Form CSAP Youth CSAP Youth CSAP Youth

Common Data Platform

Attachment 4 Final CSAP Youth 12 19 2014

CSAP Client-Level Data

OMB: 0930-0346

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ATTACHMENT 4

OMB No. 0930-XXXX

Expiration Date XX/XX/XXXX


















Questions for Prevention Programs

Youth Version - Participants Ages 12-17




























Public reporting burden for this collection of information is estimated to average 27 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, if all items are asked of a participant; to the extent that providers already obtain much of this information as part of their ongoing participant intake or follow up, less time will be required. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, 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 control number for this project is 0930-xxxx.

SECTION A

RECORD MANAGEMENT


THIS SECTION TO BE COMPLETED BY STAFF ONLY



Participant ID |____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|


Grant ID |____|____|____|____|____|____|____|____|____|____|


1. Data Collection Type [SELECT ONLY ONE TYPE]


Baseline

Exit

First follow-up after exit

Second follow-up after exit


2a. Was the data collected?


Yes

No


2b. When did the data collection take place?


Date |____|____| / |____|____| / |____|____|____|____|

Month Day Year





































SECTION B

FACTS ABOUT YOU




First, we’d like to ask some basic questions about you. Your answers will not be used to identify you in any way. Instead, your answers will help us understand how different groups (like men or women, or people of similar ages) feel about substance abuse and other issues.




3. What is your date of birth? (MONTH AND YEAR MUST BE ENTERED. DAY IS OPTIONAL AND WILL NOT BE SAVED IN THE CDP SYSTEM)


|____|____| / |____|____| / |____|____|____|____|

Month Day Year


DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


 

4.   What is your gender?

 

         Male

         Female

         Transgender

         Different identity (SPECIFY): __________________________________

         DECLINED

         DON’T KNOW/INFORMATION NOT AVAILABLE



5.   Which one of the following do you consider yourself to be?

 

         Straight

         Lesbian (if female) or Gay (if male)

         Bisexual

         DECLINED

         DON’T KNOW/INFORMATION NOT AVAILABLE


















SECTION B

FACTS ABOUT YOU (CONTINUED)



6. Are you Hispanic, Latino/a, or Spanish origin? (One or more categories may be selected)


Yes, Central American

Yes, Cuban

Yes, Dominican

Yes, Mexican, Mexican American, Chicano/a

Yes, Puerto Rican

Yes, South American

Yes, another Hispanic, Latino, or Spanish origin

No, not of Hispanic, Latino/a, or Spanish origin

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


7. What is your race? (One or more categories may be selected)

White

Black or African American

American Indian

Alaska Native

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian

Native Hawaiian

Guamanian or Chamorro

Samoan

Other Pacific Islander

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



8. How well do you speak English?



Very well

Well

Not well

Not at all

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



9. Do you speak a language other than English at home?

Yes

No [SKIP TO QUESTION 11]

DECLINED [SKIP TO QUESTION 11]

DON’T KNOW/INFORMATION NOT AVAILABLE [SKIP TO QUESTION 11]



SECTION B

FACTS ABOUT YOU (CONTINUED)



10. If you speak a language other than English at home, what language do you speak?

Spanish

Other language Identify other language: ___________________

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



11. Are you deaf or do you have serious difficulty hearing?


Yes

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



12. Are you blind or have serious difficulty seeing, even when wearing glasses?


Yes

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



13. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering or making decisions?


Yes

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



14. Do you have serious difficulty walking or climbing stairs?


Yes

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE




15. Do you have difficulty dressing or bathing?


Yes

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE






SECTION B

FACTS ABOUT YOU (CONTINUED)


16. [ASK ONLY TO PARTICIPANTS AGE 15 AND UP; OTHERWISE SELECT NOT APPLICABLE]


Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?


  • NOT APPLICABLE, PARTICIPANT IS YOUNGER THAN 15

Yes

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE




17a. Is anyone in your immediate family currently serving as a member of one the branches of the

United States Uniformed Services on active duty, reserve components or National Guard?


Yes

No (SKIP TO SECTION C)

DECLINED (SKIP TO SECTION C)

DON’T KNOW/INFORMATION NOT AVAILABLE (SKIP TO SECTION C)


17b. If anyone in your immediate family is currently serving in the uniformed services, which member(s) are currently serving? (SELECT ALL THAT APPLY)


My spouse

Unmarried partner

My mother

My father

My son or sons

My daughter or daughters

My brother or brothers

My sister or sisters

Another member of my immediate family (SPECIFY RELATIONSHIP): ________________

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


END SECTION B

FACTS ABOUT YOU

















SECTION C

ATTITUDES & KNOWLEDGE



Next, we’d like to ask you how you feel about substance use and health care services. Again, your answers are private and will not be used to identify you.


The next few questions ask about HOW MUCH you think people RISK HARMING themselves physically or in other ways by using alcohol, tobacco, and drugs.



18. How much do people risk harming themselves physically or in other ways when they smoke one or more packs of cigarettes per day?


Shape1 No risk

Shape2 Slight risk

Shape3 Moderate risk

Shape4 Great risk

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


19. How much do people risk harming themselves physically or in other ways when they smoke marijuana once or twice a week?


Shape5 No risk

Shape6 Slight risk

Shape7 Moderate risk

Shape8 Great risk

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


20. How much do people risk harming themselves physically or in other ways when they have five or more drinks of an alcoholic beverage once or twice a week?


