Form Youth Questinnaire Youth Questinnaire Youth Questinnaire

Form Approved

OMB No.: 0930-0357

Expiration Date: 03/31/2019

National Minority AIDS Initiative (MAI)

Substance Abuse/HIV Prevention Initiative

Youth Questionnaire

TO BE FILLED OUT BY THE LOCAL GRANT SITE DATA COLLECTOR

Participant ID #:

RESPONDENT OR PARTICIPANT: Before answering any of the questions, please make sure your name is correct. If incorrect, make the change in the box above. Do not write your name on any other page in this questionnaire. Thank you.

National Minority AIDS Initiative (MAI)

Substance Abuse/HIV Prevention Initiative

Youth Questionnaire

Funding for data collection supported by the

Center for Substance Abuse Prevention (CSAP),

Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS)

These questions are part of a data collection effort about how to prevent substance abuse and HIV infection. The questions are being asked of hundreds of other individuals throughout the United States. The data findings will be used to help prevention initiatives learn more about how to keep people from using drugs and getting infected with HIV.

Completing this questionnaire is voluntary. If you do not want to answer any of the questions, you do not have to. If you decide not to participate in this survey, it will have no effect on your participation in direct service programs. However, your answers are very important to us. Please answer the questions honestly—based on what you really do, think, and feel. Your answers will not be told to anyone in your family or community. Do not write your name anywhere on this questionnaire.

We would like you to work fairly quickly so that you can finish. Please work quietly by yourself. If you have any

questions or don’t understand something, let the data collector know.

We think you will find the questionnaire to be interesting and that you will like filling it out. Thank you very much for being an important part of this data collection effort!

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0298. Public reporting burden for this collection of information is estimated to average .20 hours per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Lane_{, Room 15E57-B, Rockville, MD 20857.}

INSTRUCTIONS
1. Answer each question by marking one of the answer circles. Some questions allow you to mark more than one answer. If you don’t find an answer that fits exactly, choose the one that comes closest. 2. Mark your answers carefully so we can tell which answer circle you chose. Do not mark between the circles. 3. It is very important that you answer each question truthfully. Your responses will not be helpful unless you tell the truth.
MARKING YOUR ANSWERS
Use a No. 2 black lead pencil.	EXAMPLES
Do not use an ink or ballpoint pen.
Make heavy dark marks that fill the circle completely.	Correct Marks:	Incorrect Marks:
Erase cleanly any answer you wish to change.
Make no stray marks on this questionnaire.

_{Record Management Section: To Be Completed by Designated Staff}

Grant ID

SP

Study Design Group (Select one)

 Intervention  Comparison

Participant ID

Date of Survey Administration

|___|___| / |___|___| / |___|___|___|___|

Month Day Year

Interview Type (select one)

• Baseline

• Exit

• Follow-up

• Testing Services Only (skip to section B)

A) Intervention Details

Type of Encounter (select all that apply)

 Individual  Group

Intervention Name(s) If the participant is receiving direct services from more than one intervention, please list each intervention below.

Total Number of Direct Service Encounters Count each encounter once; if you provide multiple services during an encounter it still only counts as one encounter

________ direct service encounters

Average Duration of Encounter(s) Round time to nearest five (5) minute interva)

________ minutes

B) Service Type(s) (select all that apply)

Testing Services

• HIV Testing

• Viral Hepatitis (VH) Testing

• Other STD Testing

Health Care Services

• VH Vaccination

• Primary Health Care Services

• Other Health Care Services

Individual Services

• Risk Reduction and/or Resiliency Strength Assessment

• Risk Reduction Counseling/Education

• HIV Testing Counseling

• Viral Hepatitis Testing Counseling

• Psycho-Social Counseling

• Substance Abuse Counseling

• Substance Abuse Education

• Opioid Prevention Education

• Opioid Prevention Counseling

• HIV Education

• STD Education

• Viral Hepatitis Education

• Mentoring (Peer or Other Type)

• Case Management Services

• All Other Individual Services

SPECIFY: _____________________________________

**Education may refer to population level information whereas counseling is clinical

Group Services

• Support Group

• Group Counseling/Therapy

• Skills Building Training/Education

• Health Education Classes/Sessions

• Viral Hepatitis Education

• HIV Education

• STD Education

• Substance Abuse Education

• Opioid Prevention Education

• Cultural Enhancement Activities

• Alternative Activities

• All Other Group Services

SPECIFY: _____________________________________

C) Referrals

Please mark any topic areas in which staff facilitated participant access to prevention, treatment, or recovery services. Select all that apply. If not applicable, leave blank.

