Form Adult Questionnair Adult Questionnair Adult Questionnaire
Minority Substance Abuse/HIV Prevention Initiative
2.HIV shortened Adult Questionnaire_9-10-2015-OMB
Adult
OMB: 0930-0298
Form Approved
OMB No.:0930-0298
Expiration Date:
National Minority SA/HIV Prevention Initiative
Adult Questionnaire
TO BE FILLED OUT BY THE LOCAL GRANT SITE DATA COLLECTOR
Last Name , First Name M.I.
Participant ID #: |
RESPONDENT OR PARTICIPANT: Before answering any of the questions, please make sure your name is correct. If incorrect, make the change in the box above. Do not write your name on any other page in this questionnaire. Thank you.
National Minority SA/HIV Prevention Initiative
Adult Questionnaire
Funding for data collection supported by the
Center for Substance Abuse Prevention (CSAP),
Substance
Abuse
and
Mental
Health
Services
Administration
(SAMHSA),
U.S.
Department
of Health
and
Human
Services
(HHS)
These questions are part of a data collection effort about how to prevent substance abuse and HIV infection. The questions are being asked of hundreds of other individuals throughout the United States. The data findings will be used to help prevention initiatives learn more about how to keep people from using drugs and getting infected with HIV.
Completing this questionnaire is voluntary. If you do not want to answer any of the questions, you do not have to. If you decide not to participate in this survey, it will have no effect on your participation in direct service programs. However, your answers are very important to us. Please answer the questions honestly—based on what you really do, think, and feel. Your answers will not be told to anyone in your family or community. Do not write your name anywhere on this questionnaire.
We would like you to work fairly quickly so that you can finish. Please work quietly by yourself. If you have any
questions or don’t understand something, let the data collector know.
We think you will find the questionnaire to be interesting and that you will like filling it out. Thank you very much for being an important part of this data collection effort!
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0298. Public reporting burden for this collection of information is estimated to average .30 hours per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1044, Rockville, MD 20857. |
INSTRUCTIONS |
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1. Answer each question by marking one of the answer circles. Some questions allow you to mark more than one answer. If you don’t find an answer that fits exactly, choose the one that comes closest.
2. Mark your answers carefully so we can tell which answer circle you chose. Do not mark between the circles.
3. It is very important that you answer each question truthfully. Your responses will not be helpful unless you tell the truth.
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MARKING YOUR ANSWERS |
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EXAMPLES |
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Correct Marks:
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Incorrect
Marks: |
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Record Management Section: To Be Completed by Designated Staff |
Grant ID
S |
P |
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Study Design Group (Select one)
Intervention Comparison
Participant
ID
Date of Survey Administration
/ /
Month Day Year
Interview Type (Select one)
Baseline Exit Follow-up
Service Duration (Select one)
Single-session (1 day or less duration)
Multiple-session brief (2 – 29 days’ duration))
Multiple-session long (30 days or longer duration)
Intervention Name(s)
(If the participant is receiving direct services from more than one intervention, please list each intervention below.)
1.
2.
3.
Section One: 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 HIV prevention. |
How would you describe yourself? (Gender)
Male
Female
Transgender
Male to female
Female to male
In what year were you born? (Enter all four digits of the year in the boxes below, and fill in corresponding circles)
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1 2 |
0 1 2 3 4 5 6 7 8 9 |
0 1 2 3 4 5 6 7 8 9 |
0 1 2 3 4 5 6 7 8 9 |
|
Are you of Hispanic, Latino/a, or Spanish origin? (If yes, you may select one or more categories)
No, not of Hispanic, Latino/a, or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino/a, or Spanish origin
What is your race? (Select one or more)
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
How would you describe yourself?
(Sexual orientation)
Straight or heterosexual
Bisexual
Gay or lesbian
Unsure
How well do you speak English?
Very well
Well
Not well
Not at all
What is your primary spoken language?
English
Spanish
Asian (Chinese, Japanese, or other)
American Indian (Apache, Blackfoot, Navajo, or other)
Other
What is the highest level of education you have finished, whether or not you received a degree? (Mark the highest grade you have completed.)
Elementary school
Middle school
High school
Community college or technical or trade school
Four-year college
Beyond four-year college
Are you currently attending college?
No
Yes, I live on campus
Yes, I live off campus
Which of the following best describes you? (Mark the one that fits best)
Employed full-time (35+ hours per week)
Employed part-time
Unemployed (full-time student)
Unemployed (other reason)
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone—such as visiting a doctor’s office or shopping?
