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pdfTLP Young Adult 3-Month Survey
TLP YOUNG ADULT 3-MONTH
FOLLOW UP SURVEY
▌pg. 1
TLP Young Adult 3-Month Survey
STARS [insert logo]
Young Adult 3-Month Survey
Contents
Programming Notes ............................................................................................................................... 4
Welcome ................................................................................................................................................. 5
Tracking and Verification ....................................................................................................................... 6
Gift Card Information .............................................................................................................................. 7
Section A: Where You Stay ................................................................................................................. 12
Housing History Series .................................................................................................................... 12
Housing History Loop: ..................................................................................................................... 14
Section B: Work & Employment .......................................................................................................... 19
Employment Services ...................................................................................................................... 19
Section C: Education & Training .......................................................................................................... 20
Education Services .......................................................................................................................... 21
Section D. Alcohol or Drug Treatment and Self-Help Groups............................................................ 22
In-Patient Alcohol or Drug Treatment ............................................................................................. 23
Residential Alcohol or Drug Treatment ........................................................................................... 23
Out-Patient Alcohol or Drug Treatment .......................................................................................... 25
Self-Help or Online Groups ............................................................................................................. 27
Section E. Mental Health Treatment and Counseling` ....................................................................... 29
In-Patient Mental Health Care ......................................................................................................... 30
Residential Mental Health Care ...................................................................................................... 31
Out-Patient Mental Health Care ...................................................................................................... 32
Section F: Mentoring or Coaching ....................................................................................................... 35
Section G. Physical Health Care ......................................................................................................... 36
Section H: Life and Interpersonal Skill-Building Services .................................................................. 38
Section I. Case Management .............................................................................................................. 41
▌pg. 2
TLP Young Adult 3-Month Survey
Section J: Your Experiences & Feelings ............................................................................................. 44
Depressive Symptoms ..................................................................................................................... 44
Exposure to Violence ....................................................................................................................... 44
Traumatic Stress .............................................................................................................................. 45
Self-Efficacy ..................................................................................................................................... 46
Supportive Relationships with Adults .............................................................................................. 47
Closing Screen ..................................................................................................................................... 48
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TLP Young Adult 3-Month Survey
Programming Notes
Display “back” “next” “or " buttons and on each screen.
Display a reminder not to use the forward and back buttons in the internet browser but to use the
survey forward and back buttons.
Display a progress bar on each screen.
Time out after 7 minutes of inactivity. Display a one- minute timeout warning enabling user to
extent time out period another 7 minutes.
Unless otherwise specified (by “select all that apply”), only one answer is permitted per item.
Participants may skip any item.
For each question, if a response/answer is not provided, after respondent clicks “continue,” the
following pop-up warning should appear confirming that they want to skip. It should read: “Oops we didn’t get an answer to one or more of the last questions. Are you sure you want to move
forward?” and provide two options: “Yes - next question” and “No - go back to last question.”
Code a legitimate (planned) skip as -101
Item-specific programming notes appear in Blue Font throughout the survey.
Notations regarding the construct being measured and/or its source are shown in Red Font. These
must NOT be displayed on the programmed survey.
Section headings (in black font) may be displayed if desired.
▌pg. 4
TLP Young Adult 3-Month Survey
Welcome
WELCOME TO THE STARS 3-MONTH SURVEY!
[insert study logo]
You are part of an important study called STARS (Successful Transitions to Adulthood
Research Study). You signed up for it at [insert TLP name].
What’s the study about?
The study is learning about how communities can help young adults like you develop the skills they
need to build strong futures,
What will happen?
When you joined STARS, you were asked to take part in several surveys over 12 months. Now,
we’re asking you to take the next survey. You will get a [$xx] electronic gift card to
Amazon.com for completing it.
The questions in this survey take about 30 to 45 minutes to answer. You will be asked to check
and update your contact information. You will be asked about programs or services you have
received in the last few months. Like last time, you will also be asked some questions about the
places you’ve stayed, your experiences, thoughts and feelings. You may skip questions or stop
answering questions at any time.
What happens to my answers?
Only the research team will be able to see your answers. Your name will not be attached to your
answers. Your answers will be combined and reported with the answers of over 1,200 other young
adults.
Who should I contact if I have any questions about the study?
If you have any questions about the [insert informal study name], you can call the people who are
doing the study at (XXX) XXX-XXXX. This is a free call.
Continue
▌pg. 5
TLP Young Adult 3-Month Survey
Tracking and Verification
To help us make sure we are giving you the right survey, please enter your name and date
of birth below.
Name. : First Name: ______________ Middle Initial: _____
Last Name: ______________
Date of birth: __/__/____ [MM/DD/YYYY format, provide dropdown]
Where were you born?
_________________________________
City
State
Country
Continue
[Use name and DOB or birthplace to confirm respondent’s identity, check for match in sample file,
and confirm ID match with prior wave(s) of data.]
The Paperwork Reduction Act 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 collection is xxxx-xxxx, and it expires xx/xx/xxxx. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden to [Contact Name];
[Contact Address]; Attn: OMB-PRA (xxxx-xxxx).
▌pg. 6
TLP Young Adult 3-Month Survey
Gift Card Information
First, we want to make sure we know where to send your electronic gift card after you
complete this survey and future surveys.
Gift1. After you finish and submit your survey, we will email or text you an electronic gift
card to Amazon.com. How would you like us to send you the gift card?
(Select only one answer)
Email it to me ........................................................................................................................ [ ] 01
Text it to my cell phone ........................................................................................................ [ ] 02
I do not have an email address or cell phone you can text to ............................................ [ ] 00
[If Gift1 = 0, present Gift1b. Else skip to Contact1]
Gift1b. Instead of emailing or texting you your electronic gift card, we can send the
information by mail. We will ask for the address to send it to a little later in the
survey.
[Display Contact1 and Contact2 on the same screen]
Contact1. Is your contact information shown below correct?
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
[Insert current contact info from sample file.]
