Initial Survey

Form Approved

OMB No. 0920-New

Expiration Date XX/XX/XXXX

Prevent Hepatitis Transmission among Persons Who Inject Drugs

Attachment 3B
Initial Survey Instrument

Public reporting burden of 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. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

Section: Demographics/Basic Info

DEM1: Please enter the ID for this participant:

DEM2: Today’s Date ______ / _______ / ________

DEM3: Interviewer name: _________________________

DEM4: Recruitment Site:

DEM5: What is your date of birth? _____/ ________/________

DEM6: What is your mother's first name?

DEM7: What city/town do you live in?

DEM8: What zip code do you live in?

DEM9: What was your sex at birth? (0) Male (1) Female (2) Intersex

DEM10: What sex do you identify yourself with now?

(0) Male

(1) Female

(2) Transgender - MTF

(3) Transgender - FTM

(4) Transgender - unspecified

(5) Other, please specify: _________________________________

DEM11: Do you consider yourself to be Hispanic/Latin? (0) No (1) Yes

DEM12: How would you describe your race or ethnicity? (check all that apply)

(0) White/Caucasian/European American

(1) Black/African-American

(2) Asian/Asian-American

(3) Filipino/a or Pacific Islander

(4) Native American

DEM13: What was the highest level of schooling that you have completed?

(0) Less than high school, enter last grade completed: (a)_____

(1) High school diploma or GED

(2) Some college

(3) Associates Degree/Trade or tech school degree

(4) BA/BS/Other 4-year college degree

(5) Some graduate school

(6) Graduate degree (MD/PhD/JD/MA/MS, etc)

DEM14: What is your current marital status? [SOURCE: CCAT STUDY] (check only one box)

(0) Single/Never Married

(1) Divorced

(2) Separated

(3) Widowed

(4) Married/Living together as married

(5) Other, please specify: (a)_______________________

DEM15: Do you have a way to get to medical appointments?

(0) No

(1) Yes, I have a car, access to a car or I can walk

(2) Maybe, if I can get a ride from a friend or relative

(3) Maybe, if public transportation is available (medi-cab)

Section: HCV Testing

These next questions are about Hepatitis C.

HCV1: Have you ever been tested for hepatitis C?

Yes (Go to HCV3) No (Go to HCV2)

HCV 2: There are many reasons why people have not been tested for HCV. Are any of the following reasons why you have never had an HCV test?

	Yes	No
I’m worried getting tested won’t help
I’m not interested/don’t think I need to be tested
I don’t know where to go to be tested
I don’t feel well enough to go get tested (sick, tired, weak, sad)
I can’t get into a provider to be tested
I can’t afford it
I don’t like any of the places that offer testing
It’s too difficult to get transport to any of the places that offer testing
Getting the free time to go get tested is difficult
I’m afraid of being judged or treated badly by family, friends or others in the community if they find out I got tested
I’m afraid of being judged or treated badly by the treatment staff
I’m worried getting tested will be unpleasant and interfere with my life

HCV2a: Are there any other reasons why you haven’t been tested for HCV?

Yes, please specify: _______________________

No

Go to next section (Healthcare Utilization).

HCV3: When was your last HCV test? _____Month ______Year

HCV4: Were you tested for HCV antibody or HCV RNA/viral load?

Antibodies (go to HCV5) RNA/Viral load (go to HCV6) Don’t know (go to HCV5)

HCV5: What was the result of your most recent hepatitis C test?

Negative (Go to next section)

Positive (Go to HCV7)

Don’t know (Go to next section)

HCV6: What was the result of your HCV RNA/viral load test?

Detectable virus (Go to HCV7)

No detectable virus (Go to next section)

Don’t know (Go to next section)

HCV7: Have you seen a medical provider for your HCV infection in the past 3 months?

Yes (Go to HCV10) No (Go to HCV8)

HCV8: Are any of the following reasons why you haven’t gotten treatment for your HCV infection?

	Yes	No
I’m worried treatment won’t help
I’m not interested/don’t think I need treatment
I don’t know where to go
I don’t feel well enough to go (sick, tired, weak, sad)
I can’t get into a program/provider (waitlist or not taking new clients)
I can’t afford it
I don’t like the programs/providers available to me/they don’t fit my needs
Finding transportation is difficult
Getting the free time to go is difficult
I’m afraid of being judged or treated badly by family, friends or others in the community who find out
I’m afraid of being judged or treated badly by the treatment staff
I’m worried treatment will be unpleasant and interfere with my life
I’m actively drinking or using drugs and can’t get treatment

HCV9: Which statement best reflects your feelings about getting treatment for your HCV infection?

I have no desire or intention to get treatment for my HCV infection.

I am thinking about getting treatment for my HCV infection.

I am planning on getting treatment for my HCV infection.

Go to next section.

HCV10: What type of place did you go to the last time you received your medical care for your Hep C infection?

Primary Care

Health Department

Specialist

Women’s Health Care Clinic

Emergency Department

Mobile Health Clinic

Alternative care (eg. Acupuncture, eastern/Chinese medical practitioner, chiropractor, Curandero, etc.)

Other, please specify: ____________

HCV11: What is/are the names of where/who you get HCV treatment from? (Name & location)

1. _______________________________________

2. _______________________________________

3. _______________________________________

HCV12: Have you ever been prescribed a medication(s) to treat hep c?

(0) No (Go to next section)

(1) Yes  which medication(s) have you been prescribed? (check all that apply)

(a) Interferon (Roferon A, Intron A)

(b) Ribavarin (Copegus, Rebetol, Moderiba, Ribasphere)

(c) Pegylated interferon (Pegasys, PegIntron)

(d) Antiviral (Incivek (telaprevir), Victrelis (boceprevir), Olysion (simeprevir), Sovaldi (sofosbuvir), Harvoni (sofosbuvir + ledipasvir), Viekeira (ombitasvir + paritaprevir/ritonavir + dasabuvir), taken with or without interferon or ribavirin)

(e) Other - please specify: _________________________

(f) Don’t know

HCV13: Are you currently taking any medications for your hepatitis c?