• HIV Testing

• HIV Counseling

• HIV Treatment

• VH Testing

• VH Counseling

• VH Vaccination

• VH Treatment

• Substance Abuse Treatment 

• Prescription Drugs/Opioid Treatment

• Mental Health Services (excluding HIV & VH counseling)

• Health Care Services (excluding SA, HIV, prescription drug/opioid, & VH treatment)

• Medicated-Assisted Treatment (MAT)

---Please indicate the following:

• Number of days in MAT _____

• Type of medication received ____________ (specify)

• Supportive Housing

• Other Social Support (e.g., job placement, public health care safety net, insurance programs, etc.)

SPECIFY: _____________________________________

_{Section One: Facts About You}

First, we’d like to ask some questions about you. We are not going to use this information to identify you, but instead to talk about what different groups of people have to say. For example, what 12 year olds have to say, and how that may be different from what 17 year olds have to say.

1. What is your date of birth?

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

Month Year

2. Are you of Hispanic, Latino/a, or Spanish origin?

• Yes

• No

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

• White

• Black or African American

• American Indian or Alaska Native

• Asian

• Native Hawaiian or Other Pacific Islander

4. How do you describe yourself?

• Male

• Female

• Transgender

• I do not identify as male, female, or transgender

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

 Straight/Heterosexual

 Gay/Lesbian

 Bisexual

 Other

 Prefer not to say

6. Describe where you live.

• In my own home or apartment

• In a relative’s home

• In a group home

• In campus/dormitory housing

• In a foster home

• Homeless or in a shelter

• Other

7. Who do you live with? (Mark all that apply)

• Alone

• With parents

• With relatives other than parents

• With a foster family

• With roommates

• Other

8. Have you ever been suspended from school for drug or alcohol use?

• Yes

• No

9. In the past 30 days, how many times have you been arrested?

• _____ Times

• Refused

• Don’t know

10. Have you ever been informed of your HIV status (that is, whether or not you are HIV-positive) based on the result of an HIV test?

• Yes

• No

11. Have you ever been informed of your viral hepatitis (VH) status (that is, whether or not you are infected with a hepatitis virus) based on the result of a VH test?

• Yes

• No

12. Is there a doctor’s office, health center, or other similar place that you usually go to when you are sick?

• Yes

• No

_{Section Two: Attitudes & Knowledge}

In this section, we are going to ask how you feel about certain things, such as substance use and sexual behavior. Remember, your answers are private and will not be used to identify you.

13. What level of risk do you think people have of harming themselves physically or in other ways when they use tobacco once or twice a week? By tobacco, we mean menthol cigarettes, regular cigarettes, loose tobacco rolled into cigarettes or cigars, pipe tobacco, snuff, chewing tobacco, dipping tobacco, snus, and others.

 No risk

 Slight risk

 Moderate risk

 Great risk

 Don’t know or can’t say

14. What level of risk do you think people have of harming themselves physically or in other ways when they binge drink alcoholic beverages once or twice a week? Binge drinking is 5 or more alcoholic beverages at the same time or within a couple of hours of each other for males; 4 or more for females. By alcoholic beverage, we mean beer, wine, wine coolers, malt beverages, or hard liquor.

 No risk

 Slight risk

 Moderate risk

 Great risk

 Don’t know or can’t say

15. What level of risk do you think people have of harming themselves physically or in other ways when they use marijuana or hashish once or twice a week? Marijuana is sometimes called weed, blunt, hydro, grass, or pot. Hashish is sometimes called hash or hash oil.

 No risk

 Slight risk

 Moderate risk

 Great risk

 Don’t know or can’t say

16. What level of risk do you think people have of harming themselves physically or in other ways when they use non-prescription opioid drugs once or twice a week? By non-prescription opioid drugs we mean the illegal drug heroin and illicitly made synthetic opioids such as fentanyl.

 No risk

 Slight risk

 Moderate risk

 Great risk

 Don’t know or can’t say

17. What level of risk do you think people have of harming themselves physically or in other ways when they take prescription opioid drugs without a doctor’s order once or twice a week? By prescription opioid drugs, we mean pain relievers such as oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, morphine, methadone, tramadol, hydromorphone, oxymorphine, tapentadol.

 No risk

 Slight risk

 Moderate risk

 Great risk

 Don’t know or can’t say

18. What level of risk do you think people have of harming themselves physically when they inject drugs for nonmedical reasons?