First Name _________________ Middle Initial ______ Last Name ________________
Street Address
City
State
Cell Phone Number
Zip Code
Other Phone Number
Email
Twitter Handle ___________________________________________________________
Facebook Screen Name ___________________________________________________
Follow us on Twitter: [insert study Twitter handle]
▌pg. 7
TLP Young Adult 3-Month Survey
[If Contact1=0, allow to correct contact info Change Information : Continue ]
Contact Info Check: If missing any piece of contact information across Contact1 and Contact2,
present a pop-up that reads: We do not seem to have a for you. Would you
like to go back and provide that information so we can be sure to reach you for future surveys and
to provide you with your electronic gift card from completing this survey? Go Back Continue ]
[Check that email in standard form, containing @ and .com, .net, .biz, .edu, etc. If not, present error
message that reads: “The email address you entered is not in standard form. Please re-enter you
email address.”]
[If Gift1 = 0, ask Gift3.]
[If Gift1 = 1 or 2, ask Gift2]
Gift2. Earlier you told us to send your electronic gift card to you by [if Gift1 = 1 insert
“email” if Gift1 = 2 insert “text”]. Please confirm where to send your electronic gift
card
Yes
No
(01)
(00)
[if Gift1 = 1 present:
a. Is this the address we should email it to?
[Insert email address from above.]
[if Gift1 = 2 present:
b. Is this the number we should text it to?
[Insert cell # from above.]
[If Gift2a or gift 2b = 0, ask Gift2c, else skip to Contact 3]
Gift2c. If not, please tell us how to send you your electronic gift card:
(Select only one answer)
Enter the [email address/ cell phone
number] we should use here:
Email it to me:
Text it to my cell phone:
[If Gift1 = 0, ask Gift3, else skip to Contact 3]
▌pg. 8
TLP Young Adult 3-Month Survey
Gift3. Earlier you told us that you do not have an email address or a cell phone where we
can text your electronic gift card. We can mail it to you instead.
[If has address in Contact1 or Contact 2, present Gift3a]
Gift3a. Is the address below where we should send it?
[Insert contact info from above.]
Street Address
City ____________________
State ________ Zip Code
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
[If Gift3a =0, allow to correct contact info Change Information : Continue
[If NO address in Contact1 or Contact2, present Gift3b]
Gift3b. Please tell us where to mail your electronic gift card:
Street Address _______________________________
City
_______________________________
State
_______________________________
Zip Code
_______________________________
[Ensure that address is complete and in valid format]
[If cell phone provided in Contact1 or Contact2, ask Contact3 and Contact4, else skip to Contact5]
Contact3. Is it OK for us to text your cell phone about [insert informal study name]?
(Please keep in mind that your cell phone carrier may charge a fee to receive or send text
messages, depending on your plan.)
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
Contact4. Is it OK for us to leave a message on your cell phone about [insert informal study
name]?
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
[If other phone provided in Contact1 or Contact2, ask Contact5, else skip to Contact6]
▌pg. 9
TLP Young Adult 3-Month Survey
Contact5. Is it OK for us to leave a message on your other phone about [insert informal
study name]?
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
[If Twitter handle provided in Contact1 or Contact2, ask Contac6a-6b, else skip to Contact7]
Contact6a. Is it OK for us to contact you about [insert informal study name] on Twitter? We
would only contact you on Twitter with a private message and never Tweet at you publicly.
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
Contact6b. If you would like us to contact you on Twitter, you will need to follow us. Now’s a
great time to do that! Our Twitter Handle is: [insert study Twitter handle]
[If Facebook screen name provided in Contact1 or Contact2, ask Contact6, else skip to Contact7a]
Contact7. Is it OK for us to contact you about [insert informal study name]on Facebook? We
would only contact you on Facebook with a private message and never post anything to
your wall.
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
To be sure we can reach you about future surveys, we ask you to provide contact
information for people who will always know where you are and how to reach you. We will
NOT discuss or share any of your personal information or survey answers with anyone you
list as a contact. Your personal information and answers are strictly confidential.
Contact8. Below is the information you gave us for a trusted friend, family member, or other
person who will always know where you are and how to reach you in the future in case we
have difficulty. Is the contact information we have correct?
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
[Insert current contact info from sample file.]
First name of parent/legal guardian
Last name of parent/legal guardian
Email address of parent/legal guardian
▌pg. 10
TLP Young Adult 3-Month Survey
Home address of parent/legal guardian
Cell phone number of parent/legal guardian
Home phone number of parent/legal guardian
[If Contact8=0, allow to correct contact info Change Information : Continue ]
Contact9. Below is the information you gave us for another trusted friend, family member,
or other person who will always know where you are and how to reach you in the future in
case we have difficulty. Is the contact information we have correct?
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
[Insert current contact info from sample file.]
First name of family member
Last name of family member
Relationship to you
Email address of family member
Home address of family member
Cell phone number of family member
Home phone number of family member
[If Contact9=0, allow to correct contact info Change Information : Continue ]
▌pg. 11
TLP Young Adult 3-Month Survey
Section A: Where You Stay
Housing History Series
The next questions ask about the places you have stayed from [insert RA date] to today. This
includes times when you were in a shelter or residential program for homeless people or homeless
in an unsheltered location (for example outside, on the street, in a car, bus terminal or abandoned
building).
For each place that you have stayed, we will ask you about when you started and stopped staying
there and what kind of a place it was.
We will ask you to think backwards in time – from last night until [insert RA date].
A1a.
Where did you stay last night? If the place has a name please tell us the name.
________________ [open ended, tag response as: name situation #a, used in later items]
A2a.
When did you start staying at [name situation #a]?
Click here to see a calendar of the past few months. Calendar
[Present calendar for reference]
Month
Day
Year
[Items A3a – A4a intentionally removed]
A5a.
How would you describe [name situation #a]?
(Select only one answer.)
