
Yes Sí
No
[ROSTER #1 RACE]

ROSTER #1 RACE [IF ROSTER #1 HISPANIC NE BLANK]
¿Es usted de raza blanca, negra o afro-americana, indígena americana o nativo(a) de Alaska,
nativo(a) de Hawaii o de otra isla del pacífico, o asiática?
(CHECK ALL THAT APPLY)
White Blanca
Black or African American Negra o afro-americana
American Indian or Alaska Native Indígena americana o nativo(a) de Alaska
Native Hawaiian/other Pacific Islander Nativo(a) de Hawaii o de otra isla del pacífico
Asian Asiática
Other Otra raza
[ROSTER #1 MILITARY OR IF ROSTER #1 AGE NE 17-65 CONFIRM ROSTER]

ROSTER #1 MILITARY [IF ROSTER #1 RACE NE BLANK AND ROSTER #1 AGE = 17-65]
¿Está usted actualmente en servicio activo en las fuerzas armadas de los Estados Unidos?
Yes Sí
No
Refused Se rehúsa
[CONFIRM ROSTER]

4-5

CONFIRM ROSTER [IF ROSTER #1 MILITARY NE BLANK OR IF ROSTER #1 AGE
NE 17-65 AND ROSTER #1 RACE NE BLANK]
There are two translation variations. English is also provided here for clarification.
1. ROSTER #1 AGE 17- 65
ENGLISH:
I have listed you as a (AGE) year old (GENDER) resident. You are (RACE),
(HISPANIC), and (are/are not) on active duty in the United States military.
SPANISH:
(MALE:Lo)(FEMALE: La) he anotado a usted, (GENDER: una joven/una mujer/un
joven/un hombre/una persona) de (AGE) años de edad. (Usted) es de raza (RACE:
blanca, negra o afro-americana, indígena americana o nativo(a) de Alaska, nativo(a) de
Hawaii o de otra isla del pacífico, asiática). (HISPANIC: Usted es hispana / Usted es
hispano/ Usted no es hispana / Usted no es hispano) (MILITARY: y está en servicio
activo en las fuerzas armadas de los Estados Unidos. / y no está en servicio activo en las
fuerzas armadas de los Estados Unidos).
2. ROSTER #1 UNDER AGE 17 OR OVER AGE 65
ENGLISH:
I have listed you as a (AGE) year old (GENDER) resident. You are (RACE), and (not)
(HISPANIC).
SPANISH:
(MALE:Lo)(FEMALE: La) he anotado a usted, (GENDER: una joven/una mujer/un
joven/un hombre/una persona) de (AGE) años de edad. (Usted) es de raza (RACE:
blanca, negra o afro-americana, indígena americana o nativo(a) de Alaska, nativo(a) de
Hawaii o de otra isla del pacífico, asiática). (HISPANIC: Usted es hispana / Usted es
hispano/ Usted no es hispana / Usted no es hispano).
¿Es esto correcto?
Yes Sí [IF MEMBERS 12 OR OLDER ≥ 2 OTHER MEMBERS. IF UNIT TYPE = BEDS OR
PERSONS OR UNIT TYPE = ROOMS AND TOTAL GQU MEMBERS OR MEMBERS
12 OR OLDER =1 VERIFY ROSTER DATA]
No [ROSTER #1 AGE]

4-6

OTHER MEMBERS [IF CONFIRM ROSTER = YES AND MEMBERS 12 OR OLDER ≥ 2]
READ TO RESPONDENT:
[IF MEMBERS 12 OR OLDER >2] Ahora necesito información general sobre todas las otras
personas que tengan 12 años de edad o más. Empecemos con la persona mayor hasta llegar a la
persona menor.
[IF MEMBERS 12 OR OLDER = 2] Ahora necesito información general sobre la otra persona
que tenga 12 años de edad o más.
Continue [AGE]

AGE [IF OTHER MEMBERS NE BLANK OR CONFIRM ROSTER = NO]
[IF MEMBERS 12 OR OLDER = 2] Por favor dígame la edad de esta persona en su último
cumpleaños.
[IF MEMBERS 12 OR OLDER > 2 HH MEMBERS] Por favor dígame la edad de la (persona
mayor/siguiente persona) en su último cumpleaños.
ENTER AGE [NAME]

NAME [IF AGE NE BLANK]
¿Cuál es el nombre (sin apellido) de esta persona?
ENTER FIRST NAME [GENDER]

GENDER [IF NAME NE BLANK]
ASK ONLY IF NOT OBVIOUS
¿Es esta persona hombre o mujer?
Male Hombre
Female Mujer
Refused Se rehúsa
[HISPANIC]

4-7

HISPANIC [IF GENDER NE BLANK]
¿Es (él/ella/esta persona) de origen hispano, latino o español?
(Es decir que su origen nacional o descendencia se puede describir como puertorriqueño, cubano,
cubano-americano, mexicano, mexicano-americano, chicano, centro o sudamericano, o es
nativo(a) de otro país donde se habla español?)
Yes Sí
No
Unknown No sabe
Refused Se rehúsa
[RACE]

RACE [IF HISPANIC NE BLANK]
¿Es (él/ella/esta persona) de raza blanca, negra o afro-americana, indígena americana o nativo(a)
de Alaska, nativo(a) de Hawaii o de otra isla del pacífico, o asiática?
White Blanca
Black or African American Negra o afro-americana
American Indian or Alaska Native Indígena americana o nativo(a) de Alaska
Native Hawaiian/other Pacific Islander Nativo(a) de Hawaii o de otra isla del pacífico
Asian Asiática
Other Otra raza
Unknown No sabe
Refused Se rehúsa
(CHECK ALL THAT APPLY)
[IF AGE 17-65, MILITARY, OTHERWISE CONFIRM ROSTER]

MILITARY [IF RACE NE BLANK AND AGE 17-65]
¿Está (él/ella/esta persona) actualmente en servicio activo en las fuerzas armadas de los Estados
Unidos?
Yes Sí
No
Unknown No sabe
Refused Se rehúsa
[CONFIRM ROSTER]

4-8

CONFIRM ROSTER [IF AGE 17-65 AND MILITARY IS NE BLANK, OTHERWISE
RACE NE BLANK]
There are two translation variations. English is also provided here for clarification.
1. OTHER MEMBERS AGES 17- 65
ENGLISH:
I have listed a (AGE) year old (GENDER) resident. (She/He) is (RACE), (HISPANIC)
and (is/is not) on active duty in the United States military.
SPANISH:
He anotado (GENDER: una joven/una mujer/un joven/un hombre/una persona) de
(AGE) años de edad. (Ella /Él /Esta persona) es de raza (RACE: blanca, negra o afroamericana, indígena americana o nativo(a) de Alaska, nativo(a) de Hawaii o de otra isla
del pacífico, asiática). (HISPANIC: Ella es hispana / Él es hispano/Esta persona es
hispana / Ella no es hispana / Él no es hispano/Esta persona no es hispana)
(MILITARY: y está en servicio activo en las fuerzas armadas de los Estados Unidos. / y
no está en servicio activo en las fuerzas armadas de los Estados Unidos).
2. OTHER MEMBERS UNDER AGE 17- OR OVER AGE 65
ENGLISH:
I have listed a (AGE) year old (GENDER) resident. (She/He) is (RACE), and (not)
(HISPANIC).
SPANISH:
He anotado (GENDER: una joven/una mujer/un joven/un hombre/una persona) de
(AGE) años de edad. (Ella/Él) es de raza (RACE: blanca, negra o afro-americana,
indígena americana o nativo(a) de Alaska, nativo(a) de Hawaii o de otra isla del
pacífico, asiática). (HISPANIC: Ella es hispana / Él es hispano/ Ella no es hispana / Él
no es hispano).
¿Es esto correcto?
Yes Sí [AGE FOR NEXT GQU MEMBER, OTHERWISE VERIFY ROSTER DATA]
No [AGE]

4-9

VERIFY ROSTER DATA [IF CONFIRM ROSTER = YES]
Name (First Name)
SR (Y for Screening Respondent)
A (Age)
[UPON TAPPING ROSTER LINE SHOW REMAINING COLUMNS:]
G (Gender: M, F, R)
H (Hispanic: Y, N, U, R)
R (Race: W, B, I, P, A, O)
M (Military: Y, N, U, R)
E (Eligibility: E, I)
[IF CONFIRM ROSTER = YES AND MEMBERS 12 OR OLDER=1]
DO NOT READ TO RESPONDENT. WHEN READY, TAP CONTINUE TO MAKE
SELECTION.
TO MAKE CORRECTIONS: TAP THE ROSTER LINE THAT YOU WANT TO EDIT, THEN
TAP 'FUNCTIONS' AND 'EDIT.'
[IF CONFIRM ROSTER = YES AND MEMBERS 12 OR OLDER>=2]
Necesito asegurarme que la lista está correcta. He anotado...
[READ LIST OF OCCUPANTS’ AGES AND NAMES].
TO MAKE CORRECTIONS: TAP THE ROSTER LINE THAT YOU WANT TO EDIT, THEN
TAP 'FUNCTIONS' AND 'EDIT.'
Continue [START SELECTION]

START SELECTION
THE PROGRAM WILL START THE SELECTION PROCESS. ARE YOU SURE YOU ARE
READY TO MAKE THE SELECTIONS?
Yes [RESPONDENT SELECTION]
No [VERIFY ROSTER DATA]

4-10

RESPONDENT SELECTION [START SELECTION = YES]
Interview A
Roster #: (Roster # of selected member, None)
QuestID: (7-digit Questionnaire ID, BLANK)
Name: (First Name, BLANK)
Age: (AGE, BLANK)
Race: (W, B, I, P, A, O, BLANK)

Sex: (M, F, BLANK)
Hispanic: (Y, N, BLANK)

Interview B
Roster #: (Roster # of selected member, None)
QuestID: (7-digit Questionnaire ID, BLANK)
Name: (First Name, BLANK)
Age: (AGE, BLANK)
Race: (W, B, I, P, A, O, BLANK)

Sex: (M, F, BLANK)
Hispanic: (Y, N, BLANK)

4-11

NSDUH DR Screening Application Specifications
Section 5
Select Case Screen Options
Document Format:
• Screen/menu names bolded
• Screen/question/instructional text designated by black and red text and non-italicized text in
parenthesis (Upper-lower black text to be read, red text is instructions to FI)
• Fills designated by parentheses and italics
• Logic designated by brackets
• Text of instructional message boxes provided in bracketed logic
• Response categories underlined
• Explanatory text in italics.

Select Case screen contains the date, time, battery level, CaseID, (list of cases), Address, Results for S
(Screening), A (Interview A), and B (Interview) and menus detailed below.