(0) No (Go to next section)

(1) Yes  which medication(s) have you been prescribed? (check all that apply)

(a) Interferon (Roferon A, Intron A)

(b) Ribavarin (Copegus, Rebetol, Moderiba, Ribasphere)

(c) Pegylated interferon (Pegasys, PegIntron)

(d) Antiviral (Incivek (telaprevir), Victrelis (boceprevir), Olysion (simeprevir), Sovaldi (sofosbuvir), Harvoni (sofosbuvir + ledipasvir), Viekeira (ombitasvir + paritaprevir/ritonavir + dasabuvir), taken with or without interferon or ribavirin)

(e) Other - please specify: _________________________

(f) Don’t know

Section: Healthcare Utilization

Now I am going to ask you some questions about your health and your recent medical history.

HU1: Is there a place that you usually go when you are sick or need advice about your health? [SOURCE: NHANES]

(0) No (go to HU3)

(1) Yes (go to HU2)

(2) Don’t know (go to HU3)

(9) Refused to answer (go to HU3)

HU2: What kind of place is it? [SOURCE: NHANES] (Check all that apply)

Primary Care

Health Department

Minute Clinic

Specialist

Women’s Health Care Clinic

Urgent Care Center

Emergency Department

Mobile Health Clinic

Alternative care (eg. Acupuncture, eastern/Chinese medical practitioner, chiropractor, Curandero, etc.)

Other, please specify: ____________

(0) Refused to answer

(0) Don't know

HU3: How many months or years ago did you last see or talk to a doctor or healthcare provider about your physical health?

Within the last 30 days (Go to HU4)

1-3 months ago (Go to HU4)

4-6 months ago (Go to HU6)

7-12 months ago (Go to HU6)

More than 1 year ago (Go to HU6)

HU4: How many times in the past three months have you visited a health care provider for medical treatment? ___________

HU5: What type of place did you go to the last time you got medical treatment?

Primary Care

Health Department

Minute Clinic

Specialist

Women’s Health Care Clinic

Urgent Care Center

Emergency Department

Mobile Health Clinic

Alternative care (eg. Acupuncture, eastern/Chinese medical practitioner, chiropractor, Curandero, etc.)

Other, please specify: ____________

(0) Refused to answer

(0) Don't know

Go to Health Insurance Section.

HU6: In the last 3 months, have you thought you needed to see a doctor or healthcare provider for your physical health, but did not go?

Yes (Go to HU7) No (Go to Next Section)

HU7: Are any of the following reasons for why you haven’t been to a healthcare provider in the last three months?

	Yes	No
I’m worried seeing a provider won’t help
I’m not interested/don’t think I need to see a provider
I don’t know where to go
I don’t feel well enough to go (sick, tired, weak, sad)
I can’t get into a program/provider (waitlist or not taking new clients)
I can’t afford it
I don’t like the programs/providers available to me/they don’t fit my needs
Finding transportation is difficult
Getting the free time to go is difficult
I’m afraid of being judged or treated badly by family, friends or others in the community who find out
I’m afraid of being judged or treated badly by the treatment staff
I’m worried treatment will be unpleasant and interfere with my life
I’m actively drinking or using drugs

HU8: Are there any other reasons why you haven’t been to a provider?

Yes, please specify: __________________________

No

Section: Health Insurance

HI1: Do you currently have health insurance or health care coverage?

No (Go to HI3)

Yes (Go to HI2)

Don't know (Go to HI3)

HI2: What kind of health insurance or coverage do you have? (Personalize for site)

A private health plan - through an employer/parent/spouse or purchased directly or through ACA

Medicaid - for people with low incomes

Medicare - for the elderly and people with disabilities

Some other government plan

TRICARE / CHAMPUS

Veterans Administration coverage

Some other health insurance

Other, please specify: _______________________________

HI3: Do you have a case manager or counselor who is supposed to help you get health care on a regular basis?

Yes

No

Refuse to answer

Section: HIV Testing

These next questions are about HIV.

HIV1: Have you ever been tested for HIV?

(1) Yes (Go to HIV2) (0) No (Go to next section) (3) Don’t know (Go to next section)

HIV2: When did you have your most recent HIV test? ____(Month)/ ____(Year)

HIV3: What was your most recent HIV test result?

(0) Negative

(0) Positive

(0) Indeterminate

(0) Never got the result

(0) Don’t know

(0) Refuse to answer

If subject is HIV positive proceed, otherwise skip to next section.

HIV4: Have you seen a medical provider for your HIV infection within the past 3 months?

(0) No (Go to HIV5) (1) Yes (Go to HIV6) (2) Don’t know (Go to next section)

HIV5: Are any of the following reasons for why you haven’t gotten HIV care in the last three months?

	Yes	No
I’m worried seeing a provider won’t help
I’m not interested/don’t think I need to see a provider
I don’t know where to go
I don’t feel well enough to go (sick, tired, weak, sad)
I can’t get into a program/provider (waitlist or not taking new clients)
I can’t afford it
I don’t like the programs/providers available to me/they don’t fit my needs
Finding transportation is difficult
Getting the free time to go is difficult
I’m afraid of being judged or treated badly by family, friends or others in the community who find out
I’m afraid of being judged or treated badly by the treatment staff
I’m worried treatment will be unpleasant and interfere with my life
I’m actively drinking or using drugs

Go to next section.

HIV6: What is the main place you are receiving medical care for your HIV?

Primary Care

Health Department

Specialist

Women’s Health Care Clinic

Urgent Care Center

Emergency Department

Mobile Health Clinic

Alternative care (eg. Acupuncture, eastern/Chinese medical practitioner, chiropractor, Curandero, etc.)

Other, please specify: ____________

(0) Refused to answer

(0) Don't know

HIV7: What is the name of the place where you are receiving medical care for your HIV infection? ______________________________________ (Agency Name/Location)

HIV8: Have you taken any medications for your HIV infection within the past 3 months?