The [insert TLP name] Transitional Living Program (TLP) ................................................. [ ] 01
Another Transitional Living Program (TLP) ......................................................................... [ ] 02
Another residential program for homeless people that provides a long-term
place to stay and services ...................................................................................... [ ] 03
In a shelter (for example, emergency shelter or basic center program) ............................ [ ] 04
▌pg. 12
TLP Young Adult 3-Month Survey
In an unsheltered location (for example, staying outside, on the street,
in a car, bus terminal or abandoned building) ....................................................... [ ] 05
Foster home or group home................................................................................................. [ ] 06
Room, apartment or house (not as part of a homeless program) ...................................... [ ] 07
Institution (for example, hospital, mental health facility, drug or alcohol treatment facility,
prison, jail, detention center) .................................................................................. [ ] 08
School or college dormitory (or dorm) ................................................................................. [ ] 09
Military setting (for example, base camp, deployment, combat zone) ............................... [ ] 10
Other (please specify) .......................................................................................................... [ ] 94
A6a.
When you started staying at [name situation #a], did you think it would be
temporary? By temporary, we mean it would only last a short time (for example,
couch surfing, crashing, or just passing through).
Yes, I thought it would be temporary ................................................................................... [ ] 01
No, I thought I would be there a while ................................................................................. [ ] 00
I was not sure........................................................................................................................ [ ] 02
I don’t remember.................................................................................................................. [ ] -98
[If A5a = 07 (room/apt/house), present A7a – A8a, else skip to A9a]
A7a.
At [name situation #a], are you staying…
(Select all that apply.)
Alone .................................................................................................................................... [ ]
01
With one or more family members ....................................................................................... [ ] 02
With one or more friends ...................................................................................................... [ ] 03
Other (please specify) .......................................................................................................... [ ] 94
[Logic check: If A7a = 1 (alone), R cannot also select 2 (friends) or 3 (family)]
A8a.
At [name situation #a], are you paying rent or part of the rent?
(Select only one answer.)
Yes, I always pay rent or part of the rent ............................................................................. [ ] 02
Yes, I sometimes pay rent or part of the rent ...................................................................... [ ] 01
▌pg. 13
TLP Young Adult 3-Month Survey
No, I never pay rent or part of the rent ................................................................................ [ ] 00
A9a.
Do you feel safe in [name situation #a]?
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
Don’t know .......................................................................................................................... [ ] -98
[Item A10a intentionally removed]
A11a. Did you stay anywhere else from [insert RA date] to today?
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
[If A11a = 1, continue to housing history loop. If A11a = 0, skip to next section]
Housing History Loop:
Note the questions asked in the loop are (nearly) identical to A1a – A11a
[A1b begins Housing History Loop: First turn through loop is A1b – A11b and occurs if A11a = 1
(stayed somewhere else since RA). The loop is repeated again (A1c-A11c) if A11b = 1 (stayed
somewhere else since RA). The loop continues to be repeated until A11# = 0 with a maximum of 3
times through the loop (ending with A11d). This allows us to capture up to a total of four living
situations in the housing history series]
A1b.
What is the name of the place you stayed just before [name situation #a]? If this is a
program, please use its official name.
Remember you can include times when you were in a shelter or residential program for
homeless people or homeless in an unsheltered location (for example outside, on the
street, in a car, bus terminal or abandoned building).
________________ [open ended, tag response as: name situation #b, used in later items]
A2b.
When did you start staying at [name situation #b]?
Click here to see a calendar of the past few months. Calendar
▌pg. 14
TLP Young Adult 3-Month Survey
[Present calendar for reference]
Month
A3b.
Day
Year
Are you still staying there?
Yes ........................................................................................................................................ [ ] 01
No .......................................................................................................................................... [ ] 00
[If A3b = 1 skip to A5b, else continue to A4b]
A4b.
When did you stop staying there? Your best guess is fine.
Month
A5b.
Day
Year
How would you describe [name situation #b]?
(Select only one answer.)
The [insert TLP name] Transitional Living Program (TLP) ................................................. [ ] 01
Another Transitional Living Program (TLP) ......................................................................... [ ] 02
Another residential program for homeless people that provides a long-term
place to stay and services ...................................................................................... [ ] 03
Homeless in a shelter (for example, emergency shelter or basic center program) ........... [ ] 04
Homeless in an unsheltered location (for example, staying outside, on the street,
in a car, bus terminal or abandoned building) ....................................................... [ ] 05
Foster home or group home................................................................................................. [ ] 06
Room, apartment or house (not as part of a homeless program) ...................................... [ ] 07
Institution (for example, hospital, mental health facility, drug or alcohol treatment facility,
prison, jail, detention center) .................................................................................. [ ] 08
School or college dormitory (or dorm) ................................................................................. [ ] 09
Military setting (for example, base camp, deployment, combat zone) ............................... [ ] 10
Other (please specify) .......................................................................................................... [ ] 94
▌pg. 15
TLP Young Adult 3-Month Survey
A6b.
When you started staying at [name situation #b], did you think it would be
temporary? By temporary, we mean it would only last a short time (for example,
couch surfing, crashing, or just passing through).
Yes, I thought it would be temporary ................................................................................... [ ] 01
No, I thought I would be there a while ................................................................................. [ ] 00
I was not sure........................................................................................................................ [ ] 02
I don’t remember.................................................................................................................. [ ] -98
[If A5b = 7 (room/apt/house), present A7b – A8b, else skip to A9b]
A7b.
In [name situation #b], were you staying…
(Select all that apply.)
Alone ..................................................................................................................................... [ ] 01
With one or more family members ....................................................................................... [ ] 02
With one or more friends ...................................................................................................... [ ] 03
Other (please specify) .......................................................................................................... [ ] 94
[Logic check: If A7b = 1 (alone), R cannot also select 2 (friends) or 3 (family)]
A8b.
In [name situation #b], were you paying rent or part of the rent?
(Select only one answer.)
Yes, I always paid rent or part of the rent ............................................................................ [ ] 02
Yes, I sometimes paid the rent ............................................................................................ [ ] 01
No, I never paid the rent ....................................................................................................... [ ] 00
A9b.
Did you feel safe in [name situation #b]?
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
Don’t know .......................................................................................................................... [ ] -98
▌pg. 16
TLP Young Adult 3-Month Survey
[Item A10b intentionally removed]
A11b. So far, you have told us about [insert previously identified situation(s) – i.e., name
situation #a, name situation #b, etc.].