ACTIONS MENU [ TOUCH AND HOLD CASE UNTIL ACTIONS MENU APPEARS]
Items on the Actions Menu are case specific. First a case is selected on the screen, then the action from
the Actions Menu is selected.
Screen DU/Re-Open Case
Go To Record Of Calls
View Selections
View Roster
Edit Address
Add Missed DU
Place Case On Hold/Take Case Off Hold
View Verification Information
Add Appointment
View Call Distribution

View Letters
SCREEN DU [TOUCH CASE, ACTIONS MENU, SCREEN DU]
[IF SCREENING COMPLETED, RE-OPEN CASE DISPLAYS ON ACTIONS
MENU. RE-OPENING CONFIRMATION: “CASE (CASEID) HAS ALREADY
BEEN COMPLETED. DO YOU WISH TO RE-OPEN THIS CASE? IF No, SELECT
CASE. IF Yes, CASE RE-OPEN CODE: “ENTER THE CODE TO RE-OPEN THIS
CASE, THEN TOUCH ‘OK’ TO CONTINUE.” ENTER CORRECT CODE, OK, SDU
CHARACTERISTIC]

GO TO RECORD OF CALLS [TOUCH CASE, ACTIONS MENU, GO TO RECORD OF
CALLS – FOR DETAILS SEE SECTION 6]

VIEW SELECTIONS [TOUCH CASE, ACTIONS MENU, VIEW SELECTIONS]
5-12

RESPONDENT SELECTION [IF CASE COMPLETED WITH FINAL
RESULT CODE = [31, 32]
Interview A
Roster #: (Roster # of selected member, None)
QuestID: (7-digit Questionnaire ID, BLANK)
Relation: (Relationship to householder, BLANK)
Age: (AGE, BLANK)
Race: (W, B, I, P, A, O, BLANK)

Sex: (M, F, BLANK)
Hispanic: (Y, N, BLANK)

Interview B
Roster #: (Roster # of selected member, None)
QuestID: (7-digit Questionnaire ID, BLANK)
Relation: (Relationship to householder, BLANK)
Age: (AGE, BLANK)
Race: (W, B, I, P, A, O, BLANK)

Sex: (M, F, BLANK)
Hispanic: (Y, N, BLANK)

Done [SELECT CASE]
Roster [VERIFY ROSTER DATA]
ROC [RECORD OF CALLS]

VIEW ROSTER [TOUCH CASE, ACTIONS MENU, VIEW ROSTER]
[IF CASE COMPLETED WITH FINAL RESULT CODE = 30, 31, 32, VERIFY
ROSTER DATA]
[VERIFY ROSTER DATA – FOR DETAILS, SEE SECTIONS 1& 2]
Done [SELECT CASE]
Selections [RESPONDENT SELECTION]

EDIT ADDRESS [TOUCH CASE, ACTIONS MENU, EDIT ADDRESS]
[EDIT ADDRESS – FOR DETAILS, SEE SECTIONS 1 & 2]

ADD MISSED DU [TOUCH CASE ACTIONS MENU, ADD MISSED DU]
[MISSED DU ADDRESS – FOR DETAILS, SEE SECTION 1]
[IF CASE SELECTED IS MISSED DU: CANNOT ADD UNIT: “YOU CANNOT
ADD A MISSED DU FROM A DU THAT HAS BEEN ADDED.” OK, SELECT
CASE.]
[IF ATTEMPTING TO ADD A DU TO A GQU: MISSED GQU: “YOU CANNOT
ADD MISSED GROUP QUARTERS UNITS (GQUS). YOU CAN ONLY ADD A
MISSED HOUSING UNIT THAT IS ASSOCIATED WITH A SELECTED LINE IN A
GROUP QUARTERS STRUCTURE. ARE YOU CERTAIN THE UNIT YOU WANT
TO ADD IS A HOUSING UNIT AND NOT A GROUP QUARTERS UNIT?”]

5-13

Yes [READY TO ADD: “DO YOU WANT TO ADD AN HU LINKED TO CASE
(CASEID)?” IF Yes, MISSED DU ADDRESS. IF No, SELECT CASE]
No [CALL FS: “IF THERE ARE MISSED GROUP QUARTERS UNITS IN THE
STRUCTURE, OBTAIN INFORMATION ABOUT ALL MISSED UNITS THEN
CALL YOUR FS.” OK, SELECT CASE.]

PLACE CASE ON HOLD [TOUCH CASE, ACTIONS MENU, PLACE CASE ON HOLD]
This menu option toggles between “Place Case On Hold” and “Take Case Off Hold,”
depending on the on-hold status of the case. When a case is on hold, data for that case are
transmitted, but are not pulled into the control system—the data is maintained in a separate
location to be accessed, as necessary. This allows putting a case ‘On Hold’ for
troubleshooting.
[IF CASE NOT ON HOLD, PLACE CASE ON HOLD: “ARE YOU SURE YOU
WANT TO PUT CASE (CASEID) ON HOLD?” IF No, SELECT CASE WITH CASE
NOT ON HOLD. IF Yes, SELECT CASE WITH ‘On Hold’ NEXT TO CASEID.]
[IF CASE ON HOLD, TAKE CASE OFF HOLD: “ARE YOU SURE YOU WANT TO
TAKE CASE (CASEID) OFF HOLD?” IF No, SELECT CASE WITH CASE ON
HOLD. IF Yes, SELECT CASE WITH ‘On Hold” REMOVED AND CASE NOT ON
HOLD.]

VIEW VERIFICATION INFORMATION [IF VERIFICATION INFORMATION
AVAILABLE, VERIFICATION.]

ADD APPOINTMENT [SELECT CASE, ACTIONS, ADD APPOINTMENT]
This optional calendar can be used to post work and personal appointments to help with time
management and scheduling of interview appointments.

NEW APPOINTMENT
SHOW CALENDAR WHEN DONE? (check box)
CASE: (Case ID)
FROM: (current date with link to calendar to select a beginning date) (time of day)
[IF SELECT A DIFFERENT DATE, Set CHANGES DATE,
Cancel MAINTAINS CURRENT DATE]
IF SELECT A DIFFERENT TIME, Set CHANGES TIME,
Cancel MAINTAINS CURRENT TIME]
TO: (current date with link to calendar to select a ending date) (time of day)
[IF SELECT A DIFFERENT DATE, Set CHANGES DATE,
Cancel MAINTAINS CURRENT DATE]
IF SELECT A DIFFERENT TIME, Set CHANGES TIME,
Cancel MAINTAINS CURRENT TIME]
ALL DAY? (check box)
REMINDER: (Drop-down box with incremental time choices Once reminder is set,
calendar icon appears at bottom of Select Case Screen allowing for easy access to
appointments)
TYPE: (Drop-down box with: Select Type, Screening, Interview A, Interview B, S/I
Other, Other)

5-14

DESCRIPTION: (text entry with comments describing appointment)
Done [CALENDAR with Pop Up containing appointment information. SEND VIA: not
to be used; EDIT: EDIT EVENT where changes can be easily made.] This calendar is an
interactive stock tablet tool that allows calendar viewing by day, week, month and list.
Touching the day on the calendar will show any entered appointments. New
appointments can be added, and appointments for the current day display at the bottom
of the screen.
Cancel [SELECT CASE]

VIEW CALL DISTRIBUTION [SELECT CASE, ACTIONS,VIEW CALL
DISTRIBUTION]
This optional case management feature can be used to view past work patterns based on ROC
data and to determine the times/days when contact has not been attempted at SDUs.
CALL DISTRIBUTION
Link: (line number and address of link line case)

SELECT A CASE OR SEGMENT (Drop-down list of cases and segments
that have associated ROC data entered. FI chooses desired selection
criteria.) [IF SELECT ALL CASES ROC INFORMATION ON ALL
CASES IS DISPLAYED. IF SELECT AN INDIVIDUAL CASE, ONLY
ROC DATA FROM THAT CASE DISPLAYED. IF SELECT AN
INDIVIDUAL SEGMENT, ROC DATA FROM CASES WITHIN THAT
SEGMENT ONLY IS DISPLAYED.]
SCREENING RECORDS ONLY (Drop-down list of selection criteria to
customize ROC data displayed.) [IF SELECT ALL ROC TYPE
RECORDS, ALL ROCS ENTERED DISPLAY. IF SELECT
SCREENING RECORDS ONLY, ONLY SCREENING RECORDS
DISPLAY. IF SELECT INTERIVEW A OR B RECORDS ONLY,
ONLY INTERVIEW A AND B RECORDS DISPLAY. IF SELECT
INTERVIEW A RECORDS ONLY, ONLY INTERVIEW A ROCS
DISPLAY. IF SELECT INTERVIEW B RECORDS ONLY, ONLY
INTERVIEW B ROCS DISPLAY. IF SELECT CHOOSE ROC
CODE(S), A DROP DOWN LIST OF ALL ROC CODES APPEARS TO
CHOOSE FROM.]
DATE RANGE (INCLUSIVE)
BEGIN DATE: [SELECT A DATE] Date appears allowing beginning
date selection to narrow down the ROC results SET chooses the date
entered [CALL DISTRIBUTION], CANCEL, [CALL
DISTRIBUTION].)
END DATE: [SELECT A DATE] Date appears allowing beginning
date selection to narrow down the ROC results SET chooses the date
entered [CALL DISTRIBUTION], CANCEL, [CALL
DISTRIBUTION].)
5-15

Su
M
Tu
W
Th
F
Sa
All

6A-10A 10A-12P 12P-4P 4P-6P 6P-10P 10P-6A All
-

Done [SELECT CASE]
Refresh (Refreshes displayed data based on most recent selection criteria
entered.) [IF NO CASE SELECTED, “PLEASE SELECT A CASE OR
SEGMENT FROM THE LIST THEN TAP “REFRESH”]
OK [CALL DISTRIBUTION]
ROC [IF CASE SELECTED, RECORD OF CALLS]
VIEW LETTERS [IF LETTER SENT, LETTERS]
LETTERS [IF REFUSAL LETTER HAS BEEN SENT
AND IF RECORD OF CALLS = CALL RECORD SELECTED,
FUNCTIONS, VIEW LETTERS]
(Date letter requested – letter code – result code – FS that submitted
request)
ADMINISTRATIVE TOOLS MENU [SELECT CASE, FUNCTIONS, ADMINISTRATIVE
TOOLS]

Items on Administrative Tools Menu are administrative.
Set Name and Id
Enter PT&E Data
View Transmitted PT&E Data
Reconcile Missed DUs
Reload Training Cases
Erase Training Cases

SET NAME AND ID [SELECT CASE, FUNCTIONS, ADMINISTRATIVE TOOLS, SET
NAME AND ID]

NSDUH SYSTEM IDENTIFICATION [SELECT CASE, ADMINISTRATIVE
TOOLS, SET NAME AND ID]
Government ID: (Government ID issued to iPAQ)
FIID: (RTI FI ID Number)
First Name: (FI First Name to be used on Study Introduction screen)
Last Name: (FI Last Name to be used on Study Introduction screen)

5-16

Save [SELECT CASE]
Cancel [SELECT CASE]

ENTER PT&E DATA [SELECT CASE, FUNCTIONS, ADMINISTRATIVE TOOLS,
ENTER PT&E DATA]

PT&E DATA [SELECT CASE, FUNCTIONS, ADMINISTRATIVE TOOLS, ENTER PT&E,
ADD]
Week: (Payroll week beginning date)
Quarter: 1 2, 3, 4 (Current quarter selected as default)
FS (Drop-down list of FS names who have hired FI)
Task (Drop-down list of possible task numbers)
Hours: (.25-99.99)
Miles: (1-999)
Expense: (.01-1500)
Notes: (Text entry field)
Done [CHECKS FOR COMPLETE DATA ENTRY, ANOTHER
PT&E: ‘DO YOU HAVE ANOTHER PT&E SUMMARY RECORD
TO ENTER?” IF No, PTE SUMMARY. IF Yes, PT&E DATA FOR
NEW ENTRY.
Cancel [CANCEL ENTRY: “ARE YOU SURE YOU WANT TO
CANCEL THE ENTRY OF THIS RECORD?” IF Yes, PTE
SUMMARY. IF No, PT&E DATA.
Clear [PT&E DATA WITH ENTRY CLEARED.]

PTE SUMMARY
Week (First date of work week)
Quarter (Quarter: 1, 2, 3, 4)
Task (Task number)
FS (FS Name)
Hours (Hours)
Miles (Miles)
Expenses (Expenses)
Notes (Notes)
WEEK:
FS:
TASK:
HRS:
EXP:

QUARTER:

NOTES:

Done [SELECT CASE]
Add [PT&E DATA]
Transmitted? [IF NO TRANSMITTED PT&E RECORDS, “NO
TRANSMITTED PT&E RECORDS FOUND” TOUCH
“Transmitted?” AGAIN TO DISPLAY UNTRANSMITTED
RECORDS. IF NO UNTRANSMITTED PT&E RECORDS,

5-17

“NO UNTRANSMITTED PT&E RECORDS FOUND” TOUCH
“Transmitted?” AGAIN TO DISPLAY TRANSMITTED
RECORDS.
IF TRANSMITTED PT&E RECORD(S), PTE SUMMARY
WITHOUT OPTION TO ADD, EDIT, DELETE.
IF UNTRANSMITTED PT&E RECORD(S), PTE SUMMARY
WITH ADD, EDIT, DELETE OPTIONS.]
EDIT [PT&E SUMMARY: TOUCH AND HOLD LINE TO SELECT,
ACTIONS, EDIT, PT&E DATA.]
DELETE [PT&E SUMMARY: TOUCH AND HOLD LINE TO
SELECT, ACTIONS, DELETE. PT&E DELETE CONFIRMATION:
“ARE YOU SURE YOU WANT TO DELETE THIS PT&E RECORD?”
IF No, PTE SUMMARY. IF Yes, PTE SUMMARY WITH RECORD
DELETED.]