(0) No (1) Yes (2) Don’t know (9) Refused to answer

Section: Physical Health

PH1: How would you rate your overall health right now? [SOURCE:SAMHSA GPRA]

(0) Excellent (1) Very good (2) Good (3) Fair (4) Poor (5) Refused (6) Don’t know

PH2: Do you have a chronic medical problem other than psychiatric? (check all that apply)

(a) Kidney disease

(b) Liver disease

(c) High blood pressure

Heart disease

(d) Asthma

(e) Emphysema/COPD

(f) Diabetes

() Arthritis or chronic joint pain

(f) Auto-immune disease

(i) Other, please specify: _____________________

PH3: In the past year, have you had a sexually transmitted disease?

Syphilis

Human Papillomavirus (HPV)/genital warts

Pelvic Inflammatory Disease (PID)

Chlamydia

Herpes

Gonorrhea

Other, please specify: ___________________

PH4: If female, are you currently pregnant? (0) No (1) Yes (2) Don’t Know

Section: Mental Health

These next questions are about your mental and emotional health.

MH1: Have you received any counseling, therapy, or treatment for your mental or emotional health in the last 3 months?

(0) No (Go to MH4) (1) Yes (Go to MH2) (2) Don’t know (Go to MH4) (9) Refused to answer (Go to MH4)

MH2: What type of provider did you go to the last time you received counseling, therapy, or treatment for your mental or emotional health?

Counselor, social worker, psychologist or therapist

Psychiatrist

Primary care doctor

Other _____________________________________

MH3: What is the name of the place you currently access mental health counseling? _____________________________________________________________ (Go to MH5)

MH4: Have you spoken to any provider about mental health counseling?

(0) No (1) Yes (2) Don’t know (9) Refused to answer

MH5: Have you ever been diagnosed by a medical provider with any of the following? (Check all that apply)

Depression

Anxiety

Bipolar disorder

Borderline personality disorder

Schizophrenia

ADD/ADHD

PTSD

Other, please specify: ________________________

No - no psych diagnosis ever

Don't know/unsure of diagnosis

MH6: Are you currently taking any medication for this condition? (Ask each time participant answers “yes” to one of the above conditions)

(0) No (1) Yes (2) Don’t know (9) Refused to answer

MH7: In the last 3 months, have you wanted to see someone for mental health reasons, and not gone?

(0) No (Go to next section) (1) Yes (Go to MH8) (9) Refused to answer (Go to next section)

MH8: Are any of the following reasons for why you haven’t seen someone for mental health care in the last three months?

	Yes	No
I’m worried seeing a provider won’t help
I don’t know where to go
I don’t feel well enough to go (sick, tired, weak, sad)
I can’t get into a program/provider (waitlist or not taking new clients)
I can’t afford it
I don’t like the programs/providers available to me/they don’t fit my needs
Finding transportation is difficult
Getting the free time to go is difficult
I’m afraid of being judged or treated badly by family, friends or others in the community who find out
I’m afraid of being judged or treated badly by the treatment staff
I’m worried treatment will be unpleasant and interfere with my life
I’m actively drinking or using drugs

Section: Other Drugs

Now I’m going to ask you about different drugs, first we’ll talk about using drugs in ways other than injecting.

OD1: Have you ever used any drugs to get high that you did not inject?

(0) No (Go to OD13) (1) Yes (Go to OD2) (9) Refused to answer (Go to OD13)

Type of drug	a. Have you EVER used the following drugs?	b. How old were you when you first used this substance?	c. Have you used the following drugs in the LAST 3 MONTHS?	d. How many days did you take this drug in the LAST MONTH?
OD2: Cannabis (pot, hash)	Yes 1 No 2 (skip to OD3) DA 99		Yes 1 No 2 (skip to OD3) DA 99	____________# days
OD3: Hallucinogenic drugs like acid, LSD, peyote, mescaline, mushrooms	Yes 1 No 2 (skip to OD4) DA 99		Yes 1 No 2 (skip to OD4) DA 99	____________# days
OD4: Ecstasy/X	Yes 1 No 2 (skip to OD5) DA 99		Yes 1 No 2 (skip to OD5) DA 99	___________# days
OD5: Inhalants (e.g. glue, spray paint, paint thinner, lighter fluid, gasoline, aerosols, etc.)	Yes 1 No 2 (skip to OD6) DA 99		Yes 1 No 2 (skip to OD6) DA 99	____________# days
OD6: Prescription painkillers that are opioids such as Fentanyl, codeine, Vicodin, Percocet, Percodan, Dilaudid, or morphine pills like Opana, OxyContin/oxycodone, or liquid morphine like Roxanol?	Yes 1 No 2 (skip to OD7) DA 99		Yes 1 No 2 (skip to OD7) DA 99	____________# days
OD7: Prescription medications used to treat addiction that are opioids, such as methadone, buprenorphine, Suboxone	Yes 1 No 2 (skip to OD8) DA 99		Yes 1 No 2 (skip to OD8) DA 99	____________# days
OD8: Tranquilizers or benzos (such as Diazepam, Klonopin, Rohypnol, Valium, Xanax, Librium, Ativan or Restoril)	Yes 1 No 2 (skip to OD9) DA 99		Yes 1 No 2 (skip to OD9) DA 99	____________# days
OD9: Heroin (not by injection)	Yes 1 No 2 (skip to OD10) DA 99		Yes 1 No 2 (skip to OD10) DA 99	____________# days
OD10: Speed – meth, crank, ice, crystal (not by injection)	Yes 1 No 2 (skip to OD11) DA 99		Yes 1 No 2 (skip to OD11) DA 99	____________# days
OD11: Crack (not by injection)	Yes 1 No 2 (skip to OD12) DA 99		Yes 1 No 2 (skip to OD12) DA 99	____________# days
OD12: Powder cocaine (not by injection)	Yes 1 No 2 (skip to OD13) DA 99		Yes 1 No 2 (skip to OD13) DA 99	____________# days

OD13: Do you smoke tobacco?

(0) No (Go to next section) (1) Yes (Go to OD14) (9) Refused to answer (Go to next section)

OD14: On average, how many cigarettes do you smoke each day? (20 cigarettes per pack) __________

OD15: In the past 3 months have you used any other drugs that you did NOT inject?