Did you stay anywhere else from [insert RA date] to today?
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
[End of Loop. If A11b = 1, loop back and begin with A1c. If A11b = 0, exit loop and continue to next
section. Looping continues until A11#=0 with a maximum of 3 times through the loop, ending with
A11d. After 3 times through the loop, if A11d = 1 then, present A12 - A13.]
[If A11d = 1 then present A12, Else if A11d=0 skip to next section]
A12. How many other places have you stayed from [insert RA date] to today?
________________ # places
A13.
What types of places were they?
(Select all that apply)
[Randomly order/rotate all options presented for A13]
Yes
(01)
a. The [insert TLP name] Transitional Living Program (TLP)
b. Another Transitional Living Program (TLP)
c. Another residential program for homeless people that provides a long-term
place to stay and services
d. Homeless in a shelter (for example, emergency shelter or basic center
program)
e. Homeless in an unsheltered location (for example, staying outside, on the
street, in a car, bus terminal or abandoned building)
f.
Foster home or group home
g. Room, apartment or house (not as part of a homeless program)
▌pg. 17
TLP Young Adult 3-Month Survey
h. Institution (for example, hospital, mental health facility, drug or alcohol
treatment facility, prison, jail, detention center)
i.
School or college dormitory (or dorm)
j.
Military setting (for example, base camp, deployment, combat zone)
k. Other (please specify)
▌pg. 18
TLP Young Adult 3-Month Survey
Section B: Work & Employment
B1.
At any time from [insert RA date] to today, have you worked at a job or business for
pay?
By worked at a job or business for pay, we mean working at a job where you get
paid money for the work you do or working for someone besides yourself and
getting paid for it. It does not include odd jobs, informal work, illegal or “off-thebooks” work, or work where you did not get paid.
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
Employment Services
B2.
At any time from [insert RA date] to today, did you receive information about or help
with any of the following in a class, workshop, program, or from a professional? (Do
not include help from friends and relatives.)
(Select yes or no for each)
Yes
No
(01)
(00)
a. Advice about your career goals or help deciding what kind of work
you want to do
b. Referrals to jobs or help findings jobs that you might apply for
c. Filling out job applications
d. Writing a resume or cover letter for a job application
e. Interviewing for a job
f.
Other (please specify)
▌pg. 19
TLP Young Adult 3-Month Survey
Section C: Education & Training
C1.
At any time from [insert RA date] to today, have you been enrolled in any of the
following?
(Select yes or no for each)
Yes
No
(01)
(00)
a. Adult basic education (ABE) classes.
By adult basic education (ABE), we mean classes to improve basic
reading and math skills. This is not high school or college classes.
b. English as a Second Language (ESL) classes
c. GED classes or another alternate diploma program
By GED classes, we mean classes to prepare for the GED test
d. High school
e. College or classes toward an Associates degree or Bachelors
degree at a 2-year or 4-y college
f.
Vocational, career, or technical training at a community or
private college.
By vocational, career, or technical training, we mean training for a
specific job, trade, or occupation. This is not training you get in
college courses. It is also not on-the-job training or unpaid work
experience
▌pg. 20
TLP Young Adult 3-Month Survey
Education Services
C2.
At any time from [insert RA date] to today, did you receive any of the following in a
class, workshop, program, or from a professional? (Do not include help from friends
and relatives.)
(Select yes or no for each)
Yes
No
(01)
(00)
a. Academic advising
For example:
Advice about your education goals or plans
Help finding education services or classes
Help enrolling in education services or classes
Help applying to education services, or classes
b. Advising on vocational or technical training
(By vocational, career, or technical training, we mean training for a
specific job, trade, or occupation.)
For example:
Advice about vocational or technical training goals or plans
Help finding vocational or technical training or classes
Help enrolling in vocational or technical training or classes
Help applying to vocational or technical training or classes
c. College awareness or preparation
For example:
Information about colleges
Information about going to college
Information on how to prepare for college
Help with college applications
d. Tutoring
e. Help with a learning disability or special education needs
g. Financial help for education or training
For example:
Help paying for supplies for school or training
Help paying for tuition for school or training
i. Other (please specify)
▌pg. 21
TLP Young Adult 3-Month Survey
Section D. Alcohol or Drug Treatment and Self-Help Groups
The next questions are about services you may have received to help you with your use
of alcohol or any drug.
D1a.
At any time from [insert RA date] to today, did you THINK YOU SHOULD GET
treatment or counseling for your use of alcohol or any drug, (not counting cigarettes
and other tobacco products)?
By THINK YOU SHOULD GET, we mean you thought about, needed or wanted to get
treatment or counseling – even if you never actually got it.
By drug, we mean illegal drugs such as cocaine, heroin, marijuana, and also
prescription medications, over the counter medications, inhalants, and other
substances not prescribed to you by a doctor.
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
D1b.
At any time from [insert RA date] to today, did you RECEIVE treatment or counseling
for your use of alcohol or any drug (not counting cigarettes and other tobacco
products)?
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
[If D1b = 1, ask D2, else skip to next section]
Now we’re going to ask about a few different kinds of drug or alcohol treatment. We’ll ask
about
Whether you stayed overnight or longer in a hospital to get treatment
Whether you stayed overnight or longer in a place that was not a hospital to get
treatment
Whether you got treatment as an outpatient, which means without staying
overnight
▌pg. 22
TLP Young Adult 3-Month Survey
In-Patient Alcohol or Drug Treatment
D2.
At any time from [insert RA date] to today, did you stay overnight or longer at any
type of hospital to receive treatment or counseling for your use of alcohol or any
drug?
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
[If D2 = 1, ask D3, else skip to D4]
D3.
In the time from [insert RA date] to today, about how many nights in total did you
stay in any type of hospital to receive treatment or counseling for your use of
alcohol or any drug?
_________ # nights
Residential Alcohol or Drug Treatment
D4.