VIEW TRANSMITTED PT&E DATA [SELECT CASE, FUNCTIONS,
ADMINISTRATIVE TOOLS, VIEW TRANSMITTED PT&E DATA]
[IF NO TRANSMITTED PT&E RECORDS, NO RECORD: “THERE IS
CURRENTLY NO TRANSMITTED PTE RECORD.” OK, SELECT CASE.
[IF TRANSMITTED PT&E RECORD(S): PTE SUMMARY WITHOUT
OPTION TO ADD, EDIT, DELETE.]

PTE SUMMARY (WITHOUT OPTION TO ADD, EDIT, DELETE)
Week (First date of work week)
Quarter (Quarter: 1, 2, 3, 4)
Task (Task number)
FS (FS Name)
Hours (Hours)
Miles (Miles)
Expense (Expenses)
Notes (Notes)
WEEK:
FS:
TASK:
HRS:
EXP:

QUARTER:

NOTES:

Done [SELECT CASE]
Add [PT&E DATA]
Transmitted? [IF NO TRANSMITTED PT&E RECORDS, “NO
TRANSMITTED PT&E RECORDS FOUND” TOUCH
“Transmitted?” AGAIN TO DISPLAY UNTRANSMITTED
RECORDS. IF NO UNTRANSMITTED PT&E RECORDS,
“NO UNTRANSMITTED PT&E RECORDS FOUND” TOUCH

5-18

“Transmitted?” AGAIN TO DISPLAY TRANSMITTED
RECORDS.
IF TRANSMITTED PT&E RECORD(S), PTE SUMMARY
WITHOUT OPTION TO ADD, EDIT, DELETE.
IF UNTRANSMITTED PT&E RECORD(S), PTE SUMMARY
WITH ADD, EDIT, DELETE OPTIONS.]

RECONCILE MISSED DUS [SELECT CASE, FUNCTIONS, ADMINISTRATIVE
TOOLS, RECONCILE MISSED DUS]
[IF NO MISSED DUs TO BE RECONCILED, NO MISSED DUs: “THERE ARE NO
MISSED DUs TO RECONCILE.” OK, SELECT CASE.]
[IF MISSED DUs TO BE RECONCILED, SEGMENTS AND MISSED DUs]

SEGMENTS AND MISSED DUs [SELECT CASE, FUNCTIONS,
ADMINISTRATIVE TOOLS, RECONCILE MISSED DUs]
SEGMENT (SEGID)
STREET ADDRESS (MISSED DU STREET ADDRESS)
TO RECONCILE A SEGMENT: TOUCH AND HOLD ON THE LINE, THEN
TOUCH ‘RECONCILE’ FROM THE POP-UP MENU.
Reconcile [RECONCILATION CONFIRMATION: “YOU WILL
BE REQUIRED TO RECONCILE ALL DUs WITHIN THE
SELECTED SEGMENTS. ARE YOU READY TO PROCEED?”
IF No, SEGMENTS AND MISSED DUs. IF Yes, MDU-SEGMENT
KIT CHECK.]
Exit [SELECT CASE]

MDU-SEGMENT KIT CHECK [SEGMENTS AND MISSED DUs =
RECONCILE AND RECONCILATION CONFIRMATION = YES]
Link: (line number and address of link line case)
INTERVIEWER: CONSULT YOUR SEGMENT KIT AND ANSWER THE
FOLLOWING QUESTION(S):
IS THE UNIT THAT YOU ARE ATTEMPTING TO ADD
(Missed DU Street Address)
ALREADY ON THE HANDWRITTEN LIST OF DWELLING UNITS?
(MAKE SURE YOU ARE LOOKING AT THE FULL LIST OF DWELLING
UNITS, NOT THE SELECTED DU LIST.)
Yes (UNIT NOT ADDED) [IF ANOTHER MISSED DU, NEXT

5-19

MISSED DU: “PLEASE ANSWER THE FOLLOWING QUESTIONS
TO RECONCILE THE NEXT MISSED DU.” OK, MDU-SEGMENT
KIT CHECK FOR NEXT MISSED DU.]
[IF NO OTHER MISSED DU, SELECT CASE]
No [MDU GEOGRAPHIC INTERVAL SDU CHECK]
Exit [SELECT CASE]

MDU-GEOGRAPHIC INTERVAL SDU CHECK [MDU-SEGMENT KIT
CHECK = NO]
Link: (line number and address of link line case)
IS THE MISSED UNIT LOCATED WITHIN THE SDU OR IN THE
GEOGRAPHIC INTERVAL BETWEEN THE SDU AND THE NEXT LISTED
LINE ON THE SDU PROPERTY, AS WELL AS LOCATED WITHIN THE
SEGMENT BOUNDARIES?
(IF THE SDU IS THE LAST ONE LISTED ON A MAP PAGE, TAP THE Help
BUTTON FOR FURTHER INSTRUCTIONS.)
REFER TO YOUR FI MANUAL AND YOUR SEGMENT MAPS OR CALL
YOUR FS IF YOU ARE UNSURE WHETHER THIS UNIT SHOULD BE
ADDED. IF YOU CANNOT DO THAT RIGHT NOW, TOUCH THE Exit
BUTTON TO EXIT THIS SCREEN. YOU CAN RECONCILE THIS DU
LATER.
Yes (UNIT ADDED) [MDU-ADDRESS VERIFICATION]
No (UNIT NOT ADDED) [IF ANOTHER MISSED DU, NEXT
MISSED DU: “PLEASE ANSWER THE FOLLOWING QUESTIONS
TO RECONCILE THE NEXT MISSED DU.” OK, MDU-SEGMENT
KIT CHECK FOR NEXT MISSED DU.]
[IF NO OTHER MISSED DU, SELECT CASE]
Exit [SELECT CASE]

MDU-ADDRESS VERIFICATION
Link: (line number and address of link line case)
THIS UNIT WILL BE ADDED TO THE SAMPLE. PLEASE VERIFY THE
INFORMATION BELOW. TOUCH ANY LINE TO EDIT IT.
STREET #: (street number)
STREET: (street name)
CITY: (city)
STATE: (state)
ZIP: (zip code)
CASE #: (CaseID assigned to Added DU)
Update [IF ADDITIONAL MISSED DUs TO RECONCILE,

5-20

RECONCILE NEXT: “THE ADDED DU HAS BEEN
SUCCESFULLY RECONCILED. PLEASE ANSWER THE
FOLLOWING
QUESTIONS TO RECONCILE THE NEXT MISSED DU.” OK,
MDU-SEGMENT KIT CHECK FOR NEXT MISSED DU]
[IF NO ADDITIONAL MISSED DUs TO RECONCILE, SELECT
CASE]
Exit [SELECT CASE, WITH RECONCILIATION PENDING]

RELOAD TRAINING CASES [SELECT CASE, FUNCTIONS, ADMINISTRATIVE
TOOLS,RELOAD TRAINING CASES]
RE-LOAD TRAINING CASES: “ARE YOU SURE YOU WANT TO REMOVE
AND RELOAD ALL TRAINING CASES?” IF No, SELECT CASE. IF Yes,
SELECT CASE WITH TRAINING CASES REMOVED AND RELOADED.

ERASE TRAINING CASES [SELECT CASE, FUNCTIONS, ADMINISTRATIVE
TOOLS, ERASE TRAINING CASES]
ERASE TRAINING CASES: “ARE YOU SURE YOU WANT TO ERASE ALL
TRAINING CASES?” IF No, SELECT CASE. IF Yes, SELECT CASE WITH
TRAINING CASES REMOVED.

VIEW/SORT MENU [SELECT CASE, FUNCTIONS, VIEW/SORT]
View/Sort is a case management feature that allows an FI to view and sort cases in his/her assignment by
subgroups and varying orders on the Select Case screen. The View and Sort options can be used in a
variety of combinations.

VIEW/SORT PREFERENCES
To modify the View and Sort options, Touch “View” and “Sort” then select an option from the
list.
To go back to “SELECT CASE”, touch the Done button.
View [VIEW]
Sort [SORT]
Done [SELECT CASE]

VIEW
Pending Cases (All Screening and Interview cases with Result Codes 00-09, 50-59)
Pending Screenings (All Screening cases with Result Codes 00-09)
Pending Interviews (All Interview cases with Result Codes 50-59)
Group Quarters Units (All GQU cases)
All Cases (All cases)
Final Screenings (Screening cases with Result Codes 10-32)
Final Interviews (Interview cases with Result Codes 70-79)
Added DUs (All added DUs)
On Hold Cases (All cases on hold)

5-21

Cancel [VIEW/SORT PREFERENCES]

SORT
By Case ID (Alphanumerical order by CaseID)
By Street (Alphanumerical order by street name within segment and number)
By Screening Code (Numerical order by Screening Result Code)
By Interview A Code (Numerical order by Interview A Result Code)
By Interview B Code (Numerical order by Interview B Result Code)
By ROC Date, Ascending (Ascending date order using most recent Record of Calls entry)
By ROC Date, Descending (Descending date order using most recent Record of Calls entry)
Cancel [VIEW/SORT PREFERENCES]

CALL DISTRIBUTION [SELECT CASE, FUNCTIONS, CALL DISTRIBUTION] (See Call
Distribution explanation under Actions Menu above)

ADD APPOINTMENT [SELECT CASE, FUNCTIONS, ADD APPOINTMENT] (See Add
Appointment explanation under Actions Menu above)
CALENDAR [SELECT CASE, FUNCTIONS, CALENDAR] (See Calendar explanation within the Add
Appointment portion under Actions Menu above)
TRANSMIT [SELECT CASE, FUNCTIONS, TRANSMIT]
TRANSMISSION LOG
Done [SELECT CASE]
Transmit [BEGINS DATA TRANSMISSION]

5-22

NSDUH DR Screening Application Specifications
Section 6
Record of Calls
Document Format:
• Screen names bolded
• Screen/question/instructional text designated by black and red text and non-italicized text in
parenthesis (Upper-lower black text to be read, red text is instructions to FI)
• Fills designated by parentheses and italics
• Logic designated by brackets
• Text of instructional message boxes provided in bracketed logic
• Response categories underlined

RECORD OF CALLS [TOUCH CASE, ACTIONS MENU, GO TO RECORD OF CALLS
OR ON ANY SUBSEQUENT SCREEN EXIT OR VERIFICATION, DONE OR
RESPONDENT SELECTION, DONE]
Type (Data Type: S, A, B)
Result (Result Code)
Date/time (Date, time, and day of the week ROC entered)
Done [SELECT CASE]
Add [IF CODE = PENDING SCREENING CODE, SCREENING CALL RECORD. FOR
PENDING INTERVIEW CODES, CHOOSE ROC TYPE]
CD [IF CALL RECORD ENTERED, CALL DISTRIBUTION FOR DETAILS SEE
SECTION 5]
Roster [IF CODE = 22, 25, 26, 30, 31, OR 32, VERIFY ROSTER DATA FOR DETAILS
SEE SECTION 1]
Selections [If CODE = 31 or 32, RESPONDENT SELECTION]

ACTIONS MENU [RECORD OF CALLS, TOUCH AND HOLD CASE UNTIL ACTIONS
MENU APPEARS]
Edit [IF ROC EVENT SELECTED, SCREENING CALL RECORD or
INTERIVEW CALL RECORD]
Delete [IF UNTRANSMITTED, NON-SYSTEM-GENERATED ROC EVENT (NE 26,
30, 31, 32), DELETES EVENT, RECORD OF CALLS]
View Refusal [IF CODE 07, 17, 57, 58, 77, 78, REFUSAL REPORT -FOR DETAILS
SEE SECTION 7]
View Other Specify [IF CODE 09, 23, 59, or 79, CODE [fill with 09, 23, 59, or 79]:
OTHER SPECIFY CATEGORIES]