Yes
No
If you have ever been in juvenile/adult detention, jail, or prison for more than 3 days, how long has it been since you last got out?
Never in juvenile/adult detention, jail, or prison for more than 3 days
Less than two years
Two years or more
Have you ever served in the Armed Forces, in the Reserves, or the National Guard [select all that apply]?
No (Skip to #14)
Yes, in the Armed Forces
Yes, in the Reserves
Yes, in the National Guard
13a. Are you currently on active duty in the Armed Forces, in the Reserves, or the National Guard?
Yes, in the Armed Forces
Yes, in the Reserves
Yes, in the National Guard
No, separated or retired from Armed Forces, Reserves, or National Guard
13b. Have you ever been deployed to a combat zone [select all that apply]?
Never deployed
Iraq or Afghanistan (e.g., Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn)
Persian Gulf (Operation Desert Shield or Desert Storm)
Vietnam/Southeast Asia
Korea
WWII
Deployed to a combat zone not listed above (e.g., Somalia, Bosnia, Kosovo)
Is anyone in your family or someone close to you on active duty in the Armed Forces, in the Reserves or the National Guard, or separated or retired from the Armed Forces, the Reserves, or the National Guard?
No (Skip to #16)
Yes, 1 person
Yes, 2 people
Yes, 3 people
Yes, 4 people
Yes, 5 people
Yes, 6 or more people
If yes, answer the following questions for each person you marked in question 17 (up to six people).
-
Service Member #1
Service Member #2
Service Member #3
Service Member #4
Service Member #5
Service Member #6
Service member’s relationship to you:
Mother/father
Brother/sister
Spouse/partner
Child
Other, specify
End of Section One
Section
Two:
Attitudes
&
Knowledge
Next, we’d like to ask you how you feel about substance use and sexual behavior, as well as what you know about HIV/AIDS. Again, your answers are private and will not be used to identify you. |
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
Don’t know or can’t say
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
Don’t know or can’t say
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
Don’t know or can’t say
How many of your friends and acquaintances often have 5 or more drinks in one sitting?
None of them
A few of them
Some of them
Most of them
All of them
How would you feel about your close friends frequently having 5 or more drinks in one sitting?
I would strongly disapprove
I would disapprove
I would neither approve nor disapprove
I would approve
I would strongly approve
How would you feel about your close friends regularly engaging in unprotected sexual activity?
I would strongly disapprove
I would disapprove
I would neither approve nor disapprove
I would approve
I would strongly approve
The next questions are about your beliefs and attitudes toward SEX. Some of the questions ask about having sex. By sex or sexual activity, we mean a situation where two partners get sexually excited or aroused (turned on) by touching each other’s genitals (penis or vagina) or anus (butt) with their own genitals, hands, or mouth. When a male inserts his penis into his female partner’s vagina, the partners are considered to be having vaginal sex. When one partner’s mouth is in contact with the other partner’s genitals (penis or vagina) or anus during sex, the partners are considered to be having oral sex. When a male’s penis is inserted into his male or female partner’s anus, the partners are considered to be having anal sex. Some questions ask about sexual partners. A sexual partner is someone with whom you have sex, that is, engage in sexual activity. Some questions refer to protected sex and unprotected sex. Protected sex is when a latex or polyurethane condom (rubber) is used to cover the penis; a female condom is used to cover the vagina; or a dental dam is used to cover the anus. By unprotected sex, we mean vaginal, oral, or anal sex without a barrier such as a condom or dental dam. |
We start by asking you some
questions about how risky you believe certain behaviors are.
How much do you think people risk harming themselves physically…
If they have sex (oral, vaginal, or anal) without a condom or dental dam?
No risk
Slight risk
Moderate risk
Great risk
If they have sex while high on drugs or under the influence of alcohol?
No risk
Slight risk
Moderate risk
Great risk
If they share unsanitized needles or works when using drugs?
No risk
Slight risk
Moderate risk
Great risk
Now think about your relationship with your PRIMARY (MAIN) partner. How confident are you that you could…
Refuse to have sex with your partner because you weren’t in the mood?
Not at all
A little
Somewhat
Very much
Ask your partner to wait while you got a condom or dental dam?
Not at all
A little
Somewhat
Very much
Tell your partner how to treat you sexually?
Not at all
A little
Somewhat
Very much
Refuse to engage in sexual practices you didn’t like?
Not at all
A little
Somewhat
Very much
Ask your partner to use a condom or dental dam?
Not at all
A little
Somewhat
Very much
Refuse to have sex because your partner did not want to use a condom or dental dam?