No

Yes, please specify: _____________________________

Subject: Alcohol Use

This next section is about alcohol.

ALC1: Have you ever drank any wine, beer or liquor?

(0) No (Go to next section) (1) Yes (Go to ALC2) (9) Refused to answer (Go to next section)

ALC2: In the past 3 months, did you drink any wine, beer or liquor?

(0) No (Go to next section) (1) Yes (Go to ALC3) (9) Refused to answer (Go to next section)

ALC3: How often do you have a drink containing alcohol?

Never

Monthly or less

2-4 times a month

2-3 times a week

4 or more times a week

ALC4: How many drinks containing alcohol do you have on a typical day when you are drinking?

1 or 2

3 or 4

5 or 6

7 to 9

10 or more

ALC5: How often do you have 6 or more drinks on one occasion?

Daily or almost daily

Weekly

Monthly

Less than monthly

Never

Subject: First Injection

Now I’m going to ask you some questions about the very first time you injected drugs.

FIN1: When did you first inject drugs?

__________Month _________Year

_____Age at the time

FIN2: What drug or drug combination did you inject the first time you injected? (Choose only one)

Heroin by itself

Crack cocaine by itself

Cocaine (powder) by itself

Heroin and cocaine together (speedball)

Methamphetamine/crystal by itself

Methamphetamine/crystal and heroin together

China White by itself

Black Tar by itself

Heroin and crystal/meth together

China White and crystal/meth together

OxyContin

Other prescription opiates (Vicodin, Darvon, Percocet)

Tranquilizers without a prescription (Rivotril, Diazepam, Valium, Ativan or Restoril)

Barbiturates without a prescription (Amytal, Nembutal, and Seconal)

Other drug or combination that was not already mentioned, please specify: ___________

FIN3: Who did you inject with the first time you injected? (Check all that apply)

Friends

Family

Spouse

Sexual partner (other than your spouse)

Acquaintance

Drug dealer

Strangers

Alone

Other, please specify: __________________________

FIN4: Who injected you the first time you injected?

Myself

Friend

Family

Spouse

Sexual partner (other than your spouse)

Acquaintance

Drug dealer

Stranger

Other (please specify): ________________________________

Subject: Injection Practices

Now I’m going to ask you about your injection practices.

INP1: In a typical week that you inject drugs, how many days do you inject at least once a day? (Choose only one)

1 day per week

2 days per week

3 days per week

4 days per week

5 days per week

6 days per week

Everyday

Don't Know

Refuse to Answer

Not Applicable

INP2: On the days that you inject, how many times do you inject in a day?

INP3: In the last 30 days, on how many days did you shoot up anything including medication?

INP4: In the last 3 months, where have you injected drugs? (Personalize for site)

At your home

At someone else's home

Bar/club

On the street

Park

Public restroom

Car

Other, please specify: ______________

INP5: In the last 3 months, where were you most often when you injected drugs?

At your home

At someone else's home

Bar/club

On the street

Park

Public restroom

Car

Other, please specify: __________________

Subject: Injection Use

Now we’re going to talk about several different drugs that you might inject.

Type of drug	a. Have you EVER injected the following drugs?	b. How old were you when you first injected this?	c. Have you injected the following drugs in the LAST 3 MONTHS?	d. How many days did you inject this drug in the LAST MONTH?
INJ1: Speedball or 1-on-1’s (heroin & cocaine)	Yes 1 No 2 (skip to INJ2) DA 99		Yes 1 No 2 (skip to INJ2) DA 99	____________# days
INJ2: Goofballs (heroin & speed/meth)	Yes 1 No 2 (skip to INJ3) DA 99		Yes 1 No 2 (skip to INJ3) DA 99	____________# days
INJ3: Heroin by itself – not mixed	Yes 1 No 2 (skip to INJ4) DA 99		Yes 1 No 2 (skip to INJ4) DA 99	___________# days
INJ4: Speed/meth/crystal by itself – not mixed	Yes 1 No 2 (skip to INJ5) DA 99		Yes 1 No 2 (skip to INJ5) DA 99	____________# days
INJ5: Cocaine by itself – not mixed	Yes 1 No 2 (skip to INJ6) DA 99		Yes 1 No 2 (skip to INJ6) DA 99	____________# days
INJ6: Crack	Yes 1 No 2 (skip to INJ7) DA 99		Yes 1 No 2 (skip to INJ7) DA 99	____________# days
INJ7: Prescription painkillers that are opioids such as Fentanyl, codeine, Vicodin, Percocet, Percodan, Dilaudid, or morphine pills like Opana, OxyContin/oxycodone, or liquid morphine like Roxanol?	Yes 1 No 2 (skip to INJ8) DA 99		Yes 1 No 2 (skip to INJ8) DA 99	____________# days
INJ8: Prescription medications used to treat addiction, such as methadone, buprenorphine, Suboxone	Yes 1 No 2 (skip to INJ9) DA 99		Yes 1 No 2 (skip to INJ9) DA 99	____________# days
INJ9: Tranquilizers or benzos (such as Diazepam, Klonopin, Rohypnol, Valium, Xanax, Librium, Ativan or Restoril)	Yes 1 No 2 (skip to INJ10) DA 99		Yes 1 No 2 (skip to INJ10) DA 99	____________# days

INJ10: In the last three months have you injected anything else I haven't mentioned already? (Do not include injections administered by a medical professional)

(0) No (Go to INJ12) (1) Yes (Go to INJ11) (9) Refused to answer (Go to INJ12)

INJ11: What other substances have you injected? (If more than 2, pick the 2 used the most)

INJ12: Of the drugs you inject, which drug do you inject the most often?

Subject: Opioid Addiction

If participant answered “Yes” to OD6a, OD7a, INJ7a or INJ8a, ask the questions in this section. Otherwise, skip to next section.

Now I’m going to ask you some questions specifically about using opioids.