FUNCTIONS MENU [RECORD OF CALLS, FUNCTIONS]
Add [IF PENDING CODE, CALL RECORD]
6-1

Call Distribution [IF ROCs ENTERED, CALL DISTRIBUTION]
View Roster [IF CODE = 22, 25, 26, 30, 31, OR 32, VERIFY ROSTER DATA]
View Selections [IF CODE 31 OR 32 RESPONDENT SELECTION]
Add Appointment [NEW APPOINTMENT]
Calendar [CALENDAR]
View Verification Information [IF CODE 10, 13, 18, 26, OR 30, VERIFICATION]
Help [HELP]
CHOOSE ROC TYPE [IF CODE = 32, RECORD OF CALLS, ADD]
WHICH TYPE OF CALL RECORD DO YOU WANT TO ENTER?
Screening [SCREENING CALL RECORD]
Interview A [INTERVIEW A CALL RECORD]
Interview B [INTERVIEW B CALL RECORD]
Cancel [RECORD OF CALLS]

SCREENING CALL RECORD [IF AT COMPLETION OF SCREENING PROCESS
RESPONDENT SELECTION = DONE OR IF RECORD OF CALLS = ADD]
RESULT (01-23, 26, 29)
COMMENTS: (text entry)
DO NOT CHANGE ROC DATE/TIME UNLESS INSTRUCTED BY TECH SUPPORT
OR FS.
DAY/DATE: (Day of week and Date ROC event entered)
TIME: HOUR (1-12) MINUTE (00-59) AM/PM (AM, PM)
Commit [IF CODE = 32, INTERVIEW EVENT: “REMEMBER TO ENTER CALL
RECORDS FOR INTERVIEWS A AND B.” OK, RECORD OF CALLS.]
[IF CODE = 31, INTERVIEW EVENT: “REMEMBER TO ENTER INTERVIEW
CALL RECORD FOR INTERVIEW A.” OK, RECORD OF CALLS]
[IF CODE = 10, 13, 18, 26, OR 30, VERIFICATION]
[IF 07 OR 17, REFUSAL REPORT -FOR DETAILS SEE SECTION 7]
[IF 09 OR 23, OTHER, SPECIFY]
[IF 56 OR 76, OTHER LANGUAGE]
[IF 04, 14, 54 OR 74, INCAPABLE, SPECIFY]
Cancel [ARE YOU SURE?: “ARE YOU SURE YOU WANT TO CANCEL THIS CALL
RECORD?” IF Yes, SELECT CASE. IF No, SCREENING CALL RECORD]

INTERVIEW CALL RECORD [RECORD OF CALLS, ADD, CHOOSE ROC TYPE, A OR B]
RESULT (50-59, 70-79)
COMMENTS: (text entry)
DO NOT CHANGE ROC DATE/TIME UNLESS INSTRUCTED BY TECH SUPPORT
OR FS.

6-2

DAY/DATE: (Day of week and Date ROC event entered)
TIME: HOUR (1-12) MINUTE (00-59) AM/PM (AM, PM)
Commit [SAVES DATA, RECORD OF CALLS]
[IF 57, 58, 77, 78, REFUSAL REPORT -FOR DETAILS SEE SECTION 7]
[IF 59 OR 79, OTHER, SPECIFY]
Cancel [ARE YOU SURE?: “ARE YOU SURE YOU WANT TO CANCEL THIS CALL
RECORD?” Yes, SELECT CASE, No, INT. CALL RECORD-A OR B]

CODE 09: OTHER SPECIFY CATEGORIES [SCREENING CALL RECORD =
RESULT CODE 09]
OTHER SPECIFY CATEGORIES
Screening breakoff
Selected wrong line number
Added in error
Safety issue
Controlled access
Possible vacant
Possible vacation/not primary residence
GQU is institution (ONLY ACTIVE FOR GQU CASES)
Other listing problem
Need to discuss with FS
Something else, Specify
Done [RECORD OF CALLS]

CODE 23: OTHER SPECIFY CATEGORIES [SCREENING CALL RECORD = FINAL
RESULT CODE 23]
OTHER SPECIFY CATEGORIES
Added in error
Safety issue
GQU is institution (ONLY ACTIVE FOR GQU CASES)
Something else, Specify
Done [RECORD OF CALLS]

CODE 59: OTHER SPECIFY CATEGORIES [INTERVIEW A CALL RECORD OR
INTERVIEW B CALL RECORD = RESULT CODE 59]
OTHER SPECIFY CATEGORIES
R moved
R under age 12
R in military
R rostered in error
R deceased
Interviewed wrong person
Screened wrong line
Safety issue
Controlled access

6-3

Need to discuss with FS
Something else, Specify
Done [RECORD OF CALLS]

CODE 79: OTHER SPECIFY CATEGORIES [INTERVIEW A CALL RECORD OR
INTERVIEW B CALL RECORD = RESULT CODE 79]
OTHER SPECIFY CATEGORIES
R moved
R under age 12
R in military
R rostered in error
R deceased
Interviewed wrong person
Screened wrong line
Safety issue
Controlled access
Something else, Specify
Done [RECORD OF CALLS]

OTHER LANGUAGE [SCREENING CALL RECORD = 06 OR 16, INTERVIEW A CALL
RECORD OR INTERVIEW B CALL RECORD = 56 OR 76]
LANGUAGE CATEGORIES
Arabic
Chinese
French
German
Italian
Korean
Polish
Portuguese
Russian
Tagalog
Vietnamese
Other, Specify
Specify other language or comments: (text entry)
Done [RECORD OF CALLS]
INCAPABLE, SPECIFY [SCREENING CALL RECORD = 04 OR 14, INTERVIEW A CALL
RECORD OR INTERVIEW B CALL RECORD = 54 OR 74]
CODE [fill with 04 or 14 or 54 or 74]: INCAPABLE CATEGORIES
Physically Incapable
Mentally Incapable
Done [RECORD OF CALLS]

6-4

NSDUH DR Screening Application Specifications
Section 7
Screening and Interview Refusal
Document Format:
• Screen names bolded
• Screen/question/instructional text designated by black and red text and non-italicized text in
parenthesis (Upper-lower black text to be read, red text is instructions to FI)
• Fills designated by parentheses and italics
• Logic designated by brackets
• Text of instructional message boxes provided in bracketed logic
• Response categories underlined

REFUSAL REPORT [IF SCREENING CALL RECORD = 07 P REFUSAL OR
IF SCREENING CALL RECORD = 17 F REFUSAL AND ALREADY HAS A PENDING
REFUSAL ENTERED OR IF INTERVIEW CALL RECORD = 57 P REFUSAL OR IF
INTERVIEW CALL RECORD = 58 P PARENTAL REFUSAL OR IF INTERVIEW CALL
RECORD = 77 F REFUSAL AND ALREADY HAS A PENDING REFUSAL ENTERED OR
IF INTERVIEW CALL RECORD = 78 F PARENTAL REFUSAL AND ALREADY HAS A
PENDING REFUSAL ENTERED]
[IF SCREENING CALL RECORD = 17 F REFUSAL AND DOES NOT ALREADY HAVE A
PENDING REFUSAL ENTERED: RESULT CODE ERROR: “TRY AT LEAST ONE
MORE TIME BEFORE ASSIGNING THIS FINAL CODE.” OK. SCREENING CALL
RECORD]
[IF INTERVIEW CALL RECORD = 77 F REFUSAL AND DOES NOT ALREADY HAVE A
PENDING REFUSAL ENTERED, OR IF INTERVIEW CALL RECORD = 78 F PARENTAL
REFUSAL AND DOES NOT ALREADY HAVE A PENDING REFUSAL ENTERED:
RESULT CODE ERROR: “TRY AT LEAST ONE MORE TIME BEFORE ASSIGNING
THIS FINAL CODE.” OK. INTERVIEW CALL RECORD]
Reason for refusal
Too busy/no time/did too many already
Surveys/Govt. invasive/teen exposure
Clarify confidentiality, legitimacy, selection
“Nothing in it for me”/Uncooperative
Gatekeeper/Parent/HH member disallow
Welfare/INS concern
Too ill/house messy/not dressed
Need to discuss with FS
Comment: (text entry)
Done [SAVES REASON FOR REFUSALAND COMMENTS ENTERED, RECORD OF
CALLS]

7-1

Screening and Interview Refusal Functions on ROC
1. View refusal report or edit refusal report prior to transmission:
REFUSAL REPORT [IF RECORD OF CALLS = TOUCH AND HOLD CALL RECORD, ACTION
MENU, VIEW REFUSAL]
Reason for refusal
Too busy/no time/did too many already
Surveys/Govt. invasive/teen exposure
Clarify confidentiality, legitimacy, selection
“Nothing in it for me”/Uncooperative
Gatekeeper/Parent/HH member disallow
Welfare/INS concern
Too ill/house messy/not dressed
Need to discuss with FS
Comment: (text entry)
Done [IF EDITED (BEFORE TRANSMISSION) SAVES REASON FOR REFUSAL AND
COMMENTS ENTERED, THEN RECORD OF CALLS]

7-2

NSDUH DR Screening Application Specifications
Section 8
Verification
Document Format:
• Screen names bolded
• Screen/question/instructional text designated by black and red text and non-italicized text
in parenthesis (Upper-lower black text to be read, red text is instructions to FI)
• Fills designated by parentheses and italics
• Logic designated by brackets
• Text of instructional message boxes provided in bracketed logic
• Response categories underlined

VERIFICATION [IF SCREENING RESULT CODE = 10, 13, 18, 22, 26 OR IF
RESPONDENT SELECTION = ‘NONE’ FOR BOTH A AND B INTERVIEW]
So that my supervisor may check the quality of my work, may I please have your
first name and telephone number?
CONFIRM NUMBER WITH R.
FIRST NAME: (Screening Respondent’s first name)
Not Avail.
Ref.
PHONE: (Area code and phone number)
Home
Cell
Work
Not Avail.
Ref.
NOTES TO VERIFICATION CALLER: (Text field for notes about best
times to call screening respondent or clarification about work number if
caller has to go through an operator.)

Done [CHECKS FOR COMPLETE DATA ENTRY, RECORD OF CALLS]
Clear [VERIFICATION WITH ENTRY CLEARED]
Span [Question text appears in Spanish “Para que mi supervisor pueda revisar la calidad
de mi trabajo, ¿me podría dar su primer nombre y su número de teléfono?” and button
changes to Eng]

8-1

This page intentionally left blank.

8-2

NSDUH DR Screening Application Specifications
Section 9
FI Debriefing Questions
Document Format:
• Screen names bolded
• Screen/question/instructional text designated by black and red text and non-italicized text
in parenthesis (Upper-lower black text to be read, red text is instructions to FI)
• Fills designated by parentheses and italics
• Logic designated by brackets
• Text of instructional message boxes provided in bracketed logic
• Response categories underlined
INTERVIEW DEBRIEFING QUESTIONS:
THESE QUESTIONS ARE FOR YOU TO ANSWER. DO NOT READ TO THE R.
FIDBF1
Did you conduct this interview at the respondent’s home, either inside or outside?
YES
NO
Next [IF FIDBF1=YES, GO TO FIDBF3]
FIDBF2 [IF FIDBF1=NO]
Where did you conduct this interview?
1. AT THE RESPONDENT’S WORKPLACE
2. AT THE HOME OF THE RESPONDENT’S RELATIVE OR FRIEND
3. IN SOME TYPE OF CONFERENCE ROOM IN A RESIDENCE HALL, SCHOOL OR
APARTMENT COMPLEX
4. AT A LIBRARY
5. IN SOME TYPE OF COMMON AREA, SUCH AS A LOBBY, HALLWAY, STAIRWELL,
OR LAUNDRY ROOM
6. SOME OTHER PLACE
Next [IF FIDBF2=6, GO TO FIDBF2a]
FIDBF2a [IF FIDBF2=6]
Where did the interview take place?
ALLOW 140 CHARACTERS

9-1

Next [FIDBF3]
FIDBF3
Please estimate for how much of the ACASI interview the respondent had their headphones on.
0.
1.
2.
3.
4.

NONE/R TOOK HEADPHONES OFF IMMEDIATELY
LESS THAN HALF OF THE ACASI INTERVIEW
ABOUT HALF OF THE ACASI INTERVIEW
MORE THAN HALF OF THE ACASI INTERVIEW
ALL OF THE ACASI INTERVIEW

Next [FIDBF4]
FIDBF4
How cooperative was the respondent?
1.
2.
3.
4.