Not at all
A little
Somewhat
Very much
HIV/AIDS – What You Know |
In Questions 31 – 35, please indicate whether you think each of the following two statements about HIV/AIDS is true or false or if you don’t know. |
Only people who look sick can spread HIV/AIDS?
True
False
Don’t know
Only people who have sexual intercourse with gay (homosexual) people get HIV/AIDS.
True
False
Don’t know
Birth control pills protect women from getting HIV/AIDS.
True
False
Don’t know
There are drugs available to treat HIV that can lengthen the life of a person infected with the virus.
True
False
Don’t know
There is no cure for AIDS.
True
False
Don’t know
Would you know where to go near where you live to see a health care professional regarding HIV/AIDS or other sexually transmitted health issues?
Yes
No
Would you know where to go near where you live to see a health care professional regarding a drug or alcohol problem?
Yes
No
When you need medical help, generally how difficult is it for you to get to a service provider? Would you say it is:
Not at all difficult
Not too difficult
Somewhat difficult
Very difficult
In your day-to-day life, do you ever feel that you are treated with less respect or receive poorer services than other people?
No (Skip to #40)
Yes
39a. What do you think is the main reason for these experiences? (Check all that apply to you. If none of the answers apply, check “None of the above.”)
Your race or ethnicity
Your religion
Your gender
Your age
Your sexual orientation
A disability that you have
Your mental health status
Your HIV status
None of the above
Have you ever been informed of your HIV status (that is, whether or not you are HIV-positive) based on the result of an HIV test?
Yes
No
Now we would like you to think about all the people you know. Are there certain people you could go to when you want to talk about personal matters that you wouldn’t tell just anyone?
Yes
No
In general, how important are religious or spiritual beliefs in your day-to-day life?
Not at all important
Not too important
Fairly important
Very important
End of Section Two
Section Three: Behavior & Relationships |
Cigarettes, Alcohol, and Drugs |
The next two questions are about CIGARETTES and OTHER TOBACCO PRODUCTS.
Think back over the past 30 days and record on how many days, if any, you used cigarettes, other tobacco products, or both. |
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)
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
During the past 30 days, on how many days did you use other tobacco products? (Includes tobacco product other than cigarettes, such as dipping snuff, chewing tobacco, and smoking tobacco from a pipe)
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
The next question asks about ELECTRONIC VAPOR PRODUCTS, such as blu, NJOY, or Starbuzz. Electronic vapor products include e‑cigarettes, e‑cigars, e-pipes, vape pipes, vaping pens, e‑hookahs, and hookah pens. |
During the past 30 days, on how many days did you use electronic vapor products?
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
The next two questions are 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. |
During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage?
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
During the past 30 days, on how many days did you have 5 or more drinks on the same occasion? [By “occasion,” we mean at the same time or within a couple of hours of each other.]
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
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. |
During the past 30 days, on how many days did you use marijuana or hashish?
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
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 (sometimes called angel dust) or peyote and prescription drugs used without a doctor’s orders, just to feel good or to get high.
Think back over the past 30 days and record on how many days, if any, you used other illegal drugs. |
During the past 30 days, on how many days did you use any other illegal drug?
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
Now we would like to ask about your use of three specific drugs during the past 30 days.
During the past 30 days, on how many days have you used prescription drugs without a doctor’s orders, in order to feel good or to get high?
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
During the past 30 days, on how many days did you use synthetic marijuana (also called K2, Spice, fake weed, King Kong, Yucatan Fire, Skunk, or Moon Rocks)?
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
This question is SPECIFICALLY ABOUT INJECTED DRUGS. During the past 30 days, on how many days have you injected any drugs? (Count only injections without a doctor’s orders—ones you used to feel good or to get high.)
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
The next five questions are about your
specific experiences with alcohol use. If you have never used
alcohol, you should respond to these questions by marking “No.”
Have you ever felt you should cut down on your drinking?
Yes
No
Have people annoyed you by criticizing your drinking?
Yes
No
Have you ever felt bad or guilty about your drinking?
Yes
No
Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?
Yes
No
During the past 30 days, has your use of alcohol or drugs caused you to have emotional problems?
I have not used alcohol or drugs in the past 30 days
Not at all
Somewhat
Considerably
Extremely
Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health NOT good?
Responses: IF “none,” enter 0. Otherwise, enter number of days in past 30 days.
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
Sexual Behavior |
Now we’d like to ask you about your experience with sex. If you cannot remember what we mean by sex, please refer to the definitions on page 7. Remember, your answers will be kept private. |
Have you ever had sex (vaginal, oral, or anal)?