 No risk

 Slight risk

 Moderate risk

 Great risk

 Don’t know or can’t say

19. I would be able to say no if a friend offered me a drink of alcohol.

 Strongly agree

 Agree

 Disagree

 Strongly disagree

20. I would be able to refuse if a friend offered me drugs, including marijuana.

 Strongly agree

 Agree

 Disagree

_{ Strongly disagree}

The next two questions are about SEX.

By sex or sexual activity, we mean a situation where two partners get sexually excited or aroused (turned on) by touching each other’s genitals (penis or vagina) or anus (butt) with their own genitals, hands, or mouth.

21. What level of risk do you think people have

of harming themselves if they have sex without a condom?

 No risk

 Slight risk

 Moderate risk

 Great risk

 Don’t know or can’t say

22. I could refuse if someone wanted to have sex without a condom.

 Strongly agree

 Agree

 Disagree

 Strongly disagree

_{Section Three: Behavior}

In this section we are going to ask you about substance use and sexual behavior. Remember, your answers will be kept private.

Tobacco, Alcohol, and Drugs

Think back over the past 30 days and record on how many days, if any, you did any of the following.

Over the past 30 days, how many days, if any, did you…		Definitions
Smoke cigarettes?	|___|___| Days  Don’t know or can’t say	By cigarettes, we mean menthol cigarettes, regular cigarettes, and loose tobacco rolled into cigarettes or cigars.
Use other tobacco products? Please exclude cigarettes.	|___|___| Days  Don’t know or can’t say	By other tobacco products, we mean pipe tobacco, snuff, chewing tobacco, dipping tobacco, snus, and others.
Use electronic vapor products?	|___|___| Days  Don’t know or can’t say	By electronic vapor products we mean Vapes, vaporizers, vape pens, hookah pens, electronic cigarettes (e-cigarettes or e-cigs), e-pipes or electronic nicotine delivery systems (ENDS). Some brand examples include JUUL, NJOY, Blu, Vuse, MarkTen, Logic, Vapin Plus, eGo, and Halo.
Drink alcohol? (any use at all)	|___|___| Days  Don’t know or can’t say	By alcohol, we mean beer, wine, wine coolers, malt beverages, or hard liquor.
Binge drink?	|___|___| Days  Don’t know or can’t say	Binge drinking is 5 or more alcoholic beverages at the same time or within a couple of hours of each other for males; 4 or more for females.
Use marijuana or hashish?	|___|___| Days  Don’t know or can’t say	Marijuana is sometimes called cannabis, weed, blunt, hydro, grass, or pot. Hashish is sometimes called hash or hash oil.
Use prescription opioid drugs without orders given to you by your doctor?	|___|___| Days  Don’t know or can’t say	By prescription opioid drugs, we mean pain relievers such as oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, morphine, methadone, tramadol, hydromorphone, oxymorphine, tapentadol.
Use other prescription drugs without orders given to you by your doctor? Please exclude prescription opioid drugs.	|___|___| Days  Don’t know or can’t say	By other prescription drugs, we mean substances like barbiturates, benzodiazepines, sedatives, hypnotics, non-benzo tranquilizers.
Use non-prescription opioid drugs?	|___|___| Days  Don’t know or can’t say	By non-prescription opioid drugs we mean the illegal drug heroin and illicitly made synthetic opioids such as fentanyl.
Use any other illegal drugs? Please exclude marijuana/hashish and non-prescription opioid drugs.	|___|___| Days  Don’t know or can’t say	By other illegal drugs, we mean substances like crack or cocaine, amphetamine or methamphetamine, hallucinogens (such as LSD/acid, Ecstasy/MDMA, PCP/angel dust, peyote), inhalants (sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, shoe polish).
Inject any drugs?	|___|___| Days  Don’t know or can’t say	Count only injections without orders from your doctor – those you had just to feel good or to get high.

Sexual Behavior

Now we’d like to ask you about your experience with sex. Remember, your answers will be kept private.

32. During the past 3 months, how many people did you have sex with?

 0 people
 1 person
 2 people
 3 people
 4 people
 5 people

 6 or more people

33. In the past 30 days, have you had sex after getting drunk or high?

 Yes

 No

34. During the past 30 days, have you had unprotected sex? If yes, select all that apply. Unprotected sex, is vaginal, oral, or anal sex without a barrier such as a condom

 No

 Yes, unprotected oral sex.

 Yes, unprotected vaginal sex.

 Yes, unprotected anal sex.

YOU ARE DONE!

Thank you for your help!