VERY COOPERATIVE
FAIRLY COOPERATIVE
NOT VERY COOPERATIVE
OPENLY HOSTILE

FIDBF5
Please indicate how private the interview was. Do not count yourself or a project observer as
another person in the room.
1. COMPLETELY PRIVATE – NO ONE WAS IN THE ROOM OR COULD OVERHEAR
ANY PART OF THE INTERVIEW
2. MINOR DISTRACTIONS – PERSON(S) IN THE ROOM OR LISTENING LESS THAN
1/3 OF THE TIME
3. PERSON(S) IN THE ROOM OR LISTENING ABOUT 1/3 OF THE TIME
4. SERIOUS INTERRUPTIONS OF PRIVACY MORE THAN HALF THE TIME
5. CONSTANT PRESENCE OF OTHER PERSON(S)
Next [IF FIDBF5=1, GO TO FIDBF8; IF FIDBF5 NE1, GO TO FIDBF6]
FIDBF6 [IF FIDBF5 NE1]
Not including yourself or project observers, who were the other people present or listening to the
interview?
Check all that apply
1.
2.
3.
4.
5.

PARENT(S)
SPOUSE
LIVE-IN PARTNER/BOYFRIEND/GIRLFRIEND
OTHER ADULT RELATIVE(S)
OTHER ADULT(S)
9-2

6. CHILD(REN) UNDER 15
7. OTHER
Next [IF FIDBF6=1, 2, 3, 4, 5, OR 6, GO TO FIDBF8]
FIDBF7 [IF FIDBF6=7]
Please enter a description of the other person(s) present or listening to the interview. This
description may be relationship to the respondent if you have this information, or simply the
gender and estimated age.
ALLOW 140 CHARACTERS
Next [FIDBF8]
FIDBF8 [IF FIDBF5=1; OR IF FIDBF6=1, 2, 3, 4, 5, OR 6; OR IF FIDBF7 NE BLANK]
Did the respondent make any comments about the interview being too long?
YES
NO
Next [FIDBF9]
FIDBF9
Did the respondent have trouble understanding any questions asked during the interview?
YES
NO
Next [IF FIDBF9=NO, GO TO FIDBF10]
FIDBF9a [IF FIDBF9=YES]
Enter the screen name and a brief description of what the respondent found confusing. If you do
not know the screen name, please provide as much information as possible.
ALLOW 140 CHARACTERS
Next [FIDBF10]
FIDBF10
How often did this respondent let you know what his or her answers were as he or she completed
the ACASI portion of the interview?
1. NONE OF THE TIME – I DO NOT KNOW WHAT ANY OF THE ANSWERS ARE
2. A LITTLE OF THE TIME – I KNOW WHAT A FEW OF THE ANSWERS ARE
9-3

3. SOME OF THE TIME – I KNOW WHAT SOME OF THE ANSWERS ARE
4. A LOT OF THE TIME – I KNOW WHAT A LOT OF THE ANSWERS ARE
5. ALL OF THE TIME – I KNOW WHAT ALL OF THE ANSWERS ARE
Next [FIDBF11]
FIDBF11
Please note anything else you think would be helpful for the interpretation and understanding of
this interview.
ALLOW 250 CHARACTERS
Next [RECORD OF CALLS]

9-4

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment M – Question & Answer Brochure

Answers

If you have more questions
about NSDUH, please call
1-800-848-4079
or visit our Web site at
http://nsduhweb.rti.org

For more information on SAMHSA or
RTI International, contact:
NSDUH National Study Director
SAMHSA
1 Choke Cherry Road
Room 2-1113
Rockville, MD 20857
www.samhsa.gov

to your questions

The National Survey on Drug Use and Health (NSDUH) provides up-todate information on alcohol, tobacco, and drug use, mental health and
other health-related issues in the United States. NSDUH is directed by the
Substance Abuse and Mental Health Services Administration (SAMHSA),
part of the U.S. Department of Health and Human Services (DHHS).
The study is being conducted by RTI International, a nonprofit research
organization.

National Survey
on Drug Use
and Health

NSDUH National Field Director
RTI International
3040 Cornwallis Road
Research Triangle Park, NC 27709
www.rti.org

RTI International is a trade name of Research Triangle Institute.

What Is the National Survey on
Drug Use and Health?

Sponsored by the U.S. Department of Health and Human
Services and the Substance Abuse and Mental Health Services
Administration. Conducted by RTI International.

NSDUH began in 1971 and is conducted every year. This year almost
70,000 people from across the United States will be interviewed for this
important study.
Information from NSDUH is used to support prevention and treatment
programs, monitor substance use trends, estimate the need for treatment
facilities and assist with the creation of government policy.

Answers to Your Important Questions about the National Survey on Drug Use and Health
Why Should I Participate?
You are important! Your household was one
of only a few in this area selected for this
study, and no other household or person
can take your place.
Every person who is chosen and completes
the full interview will receive $30 in cash at
the end of the interview in appreciation for
their help.
If chosen for an interview, you will represent
the residents of your community and help us
gather important information that is needed
to make sound policy decisions.
Your participation also provides vital
information to researchers and local, state
and federal agencies to design education,
treatment and prevention programs and
receive funding to support these efforts.

What if I Do Not Smoke, Drink
or Use Drugs?
In order to know the percentage of people
who smoke, drink or use drugs, we also
need to know how many people do not.

The responses of people who do not use
these substances are just as important as the
responses of people who do.

All information collected for this study will be
kept confidential and used only for statistical
purposes, as required by federal law – the
Confidential Information Protection and
Statistical Efficiency Act of 2002 (CIPSEA).

While some questions ask about drug
knowledge and experience, other questions
ask about a number of health-related topics
relevant for all people. You do not need to
know anything about drugs to answer the
questions.

What Is the Substance Abuse
and Mental Health Services
Administration?

How Was I Chosen?
Household addresses, not specific people,
are randomly selected through scientific
methods. Once a household has been
selected, it cannot be replaced for any
reason. This assures that NSDUH accurately
represents the many different types of people
in the United States.
A professional RTI interviewer will visit your
household to ask several general questions
that only take a few minutes to answer.
Afterwards, one or possibly two members of
your household may be asked to complete
the full interview. It is possible that no one
in your household will be chosen for the
interview.

Your household has been chosen at random, but no one
else can take your place. Your participation matters!

What Will Happen During the
Interview?
An interviewer will conduct the interview
with each selected person using a laptop
computer. No prior computer skills are
necessary.
Participants will answer most of the
interview questions in private, entering their
responses directly into the computer. For
other questions, the interviewer will read the
questions aloud and enter the participant’s
responses into the computer.
The interview takes about one hour to
complete. Persons who complete the full
interview will receive $30 at the end of the
interview as a token of our appreciation.

SAMHSA is an agency in the U.S. Department
of Health and Human Services (DHHS).
SAMHSA was created to improve the lives
of people with or at risk for mental and
substance use disorders.
NSDUH is used to help this mission by
gathering data on substance use, problems
related to substance use, and mental health
problems in the United States. The numbers
of people who use various substances, or
have problems related to substance use or
mental health, are important for planning
treatment and prevention services.
SAMHSA selects a qualified survey research
organization to administer NSDUH.
RTI International, a nonprofit research
organization, is under contract with SAMHSA
to conduct NSDUH.

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment V – NSDUH Highlights and
Newspaper Articles

SELECTED HIGHLIGHTS from the

2012 National Survey on Drug Use and Health
Past Month Cigarette Use among Persons Aged 12 or Older,
by Age: 2012
Tobacco Use
•

An estimated 69.5 million Americans
reported current use (during the past
month) of a tobacco product in 2012,
which is 26.7 percent of the population
aged 12 and older. About 57.5 million
(22.1 percent) smoked cigarettes.

•

The graph to the right illustrates past
month cigarette use among persons
age 12 or older.

Alcohol Use
Current Alcohol Use among Persons Aged12-20,
by Age: 2002-2012
•

Slightly more than half of all
Americans age 12 or older, 52.1
percent or an estimated 135.5 million
persons, were current drinkers in the
2012 survey, which is similar to the
133.4 million persons (51.8 percent)
reported in 2011.

•

Although consumption of alcoholic
beverages is illegal for those under
21 years of age, 24.3 percent of this
age group (9.3 million) were current
drinkers in 2012. The graph on the
left displays the current use of
alcohol for 12-20 year olds from
2002 through 2012.

Illicit Drug Use
•

An estimated 23.9 million Americans were current users of illicit drugs in 2012,
meaning they used an illicit drug at least once during the 30 days prior to the interview.
This estimate represents 9.2 percent of the population 12 years old or older.

•

Marijuana is the most commonly used illicit drug, with an estimated 18.9 million current
users, or 7.3 percent of the population 12 years old or older, similar to the 2011 rate of 7.0
percent. Similar to 2011, an estimated 1.6 million persons were current users of cocaine. In
2012, an estimated 6.8 million (2.6 percent) used prescription-type psychotherapeutic drugs
nonmedically in the past month which is similar to the 2011 estimate of 2.4 percent.

Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings,
DHHS/SAMHSA/CBHSQ, September 2013

Mental Health
•

In 2012, an estimated 16.0 million adults, or 6.9 percent of the population aged 18 or older,
had at least one major depressive episode (MDE) in the past 12 months. Among adults, the
percentage having MDE in the past year varied by age and gender, as shown in the graph below.
Major Depressive Episode in the Past Year among Adults Aged 18 or Older,
by Age and Gender: 2012

Substance Dependence or Abuse among Adults Aged 18 or Older,
by Major Depressive Episode in the Past Year: 2012
•

Persons with past year MDE
were more likely than those
without MDE to have used an
illicit drug in the past year
(28.5 vs. 14.8 percent).

•

Similarly, substance
dependence or abuse was
more prevalent among
persons with MDE than among
those without MDE (20.8 vs.
7.9 percent), as shown in the
graph to the right.

Results from the 2012 National Survey on Drug Use and Health: Mental Health Findings,
DHHS/SAMHSA/CBHSQ, 2013

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment N – Interview Incentive Receipt

Interview Incentive Receipt

U.S. Department of Health and Human Services
and
RTI International
thank you for participating in the 2014 National Survey on Drug Use and Health.
In appreciation of your participation in this important study, you are eligible to receive $30 in cash.
Since maintaining the confidentiality of your information is important to us, your name will not be entered on this
form. However, the interviewer must sign and date this form to certify you received (or declined) the cash incentive.

___________________________________
Interviewer

□

_________
Date

__ __ __ __ __ __ __ __ __ __ - __
Case ID

□

Accepted Cash Incentive

Declined Cash Incentive

If you ever feel that you need to talk to someone about mental health issues, you can call the National Lifeline
Network. Counselors are available to talk at any time of the day or night and they can give you information about
services in your area.
1-800-273-TALK or 1-800-273-8255
1-888-628-9454 (Spanish)
http://suicidepreventionlifeline.org/
If you ever feel that you need to talk to someone about drug use issues, you can call the Substance Abuse and Mental
Health Services Administration’s Treatment Referral Helpline. This is a 24-hour service that will help you locate
treatment options near you.
1-800-662-HELP or 1-800-662-4357
1-800-487-4889 (TDD)
http://findtreatment.samhsa.gov
Disposition: Top copy to Respondent, yellow to Field Supervisor, pink to Field Interviewer.

Recibo de incentivo por la entrevista

Departamento de Salud y Servicios Humanos de los Estados Unidos
y el
RTI International

le agradecen su participación en la Encuesta Nacional sobre la Salud y el Consumo de Drogas
del año 2014
Como muestra de nuestro agradecimiento por su participación en este importante estudio, usted tiene derecho a recibir
$30 dólares en efectivo.
Debido a que la privacidad de sus datos es importante para nosotros, su nombre no aparecerá en este documento. Sin
embargo, el entrevistador debe escribir la fecha en este recibo y firmarlo para certificar que usted recibió (o rechazó) el
incentivo en efectivo.