Yes
No
Have you had sex (vaginal, oral, or anal) in the past 30 days?
Yes
No
The last time you had sex (vaginal, oral, or anal), was it protected or unprotected?
I have never had sex
Protected
Unprotected
Have you ever had sex with a man?
Yes
No
Have you ever had sex with a woman?
Yes
No
During the past 3 months, how many sexual partners have you had?
-
None
6 people
1 person
7 people
2 people
8 people
3 people
9 people
4 people
10 people or more
5 people
If you have ever had unprotected sex (vaginal, anal, or oral) with someone in exchange for money, drugs, or shelter, when was the last time you did?
Never had unprotected sex in exchange for money, drugs, or shelter
Within the past 3 months
More than 3 months ago
If you have ever had unprotected sex (vaginal, anal, or oral) with a partner you knew had, or suspected of having, HIV/AIDS or another sexually transmitted disease (STD), when was the last time you did?
Never had sex with someone known to have HIV/AIDS or another STD
Within the past 3 months
More than 3 months ago
If you have ever had unprotected sex (vaginal, anal, or oral) with someone who you knew was, or whom you suspected of being, an injected drug user, when was the last time you did?
Never had sex with an injected drug user
Within the past 3 months
More than 3 months ago
If you have ever had sex while you were under the influence of drugs or alcohol, when was the last time you did?
Never had sex while under the influence of drugs or alcohol
Within the past 3 months
Longer than 3 months ago
The next two questions ask about abuse you might have experienced.
Emotional abuse might include behaviors such as swearing, calling you negative names, or keeping you from seeing family and friends. Physical abuse might include behaviors such as slapping, beating, kicking, choking, or threatening you with a weapon. Sexual abuse might include behaviors such as forcing you to have unwanted sex or physically hurting the sexual parts of your body. |
In the past 3 months, how often has anyone with whom you had an intimate relationship (sexual or not) abused you emotionally, physically, or sexually?
Never
Rarely
Sometimes
Often
Very often
During the past 12 months, how many times have you had unwanted sex (vaginal, oral, or anal) either because someone physically forced you or because you were too drunk or out of it to know what was happening?
Never
Once
Twice
3 or more times
Family, Relationships, and Work |
Describe your current relationship status.
Never married and never permanently partnered
Legally married or living with a permanent partner
Separated, divorced (or broken up with a permanent partner), or widowed
With whom do you live?
(Mark the answer that describes you best)
Alone
With partner or spouse
With parents
With relatives other than spouse or parents
With friends or roommates
Other
Describe where you live.
In my own home or apartment
In a relative’s home
In a group home (not on a college campus)
In campus housing
In a foster home
Homeless or in a shelter
Other
If you have children, during the past 12 months, how many times have you talked with your children about the dangers or problems associated with the use of tobacco, alcohol, or drugs?
I don’t have any children
0 times
1 to 2 times
A few times
Many times
Don’t know or can’t say
Think about the household members who live with you right now. About how much income have you and your family members made in the last year before taxes? (Include child support and cash payments from the government—for example, welfare [TANF], SSI, or unemployment compensation)
$0–$10,000
$10,001–$30,000
$30,001–$50,000
$50,001–$70,000
More than $70,000
The next question is about
medical or health care insurance and where you obtained it. As you
may know, new state and federal health insurance marketplaces can
be used to shop for health insurance and compare prices and
benefits. These marketplaces can also be used to enroll in Medicaid
or Medical Assistance. You may know the marketplace as
Healthcare.gov or “Obamacare,” or your state may have a
special name for its health insurance marketplace. If you have
medical or health care insurance, we are interested in learning
whether or not you obtained it from such a marketplace.
Do you have medical or health care insurance?
No
Yes, I obtained it through a health insurance marketplace
Yes, I obtained it through a source other than a health insurance marketplace
Would you be more or less likely to want to work for an employer that tests its employees for drug or alcohol use on a random basis? Would you say more likely, less likely, or would it make no difference to you? (Mark one)
More likely
Less likely
Would make no difference
Don’t know or can’t say
The
last
question
asks about
your
experience
with
this
survey.
How truthful were you when answering the questions?
Very truthful
Somewhat truthful
Somewhat untruthful
Very untruthful
YOU ARE DONE!
Thank you for your help!
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Cross-Site Evaluation of the Minority Substance Abuse/HIV Prevention Program |
| Subject | Attachment 2 |
| Author | Calverton |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |
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