OPD1: What was the first type of opioid you were exposed to? [choose only one response]

Pharmaceutical (Opana, oxycodone, OxyContin, Percocet, hydrocodone, Vicodin, methadone)

Heroin or opium

OPD2: What was the main reason you first used opioids? (Choose one)

Pain management/relief

To get high

Other, please specify: ______________________

OPD3: Thinking back to the very first time you used a prescription opioid (fentanyl, oxycodone, OxyContin, Percocet, hydrocodone, Vicodin, methadone, buprenorphine), did you get it from:

(0) A physician for pain

(1) Friend or family member gave it to you

(1) Stole it from someone’s medicine cabinet/prescription bottle

(2) Bought it from someone

(3) Other, please specify:________________________________

Now I’m going to ask you a few questions about when opioid addiction. While someone at first may use opioids to get high, once someone becomes addicted 1) they may continue to use opioids to avoid going into withdrawal, 2) have to use more opioids to get the same high as when they first started using, and 3) their opioid use causes problems with their families, their job and/or the criminal justice system.

OPD4: How old were you when you believe you had an addiction to opioids? ______

If participant says they are not addicted to opioids, skip to next section.

OPD5: What is the type of opioid that you first became addicted to? [choose only one response]
Pharmaceutical/pills

Street opioids (i.e. heroin non-injected)

Street opioids (i.e. heroin injected)

OPD6: What is the source of opioids that you believe led to your addiction?
Prescription (Go to OPD7)

Family (Go to OPD8)

Friend (Go to OPD8)

On the street (Go to OPD8)

Other ____________ (Go to OPD8)

OPD7: If prescribed: If known, please list in chronological order

Type of provider: (1)_________________ Prescription: (1)_______________
(2)_________________ (2)_______________ (3)_________________ (3)_______________

Reason for Prescription (type of pain/medical condition, cause of injury/illness):
_________________________________________________________________

If participant responded “Yes” to INJ3, ask OPD8, otherwise skip to next section.

OPD8: What is the main reason that you started injecting heroin?

Ease of access

Cost

I like it better

It’s what my friends were using

Other, please specify: ____________________

Subject: Buying Drugs

These next questions are about buying drugs with someone else.

BDR1: In the last 3 months, how often did you pool your money together with other people to buy drugs to inject?

Always

Usually

Sometimes

Rarely

Never (Go to next section)

BDR2: How many different people did you pool money with to buy drugs to inject in the past 3 months?

Subject: Rigs/Syringes

Now I’m going to ask you some questions about your rigs and sharing rigs.

RIG1: In the past 3 months, how many times did you use a syringe before you got rid of it?

RIG2: In the last 3 months when you used a syringe for injecting drugs, what did you do with the syringe when you were done? (Check all that apply)

Kept it to use on yourself again

Gave it to someone else

Left it where you shot up

Sold/rented it

Threw it away

Returned it to syringe exchange

Returned it to person you borrowed it from

Threw it away in a safe disposal box

Took it to a pharmacy

Took it to a hospital, clinic or health department

Other, please specify: ______________________________

RIG3: Since you started injecting, have you ever let someone use your rig after you used it?

(0) No (Go to RIG4) (1) Yes

RIG4: In the past 3 months, have you let someone use your rig after you used it?

(0) No (Go to RIG5) (1) Yes

RIG4: In the past 3 months, how many different people did you let use your rig after you? [SOURCE: UFO] _____

RIG5: Since you started injecting, have you ever used a rig that someone else used before you? (Including if the syringe was cleaned first)? [SOURCE: UFO] (0) No (Go to next section) (1) Yes

RIG6: In the past 3 months, have you used someone else's rig after they've used it? [SOURCE: UFO]

(0) No (Go to next section) (1) Yes

RIG7: In the last 3 months, how many different people were there whose rigs you used after them? ____________ [SOURCE: UFO]

RIG8: When you injected in the last 3 months with other people, how often did you use a syringe that had been used before by someone else, even if the syringe was cleaned first? [SOURCE: STAHR2]

Never

Less than half the time

About half of the time

More than half the time

Always

RIG9: In the last 3 months, when you injected with a syringe that had been used by somebody else, how often did you clean it with bleach before you used it? [SOURCE: STAHR2]

Never

Less than half the time

About half of the time

More than half the time

Always

Subject: Works

Now I’m going to ask you some questions about works – things like cottons, cookers, and water.

WOR1: Have you ever shared a cooker or other container for dissolving drugs, or used one that had already been used by someone else? [SOURCE: UFO] (0) No (go to WOR4) (1) Yes

WOR2: In the last 3 months, did you ever use a cooker or other container for dissolving drugs that had already been used by someone else? (0) No (Go to WOR4) (1) Yes

WOR3: In the last 3 months, how often did you use a cooker or other container for dissolving drugs that had already been used by someone else? [SOURCE: UFO]

(0) Always (0) Usually (0) Sometimes (0) Rarely (0) Never

WOR4: Have you ever injected someone's rinse (injecting the residue from someone else's cotton or cooker)? [SOURCE: UFO] (0) No (1) Yes

WOR5: Have you injected someone's rinse in the last 3 months? [SOURCE: UFO] (0) No (1) Yes

WOR6: In the past 3 months, with how many different people did you use the same cooker, cotton, or water that they had already used? [SOURCE: NHBS] _____________________

WOR7: Who did you share a cooker, cotton, or water with in the last 3 months? [SOURCE: STAHR2] (Check all that apply)

(0) Friend

(0) Family/Spouse

(0) Sexual partner (other than your spouse)

(0) Acquaintance

(0) Sex worker

(0) Your pimp

(0) Sex client/ “John”

(0) No one, I always inject alone

(0) Other (please specify): ___________________________

Subject: Dividing Drugs

Now I’m going to ask you about dividing drugs.

DID1: In the last three months did your rig get backloaded or piggybacked? By backloading, I mean using another needle to load your rig. [SOURCE: UFO] (0) No If no, skip to next section (1) Yes

DID2: In the last 3 months, how often did your rig get backloaded?