_______________________________
Entrevistador(a)

□ Aceptó el incentivo en efectivo

_________

Fecha

__ __ __ __ __ __ __ __ __ __ - _
No. de Idenficación del caso (ID)

□ Rechazó el incentivo en efectivo

Si alguna vez sintiera la necesidad de hablar con alguien acerca de asuntos relacionados con la salud mental, puede llamar a la
Red Nacional de la Línea de la Vida (National Lifeline Network). Consejeros están disponibles para hablarles a cualquier hora del
día o de la noche, y ellos le pueden dar información acerca de los servicios que se ofrecen en su zona.
1-888-628-9454 (español)
1-800-273-8255 ó 1-800-273-TALK (inglés)
http://suicidepreventionlifeline.org
Si alguna vez sintiera la necesidad de hablar con alguien acerca de asuntos relacionados con las drogas, puede llamar a la Línea
de ayuda de referencias para servicios de tratamiento de la Administración de Servicios de Abuso de Sustancias y Salud Mental.
Este centro atiende las 24 horas del día y allí le darán información sobre los lugares cercanos a usted donde se ofrecen servicios de
tratamiento.
1-800-662-4357 ó 1-800-662-HELP
1-800-487-4889 (línea TDD: para personas con problemas auditivos)
http://findtreatment.samhsa.gov
Distribución: hoja gris: participante; copia amarilla: supervisor(a); copia rosada: entrevistador(a).

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment P – Showcard Booklet

2014 National Survey on
Drug Use and Health
SHOWCARD BOOKLET

RTI INTERNATIONAL

RTI Telephone Numbers
Tech Support .......... (877) 419-1768
Headway ................ (800) 208-7043
To reach other RTI staff, call 1-800-848-4079 then ask the
operator for the employee with whom you wish to speak.
Website Addresses
NSDUH ................... http://nsduhweb.rti.org
RTI ......................... http://www.rti.org
SAMHSA ................. http://www.samhsa.gov

Interview Troubleshooting Guide

To suppress a Hard Error involving two questions:
• Read the message box carefully.
–
–
–

If the first question listed is the one to be changed, press [Enter].
If the second question listed is the one to be changed, press the down arrow to
highlight the second question, then press [Enter].
In the rare event that neither question needs to be changed and the data entered
are correct, press [Tab] until the Suppress box is highlighted and press [Enter], then
provide an explanation for why the error was suppressed.

To edit a lengthy response:

•

With the cursor in the answer field, press the Insert key [Ins]. Use the arrow keys to
move to the precise place within the answer field to edit or add to existing text. If
necessary, record additional text in a comment box, by pressing [F8].

To correct range errors:
•
•
•

For numerical questions, read the box carefully, making note of the expected range, if
provided in the message. Press [ENTER] to clear the error, then type a new answer
within range.
For pre-coded questions, read the message box carefully, then press [ENTER] to clear
the error. Type a new answer that corresponds with a pre-coded answer choice on the
screen.
For multiple choice questions (Code All That Apply), read the message box carefully,
then press [ENTER] to clear the error. Type a new answer that corresponds with a precoded answer choice on the screen, pressing the [Space bar] between each response as
needed.

To correct date errors:
•

Review the instructions on the screen to determine the date format for the question.
For “MM-DD-YYYY” format, the date must be entered with a 2-digit month and day and
4-digit year. For “MM-YYYY” format, the date must be entered with a 2-digit month and
4-digit year. Do not enter dashes or spaces—just the number including any leading
zeros for month or day.

If an R needs assistance with an ACASI question, provide the corresponding steps above
for the problem they are having. Take care not to view the screen while assisting the R, to
ensure the confidentiality of their answers. For additional details on entering CAI responses
and troubleshooting error messages, refer to Chapter 5 in your FI Computer Manual.

INTRODUCTION AND INFORMED CONSENT FOR
INTERVIEW RESPONDENTS AGE 18+

INTRODUCE YOURSELF AND STUDY AS NECESSARY: Hello, I’m ________,
and I’m working on a nationwide study sponsored by the U.S. Department of
Health and Human Services. You should have received a letter about this study.
(SHOW LEAD LETTER, IF NECESSARY.)
READ THE BOXED INFORMATION BELOW
BEFORE STARTING EVERY INTERVIEW

This year, we are interviewing about 70,000 people across the nation. You have
been randomly chosen to take part. You may choose not to take part in this study,
but no one else can take your place. We will give you $30 when you finish the
interview.
GIVE STUDY DESCRIPTION TO R IF YOU HAVE NOT ALREADY DONE SO.
This study asks about tobacco, alcohol, and drug use or non-use, knowledge and
attitudes about drugs, mental health, and other health issues. It takes about an
hour. You will answer most of the questions on the computer, so I will not see your
answers. We are only interested in the combined responses from all 70,000 people,
not just one person’s answers. This is why we do not ask for your name and we
keep your answers separate from your address. RTI may contact you by phone or
mail to ask a few questions about the quality of my work. This is why we ask for
your phone number and current address at the end of the interview.
While the interview has some personal questions, federal law keeps your answers
private. We hope that protecting your privacy will help you to give accurate
answers. You can quit the interview at any time and you can refuse to answer any
questions.
If it is all right with you, let’s get started.
(Can we find a private place to complete the interview?)

INTRODUCCIÓN Y CONSENTIMIENTO INFORMADO
PARA LOS PARTICIPANTES ENTREVISTADOS
DE 18 AÑOS DE EDAD O MÁS
PRESÉNTESE USTED MISMO Y EXPLIQUE EL ESTUDIO TAL COMO SEA
NECESARIO: Hola, me llamo ________, y trabajo para un estudio nacional
patrocinado por el Departamento de Salud y Servicios Humanos de los Estados
Unidos. Usted debe haber recibido una carta acerca de este estudio. (MUESTRE
LA CARTA, SI ES NECESARIO.)
FAVOR DE LEER LA SIGUIENTE INFORMACIÓN
ANTES DE COMENZAR CADA ENTREVISTA

Este año, estamos entrevistando a cerca de 70,000 personas en toda la nación.
Usted ha sido seleccionado(a) al azar para participar en este estudio. Usted puede
decidir no tomar parte en este estudio, pero nadie podrá tomar su lugar. Nosotros le
daremos $30 dólares en efectivo al terminar la entrevista.
ENTREGUE LA DESCRIPCIÓN DEL ESTUDIO AL PARTICIPANTE SI TODAVĺA
NO LO HA HECHO.
Este estudio hace preguntas sobre el uso o no uso de tabaco, alcohol y drogas;
conocimiento y actitudes hacia las drogas; la salud mental y otros asuntos sobre la
salud. La entrevista dura aproximadamente una hora y media. Usted usará la
computadora para responder a la mayoría de las preguntas y por lo tanto, yo no
podré ver sus respuestas. Nosotros estamos interesados únicamente en las
respuestas de todas las 70,000 personas en conjunto, y no solamente en las
respuestas de una persona. Esta es la razón por la cual nosotros no le
preguntamos por su nombre y mantenemos sus respuestas separadas de su
dirección. Es posible que el personal de RTI se comunique con usted por teléfono o
por correo para hacerle algunas preguntas acerca de la calidad de mi trabajo. Es
por eso que le preguntamos su número de teléfono y su dirección actual al final de
la entrevista.
Aunque algunas preguntas de la entrevista son personales, la ley federal mantiene
sus respuestas en forma confidencial. Esperamos que el hecho de proteger su
privacidad le ayude a darnos respuestas exactas. Usted puede dejar de participar
en cualquier momento y puede rehusarse a contestar cualquier pregunta.
Si usted está de acuerdo, podemos empezar.
(¿Podríamos ir a un lugar privado para llevar a cabo la entrevista?)

INTRODUCTION AND INFORMED CONSENT FOR
INTERVIEW RESPONDENTS AGE 12-17
READ THE SCRIPT BELOW AND OBTAIN PERMISSION FROM THE PARENT/GUARDIAN

Your (AGE) year-old child has been selected to be in this study. Your child’s participation is
voluntary. This interview asks about tobacco, alcohol, and drug use or non-use, knowledge
and attitudes about drugs, mental health, and other health related issues. All of your child’s
answers will be confidential and used only for statistical purposes. Since your child will answer
most of the questions on the computer, I will never see the answers, and you are not allowed
to see them either. If it is all right with you, we’ll get started.
(Can we find a private place to complete the interview?)

ONCE PARENTAL PERMISSION HAS BEEN GIVEN, CONFIRM THE PARENT/GUARDIAN OR
ANOTHER ADULT WILL BE PRESENT FOR THE DURATION OF THE INTERVIEW
THEN, READ THE BOXED INFORMATION BELOW BEFORE STARTING EVERY INTERVIEW WITH
A 12-17 YEAR OLD

This year, we are interviewing about 70,000 people across the nation. You have been
randomly chosen to take part. You may choose not to take part in this study, but no one else
can take your place. We will give you $30 when you finish the interview.
GIVE STUDY DESCRIPTION TO R IF YOU HAVE NOT ALREADY DONE SO.
This study asks about tobacco, alcohol, and drug use or non-use, knowledge and attitudes
about drugs, mental health, and other health issues. It takes about an hour. You will answer
most of the questions on the computer, so I will not see your answers. Your answers will
never be seen by either your parents or your school. We are only interested in the combined
responses from all 70,000 people, not just one person’s answers. This is why we do not ask
for your name and we keep your answers separate from your address. RTI may contact you
by phone or mail to ask a few questions about the quality of my work. This is why we ask for
your phone number and current address at the end of the interview.
While the interview has some personal questions, federal law keeps your answers private. We
hope that protecting your privacy will help you to give accurate answers. You can quit the
interview at any time and you can refuse to answer any questions.
If it is all right with you, let’s get started.

INTRODUCCIÓN Y CONSENTIMIENTO INFORMADO PARA LOS
PARTICIPANTES ENTREVISTADOS DE 12 A 17 AÑOS DE EDAD
LEA EL TEXTO A CONTINUACIÓN Y OBTENGA PERMISO DEL PADRE DE FAMILIA/TUTOR/GUARDIÁN

Su hijo(a) de (EDAD) años ha sido seleccionado(a) para participar en el estudio. La
participación de su hijo(a) es voluntaria. Esta entrevista le hace preguntas sobre el uso o no
uso de tabaco, alcohol y drogas; conocimiento y actitudes hacia las drogas; la salud mental y
otros asuntos sobre la salud. Todas las respuestas de su hijo(a) se mantendrán en forma
confidencial y se utilizarán con propósitos estadísticos únicamente. Ya que su hijo(a) usará la
computadora para responder la mayoría de las preguntas, yo no podré ver sus respuestas, y a
usted tampoco se le permitirá ver las respuestas. Si usted está de acuerdo, podemos
empezar.
(¿Podríamos ir a un lugar privado para llevar a cabo la entrevista?)
UNA VEZ QUE SE HAYA OBTENIDO EL PERMISO DEL PADRE DE FAMILIA/TUTOR/GUARDIÁN,
CONFIRME QUE UNO DE ELLOS U OTRO ADULTO ESTARÁ PRESENTE DURANTE EL TIEMPO
QUE TOME LA ENTREVISTA
LUEGO, LEA LA SIGUIENTE INFORMACIÓN ANTES DE EMPEZAR CADA ENTREVISTA CON UN JOVEN
DE 12 A 17 AÑOS DE EDAD

Este año, estamos entrevistando a cerca de 70,000 personas en toda la nación. Tú has sido
seleccionado(a) al azar para participar en este estudio. Tú puedes decidir no tomar parte en
este estudio, pero nadie podrá tomar tu lugar. Nosotros te daremos $30 dólares al terminar la
entrevista.
ENTREGUE LA DESCRIPCIÓN DEL ESTUDIO DE COLOR GRIS AL PARTICIPANTE SI
TODAVĺA NO LO HA HECHO.
Este estudio hace preguntas sobre el uso o no uso de tabaco, alcohol y drogas; conocimiento
y actitudes hacia las drogas; la salud mental y otros asuntos sobre la salud. La entrevista dura
aproximadamente una hora y media. Tú usarás la computadora para responder a la mayoría
de las preguntas y por lo tanto, yo no veré tus respuestas. Ni tus padres ni el personal de la
escuela podrán ver tus respuestas. Nosotros estamos interesados únicamente en las
respuestas de todas las 70,000 personas en conjunto, y no solamente en las respuestas de
una persona. Esta es la razón por la cual nosotros no preguntamos por tu nombre y
mantenemos tus respuestas separadas de tu dirección. Es posible que el personal de RTI se
comunique contigo por teléfono o por correo para hacerte algunas preguntas acerca de la
calidad de mi trabajo. Es por eso que te preguntamos por tu número de teléfono y tu dirección
actual al final de la entrevista.
Aunque algunas preguntas de la entrevista son personales, la ley federal mantiene tus
respuestas en forma confidencial. Esperamos que el hecho de proteger tu privacidad te ayude
a darnos respuestas exactas. Tú puedes dejar de participar en cualquier momento y puedes
rehusarte a contestar cualquier pregunta.
Si tú estás de acuerdo, podemos empezar.