Shape9 No risk

Shape10 Slight risk

Shape11 Moderate risk

Shape12 Great risk

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



21. Now think about the past 12 months through today. DURING THE PAST 12 MONTHS, have you talked with at least one of your parents about the dangers of tobacco, alcohol, or drug use? By PARENTS, we mean your biological parents, adoptive parents, stepparents, or adult guardians— whether or not they live with you.


Yes

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE


END SECTION C

ATTITUDES AND KNOWLEDGE



SECTION D

BEHAVIOR & RELATIONSHIPS



SECTION D1

CIGARETTES, ALCOHOL, DRUGS AND RECOVERY


The next question is about CIGARETTES.

Think back over the past 30 days and record on how many days, if any, you used cigarettes.



22. During the past 30 days, on how many days did you smoke part or all of a cigarette? (Includes menthol and regular cigarettes and loose tobacco rolled into cigarettes)


|___| ___| Number of days in past 30 days


DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



The next question asks about other tobacco products. Please include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe


23. During the past 30 days, on how many days did you use OTHER tobacco products?


|___| ___| Number of days in past 30 days

DECLINED

DON’T KNOW



The next question is about ALCOHOL. By alcohol, we mean BEER, WINE, WINE COOLERS, MALT BEVERAGES or HARD LIQUOR.


Different groups of people in the United States may use alcohol for religious reasons. For example, some churches serve wine during a church service. If you drink wine at church or for some other religious reason, do not count these times in your answers to the questions below.


Think back over the past 30 days and record on how many days, if any, you consumed alcohol.


24. During the past 30 days, on how many days did you use any alcoholic beverages?


|___| ___| Number of days in past 30 days

DECLINED

DON’T KNOW









SECTION D1

CIGARETTES, ALCOHOL, DRUGS AND RECOVERY



The next question is about MARIJUANA or HASHISH. Marijuana is sometimes called weed, blunt, hydro, grass, or pot. Hashish is sometimes called hash or hash oil.


Think back over the past 30 days and record on how many days, if any, you used marijuana or hashish.



25. During the past 30 days, on how many days did you use marijuana or hashish?


|___| ___| Number of days in past 30 days


DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



The next question is about OTHER ILLEGAL DRUGS, excluding marijuana or hashish.


These include substances like inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to feel good or get high), heroin, crack, or cocaine, methamphetamine, hallucinogens (drugs that cause people to see or experience things that are not real) such as LSD (sometimes called acid), Ecstasy (MDMA), PCP, peyote (sometimes called angel dust), and prescription drugs used without a doctor’s orders.


Think back over the past 30 days and record on how many days, if any, you used illegal drugs OTHER THAN MARIJANNA AND HASSISH.



26. During the past 30 days, on how many days did you use any illegal drug OTHER THAN MARIJUANNA AND HASSISH?


|___| ___| Number of days in past 30 days


DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



Now we would like to ask about your use of prescription drugs without a doctor’s orders during the past 30 days.



27. During the past 30 days, on how many days have you used prescription drugs without a doctor’s orders?


|___| ___| Number of days in past 30 days


DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE











SECTION D1

CIGARETTES, ALCOHOL, DRUGS AND RECOVERY (CONTINUED)



28. In the past 30 days, did you attend any voluntary self-help groups for recovery that were not affiliated with a religious or faith-based organization?


In other words, did you participate in a non-professional, peer-operated organization that is devoted to helping individuals who have addiction related problems such as: Alcoholics Anonymous, Narcotics Anonymous, Oxford House, Secular Organization for Sobriety, or Women for Sobriety, etc.


Yes If yes, |___| ___| Number of times in past 30 days

No

DECLINED

DON’T KNOW/INFORMATION OT AVAILABLE



29. In the past 30 days did you attend any religious/faith affiliated recovery self-help groups?


Yes If yes, |___| ___| Number of times in past 30 days

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



30. In the past 30 days, did you attend meetings of organizations that support recovery other than the organizations described above?


Yes If yes, |___| ___| Number of times in past 30 days

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE




End of Section D1






















SECTION D2

VIOLENCE AND TRAUMA


The next few questions ask about abuse you might have experienced.


31. In your life have you ever experienced an event, series of events, or set of circumstances that resulted in you feeling physically or emotionally harmed or threatened?


Yes

No [SKIP TO QUESTION 33]

DECLINED [SKIP TO QUESTION 33]

DON’T KNOW/INFORMATION NOT AVAILABLE [SKIP TO QUESTION 33]



32. What kind of event was this? (Please select all that apply):


Natural or man-made disaster

Community or school violence

Interpersonal violence (including physical, sexual or psychological)

Military trauma

    • Other (SPECIFY): __________________________________

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



33. In the past 30 days, how often have you been hit, kicked, slapped, or otherwise physically hurt?


Shape13 Never

Shape14 A few times

Shape15 More than a few times

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE



End of Section D2
























SECTION E

HEALTH AND HEALTH CARE SERVICES



34. Have you seen a doctor, nurse, or other health care provider in the past 12 months?


Shape16 Yes

Shape17 No

DECLINED

DON’T KNOW



35. Would you know where to go in your neighborhood to see a health care professional regarding a drug or alcohol problem?


Yes

No

DECLINED

DON’T KNOW/INFORMATION NOT AVAILABLE





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