(0) Always (0) Usually (0) Sometimes (0) Rarely (0) Never

DID3: Had the rig used to load yours ever been used by anyone (including you) to inject? [SOURCE: UFO] (0) No (1) Yes

DID4: In the past 3 months, with how many different people did you use drugs that had been divided with a syringe that they had already used? [SOURCE: NHBS] ___________________

Subject: Equipment Source

These next questions are about where you get your needles and works from.

SEP1: In the past 3 months, which place or places on this list did you personally get new sterile needles from (including getting them for other people)? [SOURCE: NHBS] (Check all that apply)

(0) Pharmacy or drug store

(0) Spouse

(0) Family member

(0) Sex partner (other than spouse)

(0) Friend

(0) Drug dealer

(0) Hot house

(0) Syringe exchange program (you exchanged it yourself)

(0) Someone who gets them from a syringe exchange program

(0) On the street (bought)

(0) Doctor/clinic/hospital/store

(0) Outreach worker

(0) Some other place, please specify: ____________________

(0) Don't know

(0) Refuse to answer

SEP2: In the past 3 months, what was the most common place where you got new sterile needles? [SOURCE: NHBS] (Choose one only)

(0) Pharmacy or drug store

(0) Spouse

(0) Family member

(0) Sex partner (other than spouse)

(0) Friend

(0) Drug dealer

(0) Shooting gallery

(0) Syringe exchange program (you exchanged it yourself)

(0) Someone who gets them from a syringe exchange program

(0) On the street (bought)

(0) Doctor/clinic/hospital/store

(0) Outreach worker

(0) Some other place, please specify: ____________________

(0) Don't know

(0) Refuse to answer

SEP3: In the past 3 months, have you gotten any new cookers, cotton, or water? [SOURCE: NHBS]

(0) No (Go to SEP5) (1) Yes

SEP4: Which place or places on this list did you get those items from? [SOURCE: NHBS]

(0) Pharmacy or drug store

(0) Spouse

(0) Family member

(0) Sex partner (other than spouse)

(0) Friend

(0) Drug dealer

(0) Shooting gallery

(0) Syringe exchange program (you exchanged it yourself)

(0) Someone who gets them from a syringe exchange program

(0) On the street (bought)

(0) Doctor/clinic/hospital/store

(0) Outreach worker

(0) Some other place, please specify: ____________________

(0) Don't know

(0) Refuse to answer

SEP5: Are you aware of any syringe exchange programs in your area? [SOURCE: STAHR2]

(0) No (Go to SEP9) (1) Yes

SEP6: Have you used a local syringe exchange program (SEP) in the last 3 months?[SOURCE: STAHR2]

(0) No (Go to SEP9) (1) Yes

SEP7: In the past 3 months, how often have you gone to the syringe exchange program?

# of times in a week: _____________

# of times in a month: ____________

SEP8: Each time you go to the SEP, on average, how many syringes do you get that are for your use only? ________

SEP9: In the last 3 months, how easy or hard was it for you to get new, unused syringes? [SOURCE: STAHR2]

Never tried to get new, unused syringes (go to SEP11)

Very Easy (go to SEP11)

Easy (go to SEP11)

Hard (go to SEP10)

Very Hard (go to SEP10)

SEP10: What was the main reason it was hard to get new, unused syringes? [SOURCE: STAHR2]

They cost too much/No money to buy them

No place to legally buy them/store won't sell to me

No syringe exchange program nearby

I'm worried about getting caught/arrested by police with syringes

Other (please specify): ______________________

SEP11: In the past 3 months, did you obtain USED syringes in any of the following ways? [SOURCE: STAHR2] (check all that apply)

By paying for it

By sharing drugs with someone

By borrowing it

By providing food/shelter to someone

By having sex with someone

By picking it up off the street

Not applicable, never obtained a used syringe

Other (please specify): _____________________________

Subject: Overdose

The next questions are about overdosing on heroin or other opioids (like OxyContin, Opana or methadone). Different people have different ideas about what an overdose is. For these questions, we mean only those times when someone loses consciousness and something had to be done to bring them back.

OD1: Have you ever overdosed? (0) No (1) Yes

OD2: Have you ever received overdose prevention education?

(0) No (1) Yes (2) Don’t know

OD3: Have you ever received Narcan (naloxone) for personal use (not administered by a medical professional)? [Interviewer note: In Ohio, if subject received an overdose prevention kit and a prescription for naloxone, but did not fill the prescription – check no.]

(0) No (Go to OD4)

(1) Yes, I received an overdose prevention kit with naloxone (Go to OD5)

(2) Don’t know (Go to OD5)

OD4: If no, why have you not received Narcan (naloxone)? [Check all that apply]

(0) I am not familiar with Narcan

(1) I do not need Narcan

(2) I do not know where to go to get Narcan

(3) I received a prescription for Narcan, but the pharmacy would not fill the prescription

(4) I do not have the money to pay for Narcan

(5) I do not need Narcan because I know someone who has it

(6) Other, please specify: _____________________________

OD5: Is there a place that you can go now to receive Narcan (naloxone)? [Interviewer note: During the course of the study, states may authorize collaborative practice agreements allowing over-the-counter purchase of naloxone at a pharmacy.]

(0) No (1) Yes (2) Don’t know

If yes, where:

(0) A public health clinic

(1) Syringe Exchange Program

(2) Doctor’s office or other health clinic

(3) Addiction or mental health treatment program

(4) Pharmacy or over-the-counter

(5) Other, please specify: _____________________________

Subject: Readiness for Treatment

These next questions are about how you feel about your current drug use.

RFT1: Which of the following statements best reflects your use of (drug used most) at the present time.

I have stopped using _____

I want to use more of _____

I have no desire or intention to stop using _____

I think about not using ______, but have no specific plan to stop yet

I have contacted a treatment agency or taken some other specific step with the intention of stopping my use of _____

RFT2: Which of the following statements best reflects your use of alcohol at the present time.

I have stopped drinking

I want to drink more

I have no desire or intention to stop drinking

I think about not drinking, but have no specific plan to stop yet

I have contacted a treatment agency or taken some other specific step with the intention of stopping my drinking

Subject: Past Experiences With Treatment

These next questions are about your past experiences with drug or alcohol treatment.