SHOWCARD 1

1

MEXICAN, MEXICAN AMERICAN, MEXICANO
OR CHICANO

2

PUERTO RICAN

3

CENTRAL OR SOUTH AMERICAN

4

CUBAN OR CUBAN AMERICAN

5

DOMINICAN (FROM DOMINICAN REPUBLIC)

6

SPANISH (FROM SPAIN)

TARJETA 1

1

MEXICANO, MEXICANOAMERICANO O
CHICANO

2

PUERTORRIQUEÑO

3

CENTROAMERICANO O SUDAMERICANO

4

CUBANO O CUBANOAMERICANO

5

DOMINICANO (DE LA REPÚBLICA DOMINICANA)

6

ESPAÑOL (DE ESPAÑA)

SHOWCARD 2

1

WHITE

2

BLACK OR AFRICAN AMERICAN

3

AMERICAN INDIAN OR ALASKA NATIVE
(AMERICAN INDIAN INCLUDES NORTH
AMERICAN, CENTRAL AMERICAN, AND SOUTH
AMERICAN INDIANS)

4

NATIVE HAWAIIAN

5

GUAMANIAN OR CHAMORRO

6

SAMOAN

7

OTHER PACIFIC ISLANDER

8

ASIAN (INCLUDING: ASIAN INDIAN, CHINESE,
FILIPINO, JAPANESE, KOREAN, AND
VIETNAMESE)

TARJETA 2

1

BLANCO

2

NEGRO O AFROAMERICANO

3

INDÍGENO AMERICANO O NATIVO DE ALASKA
(INDÍGENO AMERICANO INCLUYE INDÍGENOS DE
NORTEAMÉRICA, CENTROAMÉRICA Y
SUDAMÉRICA)

4

NATIVO DE HAWAII

5

GUAMEÑO O CHAMORRO

6

SAMOANO

7

OTRO ISLEÑO DEL PACÍFICO

8

ASIÁTICO (INCLUYENDO: INDIO ASIÁTICO,
CHINO, FILIPINO, JAPONÉS, COREANO Y
VIETNAMITA)

SHOWCARD 3

1

ASIAN INDIAN

2

CHINESE

3

FILIPINO

4

JAPANESE

5

KOREAN

6

VIETNAMESE

TARJETA 3

1

INDIO ASIÁTICO

2

CHINO

3

FILIPINO

4

JAPONÉS

5

COREANO

6

VIETNAMITA

SHOWCARD 4

1

SEPTEMBER 2001 OR LATER

2

AUGUST 1990 TO AUGUST 2001 (INCLUDING
PERSIAN GULF WAR)

3

MAY 1975 TO JULY 1990

4

VIETNAM ERA (MARCH 1961 TO APRIL 1975)

5

FEBRUARY 1955 TO FEBRUARY 1961

6

KOREAN WAR (JULY 1950 TO JANUARY 1955)

7

JANUARY 1947 TO JUNE 1950

8

WORLD WAR II (DECEMBER 1941 TO DECEMBER
1946)

9

NOVEMBER 1941 OR EARLIER

TARJETA 4

1

SEPTIEMBRE DEL 2001 O DESPUÉS

2

AGOSTO DE 1990 A AGOSTO DEL 2001
(INCLUYENDO LA GUERRA DEL GOLFO PÉRSICO)

3

MAYO DE 1975 A JULIO DE 1990

4

ÉPOCA DE VIETNAM (MARZO DE 1961 A ABRIL
DE 1975)

5

FEBRERO DE 1955 A FEBRERO DE 1961

6

LA GUERRA DE COREA (JULIO DE 1950 A ENERO
DE 1955)

7

ENERO DE 1947 A JUNIO DE 1950

8

SEGUNDA GUERRA MUNDIAL (DICIEMBRE DE
1941 A DICIEMBRE DE 1946)

9

NOVIEMBRE DE 1941 O ANTES

SHOWCARD 5
0

NO SCHOOLING COMPLETED

1

1ST GRADE COMPLETED

2

2ND GRADE COMPLETED

3

3RD GRADE COMPLETED

4

4TH GRADE COMPLETED

5

5TH GRADE COMPLETED

6

6TH GRADE COMPLETED

7

7TH GRADE COMPLETED

8

8TH GRADE COMPLETED

9

9TH GRADE COMPLETED

10

10TH GRADE COMPLETED

11

11TH GRADE COMPLETED

12

REGULAR HIGH SCHOOL DIPLOMA

13

12TH GRADE, NO DIPLOMA

14

GED CERTIFICATE OF HIGH SCHOOL
COMPLETION

15

SOME COLLEGE CREDIT, BUT NO DEGREE

16

ASSOCIATE’S DEGREE (FOR EXAMPLE, AA, AS)

17

BACHELOR’S DEGREE (FOR EXAMPLE, BA, BS)

18

MASTER’S DEGREE (FOR EXAMPLE, MA, MS,
MENG, M. ED, MSW, MBA)

19

DOCTORATE DEGREE (FOR EXAMPLE, PHD, EDD)

20

PROFESSIONAL DEGREE BEYOND A BACHELOR’S
DEGREE (FOR EXAMPLE, MD, DDS, DVM, LLB, JD)

TARJETA 5
0

NUNCA ASISTIÓ A LA ESCUELA

1

COMPLETÓ EL 1er. GRADO

2

COMPLETÓ EL 2o. GRADO

3

COMPLETÓ EL 3er. GRADO

4

COMPLETÓ EL 4o. GRADO

5

COMPLETÓ EL 5o. GRADO

6

COMPLETÓ EL 6o. GRADO

7

COMPLETÓ EL 7o. GRADO

8

COMPLETÓ EL 8o. GRADO

9

COMPLETÓ EL 9o. GRADO

10

COMPLETÓ EL 10o. GRADO

11

COMPLETÓ EL 11o. GRADO

12

DIPLOMA DE ESCUELA PREPARATORIA O “HIGH SCHOOL”

13

GRADO 12, SIN DIPLOMA

14

CERTIFICADO “GED” POR COMPLETAR “HIGH SCHOOL”

15

ALGUNOS CRÉDITOS UNIVERSITARIOS, PERO SIN TÍTULO

16

TÍTULO DE ASOCIADO UNIVERSITARIO (POR
EJEMPLO, AA, AS)

17

TÍTULO DE LICENCIATURA UNIVERSITARIA (POR
EJEMPLO, BA, BS)

18

TÍTULO DE MAESTRÍA (POR EJEMPLO, MA, MS, MENG,
M. ED, MSW, MBA)

19

TÍTULO DE DOCTORADO (POR EJEMPLO, PHD, EDD)

20

TÍTULO PROFESIONAL POSTERIOR A UN TÍTULO DE
LICENCIATURA UNIVERSITARIA (POR EJEMPLO, MD,
DDS, DVM, LLB, JD)

SHOWCARD 6

1

SELF

2

FATHER (INCLUDES STEP, FOSTER,
ADOPTIVE)

3

SON (INCLUDES STEP, FOSTER, ADOPTIVE)

4

BROTHER (INCLUDES HALF, STEP, FOSTER,
ADOPTIVE)

5

HUSBAND

6

UNMARRIED PARTNER

7

HOUSEMATE OR ROOMMATE

8

SON-IN-LAW

9

GRANDSON

10

FATHER-IN-LAW

11

GRANDFATHER

12

BOARDER OR ROOMER

13

OTHER RELATIVE

14

OTHER NON-RELATIVE

TARJETA 6
1

SÍ MISMO

2

PADRE (INCLUYE PADRASTRO, PADRE
“FOSTER” O DE CRIANZA, PADRE ADOPTIVO)

3

HIJO (INCLUYE HIJASTRO, HIJO “FOSTER”
O DE CRIANZA, HIJO ADOPTIVO)

4

HERMANO (INCLUYE MEDIO HERMANO,
HERMANASTRO, HERMANO “FOSTER” O DE
CRIANZA, HERMANO ADOPTIVO)

5

ESPOSO

6

PAREJA (SIN ESTAR CASADOS)

7

COMPAÑERO DE CASA O DE CUARTO

8

YERNO

9

NIETO

10

SUEGRO

11

ABUELO

12

INQUILINO O HUÉSPED

13

OTRO PARIENTE

14

OTRO QUE NO SEA PARIENTE

SHOWCARD 7
1

SELF

2

MOTHER (INCLUDES STEP, FOSTER,
ADOPTIVE)

3

DAUGHTER (INCLUDES STEP, FOSTER,
ADOPTIVE)

4

SISTER (INCLUDES HALF, STEP, FOSTER,
ADOPTIVE)

5

WIFE

6

UNMARRIED PARTNER

7

HOUSEMATE OR ROOMMATE

8

DAUGHTER-IN-LAW

9

GRANDDAUGHTER

10

MOTHER-IN-LAW

11

GRANDMOTHER

12

BOARDER OR ROOMER

13

OTHER RELATIVE

14

OTHER NON-RELATIVE

TARJETA 7
1

SÍ MISMA

2

MADRE (INCLUYE MADRASTRA, MADRE
“FOSTER” O DE CRIANZA, MADRE ADOPTIVA)

3

HIJA (INCLUYE HIJASTRA, HIJA “FOSTER” O
DE CRIANZA, HIJA ADOPTIVA)

4

HERMANA (INCLUYE MEDIA HERMANA,
HERMANASTRA, HERMANA “FOSTER” O DE
CRIANZA, HERMANA ADOPTIVA)

5

ESPOSA

6

PAREJA (SIN ESTAR CASADOS)

7

COMPAÑERA DE CASA O DE CUARTO

8

NUERA

9

NIETA

10

SUEGRA

11

ABUELA

12

INQUILINA O HUÉSPED

13

OTRA PARIENTE

14

OTRA QUE NO SEA PARIENTE

SHOWCARD 8

1

PERSON IN FAMILY WITH HEALTH INSURANCE LOST
JOB OR CHANGED EMPLOYERS

2

LOST MEDICAID OR MEDICAL ASSISTANCE
COVERAGE BECAUSE OF NEW JOB OR INCREASE IN
INCOME

3

LOST MEDICAID OR MEDICAL ASSISTANCE
COVERAGE FOR SOME OTHER REASON

4

COST IS TOO HIGH / CAN’T AFFORD PREMIUMS

5

BECAME INELIGIBLE BECAUSE OF AGE OR
LEAVING SCHOOL

6

EMPLOYER DOES NOT OFFER COVERAGE, OR
NOT ELIGIBLE FOR COVERAGE

7

GOT DIVORCED OR SEPARATED FROM PERSON
WITH INSURANCE

8

DEATH OF SPOUSE OR PARENT

9

INSURANCE COMPANY REFUSED COVERAGE

10

DON’T NEED IT

11

RECEIVED MEDICAID OR MEDICAL INSURANCE
ONLY WHILE PREGNANT

TARJETA 8

1

LA PERSONA EN LA FAMILIA CON SEGURO DE SALUD
PERDIÓ EL EMPLEO O CAMBIÓ DE EMPLEADOR O
PATRÓN

2

PERDIÓ LA COBERTURA DE MEDICAID O DE
BENEFICIOS MÉDICOS POR CAMBIAR DE EMPLEO O
POR UN AUMENTO EN LOS INGRESOS

3

PERDIÓ LA COBERTURA DE MEDICAID O DE
BENEFICIOS MÉDICOS POR ALGUNA OTRA RAZÓN

4

EL COSTO ES DEMASIADO ALTO / NO PUEDE PAGAR
LAS CUOTAS (PRIMAS)