At any time from [insert RA date] to today, did you stay overnight or longer in any
residential drug or alcohol rehabilitation facility to receive treatment or counseling
for your use of alcohol or any drug?
By residential drug or alcohol rehabilitation facility, we mean a place that was not a
hospital where you stayed overnight or longer for rehab or detox.
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
[If D4 = 1, ask D5a – D5c, else skip to D6]
D5.
Please think about the time from [insert RA date] to today and the alcohol or drug
treatment or counseling you received in any residential drug or alcohol
rehabilitation facility.
▌pg. 23
TLP Young Adult 3-Month Survey
By residential drug or alcohol rehabilitation facility, we mean a place that was not a
hospital where you stayed overnight or longer for drug or alcohol rehab or detox.
D5a.
About how many nights in total did you stay in a residential drug or alcohol
rehabilitation facility to receive treatment or counseling for your use of
alcohol or any drug?
_________ # nights
D5b.
While there, did you receive any of the following treatment or counseling
services for your use of alcohol or any drug?
(Select all that apply.)
Yes
(01)
a. Individual counseling or individual therapy
By this we mean, you met one-on-one with a
psychologist, therapist, or counselor to talk about
problems or things that were bothering you
b. Family counseling
By this we mean, you and members of your family met
with a psychologist, therapist, or counselor to talk
about problems or things that were bothering you and
your family
c. Group counseling (not with family members)
By this we mean, you met in a group with a
psychologist, therapist, or counselor to talk about
problems or things that were bothering you and other
people in the group
d. Peer-to-peer counseling
By this we mean, you met with a peer (a friend or
someone your age) to talk about problems or things
that were bothering you
e. Medical attention from a doctor or psychiatrist
By this we mean, you met with a doctor or psychiatrist
to get medication
f.
Other (please specify)
▌pg. 24
TLP Young Adult 3-Month Survey
Out-Patient Alcohol or Drug Treatment
D6.
At any time from [insert RA date] to today, did you receive outpatient treatment or
counseling for your alcohol or drug use from any of the following?
By outpatient, we mean that you did NOT spend the night.
(Select all that apply.)
Yes
(01)
a. A partial day hospital or day treatment program
b. A therapist, psychologist, social worker, counselor, psychiatrist, doctor, or nurse
(NOT in a partial day hospital or day treatment program)
[If D6a = 1, ask D7a – D7b]
D7.
Please think about the time from [insert RA date] to today and the alcohol or drug
treatment or counseling you received in a partial day hospital or day treatment
program
D7a.
About how many times in total did you go to a partial day hospital or day
treatment program to receive alcohol or drug treatment or counseling?
_________ # times
D7b.
When you went to a partial day hospital or day treatment program to receive
alcohol or drug treatment or counseling, how long did your visit usually
last?
_________ # minutes/hours
[If D6b = 1, ask D8a – D8b]
D8.
Please think about the time from [insert RA date] to today and the alcohol or drug
treatment or counseling you received from a therapist, psychologist, social worker,
counselor, psychiatrist, doctor, or nurse (NOT in a partial day hospital or day
treatment program).
D8a.
About how many times in total did you go to a therapist, psychologist, social
worker, counselor, psychiatrist, doctor, or nurse (NOT in a partial day
▌pg. 25
TLP Young Adult 3-Month Survey
hospital or day treatment program) to receive alcohol or drug treatment or
counseling?
_________ # times
D8b.
When you went to a therapist, psychologist, social worker, counselor,
psychiatrist, doctor, or nurse (NOT in a partial day hospital or day treatment
program) to receive alcohol or drug treatment or counseling, how long did
your visit usually last?
_________ # minutes/hours
D9.
Please think about the time from [insert RA date] to today and the alcohol or drug
treatment or counseling you received in:
[Present only the settings selected in D6]
A partial day hospital or day treatment program
A therapist, psychologist, social worker, counselor, psychiatrist, doctor, or nurse
(not in a partial day hospital or day treatment program)
D9a.
Did you receive any of the following treatment or counseling services for
your use of alcohol or any drug?
(Select all that apply.)
Yes
(01)
a. Individual counseling or individual therapy
By this we mean, you met one-on-one with a
psychologist, therapist, or counselor to talk about
problems or things that were bothering you
b. Family counseling
By this we mean, you and members of your family met
with a psychologist, therapist, or counselor to talk
about problems or things that were bothering you and
your family
c. Group counseling (not with family members)
By this we mean, you met in a group with a
psychologist, therapist, or counselor to talk about
problems or things that were bothering you and other
people in the group
▌pg. 26
TLP Young Adult 3-Month Survey
d. Peer-to-peer counseling
By this we mean, you met with a peer (a friend or
someone your age) to talk about problems or things
that were bothering you
e. Medical attention from a doctor or psychiatrist
By this we mean, you met with a doctor or psychiatrist
to get medication
f.
Other (please specify)
Self-Help or Online Groups
D10.
At any time from [insert RA date] to today, did you participate in a self-help group
(such as Alcoholics Anonymous (Alanon), Alateen, or Narcotics Anonymous) for
your use of alcohol or any drug?
By participate, we mean go to meetings in person or receive support online.
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
[If D10 = 0 (no self-help group), skip to next section]
D11.
Please think about the time from [insert RA date] to today and your in-person or
online participation in a self-help group (such as Alcoholics Anonymous (Alanon),
Alateen, or Narcotics Anonymous) for your use of alcohol or any drug.
D11a. About how many times in total did you participate in person in self-help
group meetings?
_________ # times
D11b. When you participated in person in a self-help group, how long did your inperson meetings or sessions usually last?
_________ # minutes/hours
D11c. About how many times in total did you participate online in a self-help
group?
▌pg. 27
TLP Young Adult 3-Month Survey
_________ # times
D11d. When you participated online in a self-help group, how long did your online
meetings or sessions usually last?
_________ # minutes/hours
▌pg. 28
TLP Young Adult 3-Month Survey
Section E. Mental Health Treatment and Counseling`
The next questions are about services you may have received to help you with your
feelings, thoughts, or behaviors.
E1a.