PET1: Have you ever been in any kind of treatment or counseling for drug or alcohol use?

Yes No (Go to next section)

PET2: How many times in your life have you received any type of professional help for your use of drugs?

PET3: How old you were you the first time you received drug treatment?

PET4: For which drugs have you ever received treatment? (Check all that apply)

Alcohol

Heroin

Prescription opioids (fentanyl, Opana, oxycodone, OxyContin, Percocet, hydrocodone, Vicodin)

Benzos: Sedatives or sleeping pills (Soma, Valium, Serepax, Ativan, Xanax, Librium, Rohypnol)

Cocaine or crack

Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills)

Amphetamines

Cannabis (marijuana, pot, grass, hash)

Inhalants

Other, please specify

PET5: What kind of drug treatment have you ever received in the past? (Check all that apply)

Methadone detox

Methadone maintenance

Buprenorphine detox

Buprenorphine maintenance

Residential treatment

NA, AA, 12-step or other abstinence-based program

Outpatient program

Intensive outpatient program

Outpatient stimulant program

Alternative treatments

Other, Please specify:

PET6: If “Methadone detox” is selected, specify the length of time you stayed in the methadone detox ______________

PET7: If “Buprenorphine detox” is selected, specify the length of time you stayed in the buprenorphine detox. ____________________

Subject: Recent Experiences with Treatment

These next questions are about your recent experiences with drug or alcohol treatment.

RET1: Have you attended or participated in any form of drug treatment in the past 3 months?

Yes No (Go to RET6)

RET2: For which drugs did you receive treatment in the past 3 months? (Check all that apply)

Alcohol

Heroin

Other opioids or painkillers

Other sedatives

Cocaine or crack

Amphetamines

Cannabis

Inhalants

Other, please specify

RET3: What kind of drug treatment did you receive in the past 3 months? (Check all that apply)

Methadone detox

Methadone maintenance

Buprenorphine detox

Buprenorphine maintenance

Residential treatment

NA, AA, 12-step or other abstinence-based program

Outpatient program

Intensive outpatient program

Outpatient stimulant program

Alternative treatments

Other, Please specify:

RET4: If “Methadone detox” is selected, specify the length of time you stayed in the methadone detox {eg '21 day'} program._________________

RET5: If “Buprenorphine detox” is selected, specify the length of time you stayed in the buprenorphine detox {eg '21 day'} _______________________

RET6: During the last 3 months, did you want to get drug treatment but did not go?

Yes No (Go to next section)

RET7: Are any of the following reasons for why you haven’t gotten treatment in the last three months?

	Yes	No
I’m worried going to treatment won’t help
I’m not interested/don’t think I need treatment
I don’t know where to go
I don’t feel well enough to go (sick, tired, weak, sad)
I can’t get into a program (waitlist or not taking new clients)
I can’t afford it
I don’t like the programs/providers available to me/they don’t fit my needs
Finding transportation is difficult
Getting the free time to go is difficult
I’m afraid of being judged or treated badly by family, friends or others in the community who find out
I’m afraid of being judged or treated badly by the treatment staff
I’m worried treatment will be unpleasant and interfere with my life

RET8: Are there any other reasons why you haven’t been to a drug treatment/medical provider or program?

Yes, please specify: _______________________

No

RET9: In the past three months, have you been on a waiting list to receive drug treatment?

Yes No (Go to RET13)

RET11a: If yes, where are you on a waitlist for treatment? __________________________

RET11b: How long have you been on a waitlist? ___________________________

RET10: What type of treatment?

Methadone maintenance

Buprenorphine maintenance

Other, please specify

RET11: Have you ever received medication assisted treatment (MAT) (buprenorphine, methadone, vivitrol, naltrexone, etc.) for drug dependence/addiction?

(0) No

(1) Yes

RET12: Are you currently receiving MAT?

(1) Yes, I’m currently receiving MAT  please specify:

…. Name/location of treatment provider: __________________________

…...Name of medication taking (0) Suboxone/Subutex (buprenorphine)

(0) Methadone

(0) Vivitrol/oral naltrexone

(0) Other, please specify: ________________________

(0) No

Subject: Sex Partners

This next set of questions is about people that you have had sex with in the last 3 months, which means anyone that you have had vaginal, anal or oral sex with, even if it was only once. We’ll also talk about people you shoot up with, so people that are injecting in the same room or space with you, and who you might share injectable drugs or equipment such as needles, cookers, cottons, or rinse water.

SEX1: Have you ever had any sexual partners? (0) No (skip to next section) (1) Yes

SEX2: In the last 3 months, how many different people did you have sex with? ____________

SEX3: In the last 3 months, how often did you use a condom when you had vaginal or anal sex with partners? [SOURCE: UFO]

(0)Never (1)Sometimes (2)About half of the time (3)Often (4)Always

SEX4: How many of your sex partners in the last 3 months paid for sex with money? ____________

SEX5: How many of your sex partners in the last 3 months did you have sex with who gave you drugs, food, clothing, a place to stay or other things you needed (but not cash) in exchange for sex, where you wouldn't have had sex with them otherwise? [SOURCE: UFO] _________________

SEX6: In the past 3 months, of all the people you had sex with, how many of them did you also inject with? [SOURCE: UFO] __________

SEX7: Of those, how many did you share a syringe with? ____________

SEX8: Even if you didn’t share a syringe, how many did you share a cotton, cooker and/or rinse water with? ____________

Subject: Injection Partners

In this next session we’re going to talk more about injecting with other people.

INP1: In the last 3 months, how often did you shoot up alone? [SOURCE: UFO]

Always (Go to next section) Usually Sometimes Rarely Never

INP2: In the last 3 months, thinking of the times you have injected with other people, on average how many different people did you usually inject with? _________________

Now I'd like to ask you some more detailed questions about the 3 people you've injected with the most in the LAST 3 MONTHS.