5

PERDIÓ LOS BENEFICIOS DEBIDO A LA EDAD O POR
DEJAR LA ESCUELA

6

EL EMPLEADOR NO OFRECE COBERTURA O LA
PERSONA NO CALIFICA PARA RECIBIR COBERTURA

7

SE DIVORCIÓ O SE SEPARÓ DE LA PERSONA CON
SEGURO

8

LA MUERTE DEL CÓNYUGE O DEL PADRE O LA MADRE

9

LA COMPAÑÍA DE SEGUROS LE NEGÓ COBERTURA

10

NO LO NECESITA

11

RECIBIÓ MEDICAID O SEGURO MÉDICO SOLAMENTE
DURANTE EL EMBARAZO

SHOWCARD 9

1

COST IS TOO HIGH / CAN’T AFFORD PREMIUMS

2

EMPLOYER DOES NOT OFFER COVERAGE, OR
NOT ELIGIBLE FOR COVERAGE

3

INSURANCE COMPANY REFUSED COVERAGE

4

DON’T NEED IT

TARJETA 9

1

EL COSTO ES MUY ALTO / NO PUEDE PAGAR LAS
CUOTAS (PRIMAS)

2

EL EMPLEADOR NO OFRECE COBERTURA O
LA PERSONA NO CALIFICA PARA RECIBIR
COBERTURA

3

LA COMPAÑÍA DE SEGUROS LE NEGÓ
COBERTURA

4

NO LO NECESITA

SHOWCARD 10

INCOME EARNED AT A JOB OR BUSINESS
RETIREMENT, DISABILITY, OR SURVIVOR PENSION
UNEMPLOYMENT OR WORKER’S COMPENSATION
VETERAN’S ADMINISTRATION PAYMENTS
CHILD SUPPORT
ALIMONY
INTEREST INCOME
DIVIDENDS FROM STOCKS OR MUTUAL FUNDS
INCOME FROM RENTAL PROPERTIES, ROYALTIES,
ESTATES OR TRUSTS

TARJETA 10

INGRESOS OBTENIDOS DE UN EMPLEO O NEGOCIO
JUBILACIÓN, DISCAPACIDAD O PENSIÓN PARA
SUPERVIVIENTE
COMPENSACIÓN POR DESEMPLEO O DE
TRABAJADORES
PAGOS DE LA ADMINISTRACIÓN DE VETERANOS
MANUTENCIÓN INFANTIL
PENSIÓN ALIMENTICIA
INGRESO PROVENIENTE DE INTERESES
DIVIDENDOS PROVENIENTES DE ACCIONES O
FONDOS MUTUOS
INGRESOS POR ALQUILER DE PROPIEDADES,
REGALÍAS, HERENCIAS O FIDEICOMISOS

SHOWCARD 11

1

LESS THAN $1,000

2

$1,000 - $1,999

3

$2,000 - $2,999

4

$3,000 - $3,999

5

$4,000 - $4,999

6

$5,000 - $5,999

7

$6,000 - $6,999

8

$7,000 - $7,999

9

$8,000 - $8,999

10

$9,000 - $9,999

11

$10,000 - $10,999

12

$11,000 - $11,999

13

$12,000 - $12,999

14

$13,000 - $13,999

15

$14,000 - $14,999

16

$15,000 - $15,999

17

$16,000 - $16,999

18

$17,000 - $17,999

19

$18,000 - $18,999

20

$19,000 - $19,999

TARJETA 11

1

MENOS DE $1,000

2

$1,000 - $1,999

3

$2,000 - $2,999

4

$3,000 - $3,999

5

$4,000 - $4,999

6

$5,000 - $5,999

7

$6,000 - $6,999

8

$7,000 - $7,999

9

$8,000 - $8,999

10

$9,000 - $9,999

11

$10,000 - $10,999

12

$11,000 - $11,999

13

$12,000 - $12,999

14

$13,000 - $13,999

15

$14,000 - $14,999

16

$15,000 - $15,999

17

$16,000 - $16,999

18

$17,000 - $17,999

19

$18,000 - $18,999

20

$19,000 - $19,999

SHOWCARD 12

21

$20,000 - $24,999

22

$25,000 - $29,999

23

$30,000 - $34,999

24

$35,000 - $39,999

25

$40,000 - $44,999

26

$45,000 - $49,999

27

$50,000 - $74,999

28

$75,000 - $99,999

29

$100,000 - $149,999

30

$150,000 OR MORE

TARJETA 12

21

$20,000 - $24,999

22

$25,000 - $29,999

23

$30,000 - $34,999

24

$35,000 - $39,999

25

$40,000 - $44,999

26

$45,000 - $49,999

27

$50,000 - $74,999

28

$75,000 - $99,999

29

$100,000 - $149,999

30

$150,000 O MÁS

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment R – Confidentiality Agreement

CIPSEA Confidentiality Agreement, SAMHSA/CBHSQ
Administered by RTI International
This agreement is intended for review and signature by employees of RTI International and all its subcontractors who have
access to information designated as confidential on a research study sponsored by SAMHSA/CBHSQ covered under CIPSEA.
This agreement must be renewed each year as part of mandated CIPSEA training to maintain access to confidential project
information.
Assurances of Confidentiality under CIPSEA
For any research study sponsored by the Substance Abuse and Mental Health Services Administration’s (SAMHSA)
Center for Behavioral Health Statistics and Quality (CBHSQ) that is covered under the Confidential Information
Protection and Statistical Efficiency Act (CIPSEA) of 2002* and Section 501(n) of the Public Health Service Act, all
data and associated materials collected and/or utilized on that study are subject to protection by CIPSEA. CIPSEA
ensures the confidentiality of all information provided is protected by Federal Law and stipulates that all
information collected shall be used exclusively for statistical purposes. All research subjects contacted on
SAMHSA/CBHSQ’s behalf by RTI International are notified of these protections prior to study participation.
You have been identified as a person who has access to confidential information on a SAMHSA/CBHSQ-sponsored
study covered under CIPSEA (NSDUH and/or DAWN**) and therefore have been designated as an Agent under
CIPSEA. This confidential information includes (but is not limited to) all electronic and hard copy documents
containing respondent information and data, as well as non-data related records containing information that could
identify a location or respondent associated with a particular study.
Protection Agreement under CIPSEA
Per CIPSEA regulations, you agree that any materials that would permit the identification of research subjects are
to be treated as confidential, and that you will never share or use that confidential information with anyone else or
in a manner other than those authorized by CBHSQ. This includes never disclosing confidential information with
law enforcement officials, officers of the court or your supervisor (if not also authorized as an Agent).
To ensure the protection of all confidential information in both physical and electronic form, as an Agent, you also
agree to:
1) keep all confidential information in a space where access is limited only to authorized personnel,
whether on a computer or in hard copy form;
2) keep all confidential information within computer memory controlled by password protection;
3) maintain a secure location (such as file cabinet or locked drawer) for printed materials, diskettes, and
data on hard disks of personal computers when not in use;
4) never remove confidential information from your approved worksite without prior approval from
CBHSQ and/or RTI International;
5) never permit any unauthorized removal of any confidential project information from the limited access
space protected under the provisions of this agreement without first notifying and obtaining written
approval from RTI;
6) notify RTI when you no longer have access to electronic or hard copy files or printed materials
containing confidential project information;
* Public Law 107-347, Title V; for more info: http://www.whitehouse.gov/omb/fedreg/2007/061507_cipsea_guidance.pdf
**National Survey on Drug Use and Health (NSDUH); Drug Abuse Warning Network (DAWN)

v. 12.12

CIPSEA Confidentiality Agreement, SAMHSA/CBHSQ
Administered by RTI International

7) when appropriate, return all confidential project information to RTI;
8) complete annual training on restrictions associated with the use of confidential information;
9) agree that representatives of CBHSQ have the right to make unannounced and unscheduled
inspections of the facilities where you work to evaluate compliance with this agreement;
10) notify RTI International immediately upon receipt of any legal, investigatory, or other demand for
disclosure of confidential project information;
11) notify RTI International immediately upon discovering any breach or suspected breach of security or
any disclosure of confidential project information to unauthorized parties or agencies.
12) and agree that obligations under this agreement will survive the termination of any assignment with
SAMHSA/CBHSQ and/or RTI International.
Penalties under CIPSEA
Any violation of the terms and conditions of this agreement may subject you, the Agent, to immediate termination
of access to confidential information by RTI International or CBHSQ, and will require the immediate return of all
electronic and hard copy files and materials in your possession.
Any violation of this agreement may also be a violation of Federal criminal law under Title V, subtitle A of the EGovernment Act of 2002 (P.L. 107-347); and/or Section 501(n) of the Public Health Services Act. Alleged violations
under the Title V, subtitle A of the E-Government Act of 2002 are subject to prosecution by the United States
Attorney. The penalty for violation of subtitle A of the E-Government Act of 2002 is a fine of not more than
$250,000 and imprisonment for a period of not more than 5 years. In addition to the above, all relevant statutory
and regulatory penalties apply.
Your signature (whether in electronic or written form) below affirms your understanding and acknowledgement of
all the regulations, requirements and penalties associated with CIPSEA as part of your work on this
SAMHSA/CBHSQ project for RTI International.

Name

ID Number (if applicable, RTI employees only)

Signature

Company Name

Date

Job Title

v. 12.12

2015 NSDUH Text-to-Speech Pretest,
Supporting Statement
Attachment S –Data Collection Agreement

Project Name:
DATA COLLECTION AGREEMENT

Project No.:

National Survey on Drug
Use and Health
.
0213757
.

I, __________________________________________, an employee of Headway, agree to provide field data collection
services for the benefit of RTI in connection with the RTI Project shown above (“the Project”). Further, I
1)

am aware that the research being conducted by RTI is being performed under contractual arrangement with the
Substance Abuse and Mental Health Services Administration (SAMHSA);

2)

hereby accept all duties and responsibilities of performing specified data collection tasks and will do so
personally, in accordance with the training and guidelines provided to me. At no time will I engage the services
of another person to perform any data collection tasks for me without the prior written approval of both my
employer (Headway) and RTI;

3)

agree to treat as confidential all information secured during interviews or obtained in any Project-related way
during the period I am working on the Project,, as required by the Confidential Information Protection and
Statistical Efficiency Act of 2002 (CIPSEA), and understand, under Section 513 of this Act, I am subject to
criminal felony penalties of imprisonment for not more than five years, or fines of not more than $250,000, or
both, for voluntary disclosure of confidential information. Any breach of confidentiality must be reported
immediately to the National Field Director. This information will be shared with the SAMHSA Project Officer
and Headway. I have also completed and fully understand the CIPSEA training provided to me;

4) agree to treat as confidential and proprietary to RTI/SAMHSA any and all information provided by the
public, whether collected or accessed in electronic or printed form during the course of my service on this
Project, including but not limited to all data collection computer software and respondent data, and will protect
such items from unauthorized use or disclosure;
5) am aware that the survey instruments completed form the basis from which all analyses will be drawn, and
therefore, agree that all work for which I submit invoices will be legitimate, of high quality and performed in
compliance with all Project specifications to ensure the scientific integrity of the data;
6) understand that I am fully and legally responsible for taking all reasonable and appropriate steps to ensure that
any computer equipment issued to me for use on this Project is safeguarded against damage, loss, or theft. I also
understand that I have a legal obligation to immediately return all equipment at the conclusion of my
assignment or at the request of my supervisor;
7) fully agree to conduct myself at all times in a manner that will obtain the respect and confidence of all
individuals that I encounter as a representative of the Project and I will not betray this confidence by divulging
information obtained to anyone other than authorized Project representatives of RTI;
8) understand that evidence of falsification, fabrication or distortion of any data collected for this Project will
be reported to RTI's Scientific Integrity Committee, and such acts are grounds for immediately removing me
from the Project and can result in my suspension from any government-funded research. Also, if falsification of
data is substantiated, I understand a formal fraud complaint will be submitted to the U.S. Department of
Health and Human Services’ Office of Inspector General (OIG) and I could be subject to criminal and/or
civil prosecution and thereby face imprisonment, financial penalties or both;
9)

understand my obligations under this agreement supersede any prior or existing agreements on the same subject
matter and will survive the termination of any assignment with RTI and/or my employment by Headway.

_________________________________________________________

__________________________

Employee Signature

Date

Disposition: Original to Headway, Yellow retained by employee.

4/13