At any time from [insert RA date] to today, did you THINK YOU SHOULD GET
treatment or counseling for any of the following problems with your behaviors or
emotions?
By THINK YOU SHOULD GET, we mean you thought about, needed or wanted to get
treatment or counseling – even if you never actually got it.
(Select all that apply)
Yes
No
(01)
(00)
a. Emotional problems
b. Nerves, anxiety, or fears
c. Mental health issues
d. Problems paying attention, concentrating, or remaining still and calm
e. Depression or long periods of feeling sad or down
f.
g. Eating disorders
h. Behavior problems (anger, violence, aggression)
i.
Problems with family, friends, or getting along with other people
j.
Other (Please specify)
Trauma or something very upsetting
E1b.
At any time from [insert RA date] to today, did you RECEIVE treatment or counseling
for any of the following problems with your behaviors or emotions?
(Select all that apply)
a.
Emotional problems
b. Nerves, anxiety, or fears
Yes
No
(01)
(00)
▌pg. 29
TLP Young Adult 3-Month Survey
c. Mental health issues
d. Problems paying attention, concentrating, or remaining still and calm
e. Depression or long periods of feeling sad or down
f.
g. Eating disorders
h. Behavior problems (anger, violence, aggression)
i.
Problems with family, friends, or getting along with other people
j.
[Other auto-fill from E1aj ]
Trauma or something very upsetting
k. Other (Please specify)
[If any in E1ba-E1b = 1 (received), continue to E2, else skip to next section]
Now we’re going to ask about a few different kinds of treatment or counseling for problems
with your behaviors or emotions. We’ll ask about
Whether you stayed overnight or longer in a hospital to get treatment
Whether you stayed overnight or longer in a place that was not a hospital to get
treatment
Whether you got treatment as an outpatient, which means without staying overnight
In-Patient Mental Health Care
E2.
At any time from [insert RA date] to today, have you stayed overnight or longer at
any type of hospital or psychiatric facility to receive treatment or counseling for
problems with your behaviors or emotions?
Yes ........................................................................................................................... [ ]
01
No ............................................................................................................................. [ ]
[If E2 = 1, ask E3, else skip to E4]
00
E3.
In the time from [insert RA date] to today, about how many nights in total did you
stay in any type of hospital or psychiatric facility to receive treatment or counseling
for problems with your behaviors or emotions?
_________ # nights
▌pg. 30
TLP Young Adult 3-Month Survey
Residential Mental Health Care
E4.
At any time from [insert RA date] to today, did you stay overnight or longer in any
residential treatment center or program to receive treatment or counseling for
problems with your behaviors or emotions?
By residential treatment center or program, we mean a place (other than a hospital
or psychiatric facility) where you stayed overnight or longer.
Yes ........................................................................................................................... [ ]
01
No ............................................................................................................................. [ ]
00
[If E4 = 1, ask E5a – E5c, else skip to E6]
E5.
Please think about the time from [insert RA date] to today and the treatment or
counseling you have received in a residential treatment center for problems with
your behaviors or emotions.
By residential treatment center or program, we mean a place (other than a hospital
or psychiatric facility) where you stayed overnight or longer.
E5a.
About how many nights in total did you stay in a residential treatment center
to receive treatment or counseling for problems with your behaviors or
emotions?
_________ # nights
E5b.
While there, did you receive any of the following treatment or counseling
services for problems with your behaviors or emotions?
(Select all that apply.)
a. Individual counseling or individual therapy
By this we mean, you met one-on-one with a
psychologist, therapist, or counselor to talk about
problems or things that were bothering you
Yes
No
(01)
(00)
▌pg. 31
TLP Young Adult 3-Month Survey
b. Family counseling
By this we mean, you and members of your family met
with a psychologist, therapist, or counselor to talk
about problems or things that were bothering you and
your family
c. Group counseling (not with family members)
By this we mean, you met in a group with a
psychologist, therapist, or counselor to talk about
problems or things that were bothering you and other
people in the group
d. Peer-to-peer counseling
By this we mean, you met with a peer (a friend or
someone your age) to talk about problems or things
that were bothering you
e. Medical attention from a doctor or psychiatrist
By this we mean, you met with a doctor or psychiatrist
to get medication
f.
Other (please specify)
Out-Patient Mental Health Care
E6.
At any time from [insert RA date] to today, did you receive outpatient treatment or
counseling for problems with your behaviors or emotions from any of the following?
By outpatient we mean that you did NOT spend the night.
(Select all that apply)
Yes
No
(01)
(00)
a. A partial day hospital or day treatment program
b. A therapist, psychologist, social worker, counselor, psychiatrist, doctor or
nurse (NOT in a partial day hospital or day treatment center)
[If E6a = 1, ask E7a – E7b]
▌pg. 32
TLP Young Adult 3-Month Survey
E7.
Please think about the time from [insert RA date] to today and treatment or
counseling for problems with your behaviors or emotions you received in a partial
day hospital or day treatment program.
E7a.
About how many times in total did you go to a partial day hospital or day
treatment program to receive treatment or counseling for problems with
your behaviors or emotions?
_________ # times
E7b.
When you went to a partial day hospital or day treatment program to receive
treatment or counseling for problems with your behaviors or emotions, how
long did your visit usually last?
_________ # minutes/hours
[If E6b = 1, ask E8a – E8b]
E8.
Please think about the time from [insert RA date] to today and treatment or
counseling for problems with your behaviors or emotions you received from a
therapist, psychologist, social worker, counselor, psychiatrist, doctor, or nurse
(NOT in a partial day hospital or day treatment program).
E8a.
About how many times in total did you did you go to a therapist,
psychologist, social worker, counselor, psychiatrist, doctor, or nurse (NOT
in a partial day hospital or day treatment program) treatment or counseling
for problems with your behaviors or emotions?
_________ # times
E8b.
When you went to a therapist, psychologist, social worker, counselor,
psychiatrist, doctor, or nurse (NOT in a partial day hospital or day treatment
program) to receive treatment or counseling for problems with your
behaviors or emotions, how long did your visit usually last?