NAME/ Nickname

Gender 1=Male 2=Female 3=Transgender

Estimated Age in Years

RELATIONSHIP*

How long have you known this person?

What TOWN/ CITY does this person live in?

IDU/SEXUAL PARTNER (0=Neither, 1=IDU Only, 2=Sex Only, 3=IDU+Sex)

IDU SHARING (0=None, 1=Syringe, 2=Water, 3=Cooker, 4=Cotton, 5=Other)

HEP C STATUS (0=Negative, 1=Positive, 2=Don’t know)

KNOWS MY HEP C STATUS (0=No, 1=yes)

FREQUENCY IDU SHARING (0=Less than monthly, 1=monthly, 2=weekly, 3=daily)

IDU DRUGS W/PERSON (1=Heroin, 2=Rx Opioids, 3=Meth/Amphetamines., 4=Cocaine, 5=Other; enter multiple numbers for combined drugs injected)

FREQUENCY DIVIDING DRUGS (1=Always, 2=Usually, 3=Sometimes, 4=Rarely, 5=Never)

HIV STATUS (0=Negative, 1=Positive, 2=Don’t know)

KNOWS MY HIV STATUS (0=No, 1=yes)

1.

2.

3.

NOTES: IDU=injection drug use

*1=Friend, 2=Family, 3=Spouse (Legal or common law), 4=Sexual partner (other than spouse), 5=Acquaintance, 6=Dealer, 7=Stranger, 8=Sex worker, 9=other

Prison/Jail

Subject: Prison/Jail Time

These next questions are about your experience with prison and jail. Jail is a county or city detention center for persons awaiting trial or those convicted of minor crimes (petty theft, urinating in the street). Prison is under state or federal jurisdiction for persons convicted of serious crimes.

PRI1: Have you ever been on probation or parole at any time in your life?

Yes No (Go to PRI4)

PRI2: Are you currently on probation or parole, or have you been on probation in the last 3 months?

Yes No (Go to PRI4)

PRI3: Was it drug related?

Yes No

PRI4: How many times have you been in jail or prison?

Subject: Technology

In this section I will ask you about your experiences with cell phones and the internet.

TECH1: Do you have your own personal computer, meaning you are the person using it the majority of the time? [SOURCE: NAR] (0) No (1) Yes

TECH2: Do you currently have a cell/mobile phone? [SOURCE: NAR] (0) No (1) Yes 

TECH2A: Do you have a (1) Monthly contract (2) Annual contract (3) Other, specify: _____

TECH3: Do you access the internet from your phone? (0) No (1) Yes

TECH4: Do you have unlimited text messaging? (0) No (1) Yes

Have you used?			If Used, Frequency of Use
Internet…………...	(0)No	(1)Yes	8b) (0)Yearly	(1)Monthly	(2)Weekly	(3)Daily
Text messaging ….	(0)No	(1)Yes	9b) (0)Yearly	(1)Monthly	(2)Weekly	(3)Daily
Blogs …………...	(0)No	(1)Yes	10b) (0)Yearly	(1)Monthly	(2)Weekly	(3)Daily
Instant Messaging	(0)No	(1)Yes	11b) (0)Yearly	(1)Monthly	(2)Weekly	(3)Daily
Online Discussion Boards/Chat Rooms ..	(0)No	(1)Yes	12b) (0)Yearly	(1)Monthly	(2)Weekly	(3)Daily
Skype……………	(0)No	(1)Yes	13b) (0)Yearly	(1)Monthly	(2)Weekly	(3)Daily
Facebook ……….	(0)No	(1)Yes	14b) (0)Yearly	(1)Monthly	(2)Weekly	(3)Daily
Twitter …………	(0)No	(1)Yes	15b) (0)Yearly	(1)Monthly	(2)Weekly	(3)Daily
Other, please specify:	(0)No	(1)Yes	16b) (0)Yearly	(1)Monthly	(2)Weekly	(3)Daily

Please indicate your interest in using the following regarding hep c prevention & treatment:	Very Interested	Somewhat Interested	Somewhat Disinterested	Very Disinterested
Appointment reminders via e-mail	(0)	(1)	(2)	(3)
Appointment reminders via text message	(0)	(1)	(2)	(3)
Appointment reminders via phone message	(0)	(1)	(2)	(3)
Using video conferencing to communicate with your doctor/clinician/counselor	(0)	(1)	(2)	(3)
Reminders regarding taking prescription via e-mail	(0)	(1)	(2)	(3)
Reminders regarding taking prescription via text message	(0)	(1)	(2)	(3)
Reminders regarding taking prescription via phone message	(0)	(1)	(2)	(3)
Peer support group online	(0)	(1)	(2)	(3)
Ability to download educational information on hep c	(0)	(1)	(2)	(3)
Smartphone applications related to hep c	(0)	(1)	(2)	(3)
Receiving hep C prevention & treatment information via e-mail	(0)	(1)	(2)	(3)

Housing/Income

Subject: Housing and Income

HAI1: In the past 3 months, where have you been living most of the time?[SOURCE: SAMHSA GPRA] [Do not read the responses to the participant.]

(0) Shelter (Safe havens, transitional living center, low-demand facilities, reception center, other temporary day or evening facility)

(1) Street/outdoors (sidewalk, doorway, park, public or abandoned building)

(2) Institution (hospital, nursing home, jail/prison)

(3) Own/rent apartment, room or house

(4) Someone else’s apartment, room or house

(5) Dormitory/college residence

(6) Halfway house

(7) Residential treatment facility/program (mental health or substance abuse)

(8) Other, specify: 10a __________________

(77) Refused

(88) Don’t know

HAI2: Are you currently a student?

Yes

No

HAI3: In the last 3 months, what were all your sources of income? [SOURCE: UFO] (Check all that apply)

Regular job, employed with a regular salary (full or part-time)

Informal work, temporary work or odd jobs (include under-the-table)

Student financial aid

SSI/disability/VA

GA/welfare/food stamps/AFDC

Unemployment benefits

Family/friends/partner

Panhandling

Selling sex

Selling drugs

Stealing/Boosting

No income

Other, please specify: ___________________________

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