Form CSAP Youth CSAP Youth CSAP Youth

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

         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?

No risk

Slight risk

Moderate risk

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?

No risk

Slight risk

Moderate risk

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?

No risk

Slight risk

Moderate risk

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?

Never

A few times

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?

Yes

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