_________ # minutes/hours
▌pg. 33
TLP Young Adult 3-Month Survey
E9.
Please think about the time from [insert RA date] to today and the treatment or
counseling for problems with your behaviors or emotions you received in:
[Present only the settings selected in E6]
A partial day hospital or day treatment program
A therapist, psychologist, social worker, counselor, psychiatrist, doctor, or nurse
(not in a partial day hospital or day treatment program)
E9a.
Did you receive any of the following treatment or counseling services for
problems with your behaviors or emotions?
(Select all that apply.)
Yes
No
(01)
(00)
e. Medical attention from a doctor or psychiatrist
By this we mean, you met with a doctor or psychiatrist to
get medication
f.
a. Individual counseling or individual therapy
By this we mean, you met one-on-one with a
psychologist, therapist, or counselor to talk about
problems or things that were bothering you
b. Family counseling
By this we mean, you and members of your family met
with a psychologist, therapist, or counselor to talk about
problems or things that were bothering you and your
family
c. Group counseling (not with family members)
By this we mean, you met in a group with a psychologist,
therapist, or counselor to talk about problems or things
that were bothering you and other people in the group
d. Peer-to-peer counseling
By this we mean, you met with a peer (a friend or
someone your age) to talk about problems or things that
were bothering you
Other (please specify)
▌pg. 34
TLP Young Adult 3-Month Survey
Section F: Mentoring or Coaching
F1.
At any time from [insert RA date] to today, has a program or organization MATCHED
you with a mentor, coach, or “buddy” who provides you support, advice or
guidance?
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
F2.
Are you still talking to or meeting with your mentor, coach, or “buddy?”
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
▌pg. 35
TLP Young Adult 3-Month Survey
Section G. Physical Health Care
G1.
At any time from [insert RA date] to today, did you THINK YOU SHOULD SEE a
doctor, nurse, or other health professional for any of the following reasons?
By THINK YOU SHOULD SEE, we mean you thought about, needed or wanted to see
a doctor, nurse, or other health professional – even if you never actually went.
(Select yes or no for each).
Yes
No
(01)
(00)
a. I was physically sick
b. I was physically injured
c. I had a chronic or on-going health problem (for example, asthma
or diabetes)
d. I needed dental care
e. I needed prescription medicines
f.
I needed regular check-ups with a doctor
g. I needed medical services related to my pregnancy [present only
if female based on sample file]
h. I had other healthcare need(s)
▌pg. 36
TLP Young Adult 3-Month Survey
G2.
At any time from [insert RA date] to today, did you RECEIVE care from a doctor,
nurse, or other health professional for any of the following reasons?
(Select yes or no for each.)
Yes
No
(01)
(00)
a. I was physically sick
b. I was physically injured
c. I had a chronic (on-going) health problem (such as asthma or
diabetes)
d. I needed dental care
e. I needed prescription medicines
f.
I needed regular check-ups with a doctor
g. I needed medical services related to my pregnancy. [present only if
female based on sample file]
h. I had other healthcare need(s)
▌pg. 37
TLP Young Adult 3-Month Survey
Section H: Life and Interpersonal Skill-Building Services
H1.
At any time from [insert RA date] to today, did you receive information about any of
the following things from a class, program, workshop, or from your case manager?
(Select yes or no for each)
Yes
No
(01)
(00)
a. Daily living skills
For example:
Food and nutrition
Home cleanliness
Home safety
Home repairs
Handling emergencies
Using a computer
Using the Internet to find resources or information you need
b. Self-care skills
For example:
Health care
Personal hygiene (personal cleanliness)
Personal safety
c. Housing and money management
For example:
Budgeting, spending, and saving money
Banking and credit
Income taxes
Transportation
d. Personal Development
For example:
Knowing and respecting yourself
Knowing and respecting your goals
Knowing and respecting your responsibilities
▌pg. 38
TLP Young Adult 3-Month Survey
Yes
No
(01)
(00)
e. Relationships and communication skills
For example:
Managing your anger
Resolving conflicts
Caring about and respecting others
Starting friendships
Keeping healthy relationships
Communicating with family
Communicating with friends
Communicating at school or at work
f. Cultural competency
For example:
Understanding your cultural identity
Understanding different cultural groups
g. Domestic violence
For example:
Knowing the signs of physical and verbal abuse
Knowing how to avoid abusive relationships
h. Parenting
For example:
Pregnancy and pre-natal care
Parenting or being a good parent
i. Sexual Health
For example:
Protecting yourself from sexually transmitted diseases (STDs)
Preventing pregnancy
Abstinence (not having sex)
▌pg. 39
TLP Young Adult 3-Month Survey
Yes
No
(01)
(00)
j. Work skills and study skills
For example:
Managing your time
Studying for a test
Doing homework
How to behave at school
Filling out a job application
Writing a resume or cover letter for a job application
Interviewing for a job
How to behave at work
▌pg. 40
TLP Young Adult 3-Month Survey
Section I. Case Management
I1.
Sometimes people get help from professionals called case managers or care
coordinators who help to find or organize services or treatment for problems or
difficulties they are experiencing. This type of help is sometimes called case
management or care coordination.
A case manager might work with you to:
Assess your needs and set goals
Create a service plan for you
Contact different organizations and programs to get you the services you need
Coordinate your services in different organizations and program
Provide support to you in getting the help you need
Check on your progress
At any time from [insert RA date]) to today, did you receive case management?
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
Don’t Know .......................................................................................................................... [ ] -98
[If I1 = 1, ask I2, else skip to next section]
I2.
Thinking about the time from [insert RA date] to today, did your case manager…?
(Select yes or no for each)
Yes
No
(01)
(00)
a. Assess your needs and set goals
b. Create a service plan for you
c. Contact providers or get you the services you need
d. Provide support to you in getting the help you need
e. Check on your progress
▌pg. 41
TLP Young Adult 3-Month Survey
I3.
Sometimes people get their case management from one (1) case manager who helps
them get all their services. Other times people work with a few different case
managers at the same time who each help them with different services.
In the time from [insert RA date] to today, did you work with just one (1) case
manager or did you work with two (2) or more case managers at the same time?
1 case manager ..................................................................................................................[ ]
01
2 or more case managers at the same time ......................................................................[ ]
02
[If I3= 1 (only 1 case manager), ask I4. If L3= 2 (more than 1 case manager) skip to I5]
I4.
In the time from [insert RA date] to today, did your case manager help you with only
one (1) type of service or with many types of services?
Only 1 kind of service .........................................................................................................[ ]
01
A variety of different services .............................................................................................[ ]
02
[If I3=2 (more than 1 case manager) ask I5, else skip to I7]
I5.
In the time from [insert RA date] to today, did each of your case managers help you
with different services or did they all help you with the same services?
Yes, they each helped me with different services .............................................................[ ]
01
No, they all helped me with the same services .................................................................[ ]
00
[If I5=1 (each helped with different) ask I6, else skip to I7]
I6.
In the time from [insert RA date] to today, did your case managers talk to each other
and work together as a team to help you get your services or did they work
separately?
Talked to each other or worked together as a team .........................................................[ ]
01
Worked separately ..............................................................................................................[ ]
02
▌pg. 42
TLP Young Adult 3-Month Survey
I7.
When did you start receiving case management?
Click here to see a calendar of the past few months. Calendar
[Present calendar for reference]
Month
I8.
Day
Year
Are you still receiving case management?
Yes ...................................................................................................................................... [ ] 01
No ........................................................................................................................................ [ ] 00
[If I8 = 0, ask I9, else skip to I10]
I9.
When did you stop receiving case management?
Click here to see a calendar of the past few months. Calendar
[Present calendar for reference]
Month
I10.
Day
Year
Please think about ALL the case management you have received in the time from
[insert RA date] to today..
I10a.
In an average week, how much time did you usually spend meeting or
talking with your case manager?
________________ # minutes/hours a week
▌pg. 43
TLP Young Adult 3-Month Survey
Section J: Your Experiences & Feelings
Depressive Symptoms
J1. Below is a list of the ways you might have felt or behaved. How often you have felt this
way during the past week?
During the past week…
Hardly ever or
never
(00)
Some of the
time
(01)
Much or most
of the time
(02)
1. I did not feel like eating; my appetite
was poor.
2. I felt depressed.
3. I felt that everything I did was an
effort
4. My sleep was restless.
5. I was happy.
6. I felt lonely.
7. People were unfriendly.
8. I enjoyed life.
9. I felt sad.
10. I felt that people dislike me.
11. I could not get “going.”
Exposure to Violence
J2.
In the time from [insert RA date] to today, how often did each of the following things
happen?
Never
Once
More than
Once
(0)
(1)
(2)
a. You saw someone shoot or stab another person.
b. Someone pulled a knife or gun on you.
c. Someone shot you.
d. Someone cut or stabbed you.
e. You got into a physical fight.
▌pg. 44
TLP Young Adult 3-Month Survey
f.
Never
Once
More than
Once
(0)
(1)
(2)
You were jumped.
g. You pulled a knife or gun on someone.
h. You shot or stabbed someone.
Traumatic Stress
J3. The next questions are about problems and complaints that people sometimes have in
response to stressful life experiences. Please indicate how much you have been bothered
by each problem in the past month. For these questions, the response options are: “not at
all”, “a little bit”, “moderately”, “quite a bit”, or “extremely”.
Not at all A little bit Moderately Quite a bit Extremely
1
2
3
4
5
1. Repeated, disturbing
memories, thoughts, or
images of a stressful
experience from the past?
2. Feeling very upset when
something reminded you of
a stressful experience from
the past?
3. Avoiding activities or
situations because they
reminded you of a stressful
experience from the past?
4. Feeling distant or cut off
from other people?
5. Feeling irritable or having
angry outbursts?
6. Having difficulty
concentrating?
▌pg. 45
TLP Young Adult 3-Month Survey
Self-Efficacy
J4.
Thinking about yourself, how accurate is each of these statements?
To answer, please use a scale of 1 to 4, where 1 = Not at All True and 4 = Exactly True.
Not at all
true
1
Hardly
true
Moderately
true
2
3
Exactly
true
4
a. I can always manage to solve difficult problems if
I try hard enough.
b. If someone opposes me, I can find the means and
ways to get what I want.
c. It is easy for me to stick to my aims and
accomplish my goals.
d. I am confident that I could deal efficiently with
unexpected situations well.
e. Thanks to my resourcefulness, I know how to
handle unforeseen situations.
f.
I can solve most problems if I invest the
necessary effort.
g. I can remain calm when facing difficulties
because I can rely on my coping abilities.
h. When I am confronted with a problem, I can
usually find several solutions.
i.
If I am in trouble, I can usually think of a solution.
j.
I can usually handle whatever comes my way.
▌pg. 46
TLP Young Adult 3-Month Survey
Supportive Relationships with Adults
J5.
Currently, in your life, are there responsible adults or mentors who…?
(Select yes or no for each).
Yes
No
(01)
(00)
a. Pay attention to what’s going on in your life?
b. Say something nice to you if you do something good?
c. You can talk to about personal problems?
d. You can go to if you are really upset about something?
e. Care about what happens to you?
f.
Help you reach your goals?
▌pg. 47
TLP Young Adult 3-Month Survey
Closing Screen
[
Closing1.
Thank you for taking this survey and being part of STARS!
After you submit your survey, we will [insert mode selected: email/text] your electronic gift
card to:
[insert gift card contact]
Closing1a.
If this information is wrong, click here: CHANGE INFORMATION
Closing 1b.
If this information is correct, click here to submit your survey: SUBMIT
Closing1c.
(Once you submit your survey, you cannot go back and change your answers.)
You will receive your electronic gift card within [xx] days.
If you have any questions about STARS, you can call the people who are doing the research
at (XXX) XXX-XXXX. This is a free call.
Thanks again!
You are a very important part of STARS!
▌pg. 48
| File Type | application/pdf |
| File Modified | 2015-05-29 |
| File Created | 2015-05-29 |