Download:
pdf |
pdf2020 NSDUH Clinical Validation Study (CVS)
Attachment CVS-1 – Follow-Up Clinical
Interview Questionnaire
SCID-5-RV Overview
1
Module Start Time: ____ ____ : ____ ____ AM/PM
I’m going to be asking you about problems or difficulties you may have had, and I’ll be
making some notes as we go along. Do you have any questions before we begin?
NOTE: Any current suicidal thoughts, plans, or actions should be thoroughly assessed by the
clinician and action taken if necessary.
Demographic Data
What’s your date of birth?
Are you married?
IF NO: Do you live with someone as if
you are married?
IF NO: Were you ever married?
GENDER: 1 Male
2 Female
3 Other (e.g.,
transgendered)
OV1
DOB: _____ _____ ______
month day
year
AGE: ___ ___
OV2
MARITAL STATUS (most recent):
1 Married or living with someone
as if married
2 Widowed
3 Divorced or annulled
4 Separated
5 Never married
OV4
How long have you been
(MARITAL STATUS)?
_______________________________
IF EVER MARRIED: How many times
have you been married?
_______________________________
Do you have any children?
IF YES: How many? (What are their
ages?)
With whom do you live? (How many
children under the age of 18 live in your
household?)
In what city, town, or neighborhood do
you live?
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
OV3
SCID-5-RV Overview
In what kind of place do you live?
(A house, an apartment, a shelter, a
halfway house, or some other living
arrangement? Are you homeless?)
2
_______________________________
_______________________________
_______________________________
Education and Work History
How far did you go in school?
IF FAILED TO COMPLETE A PROGRAM
IN WHICH THEY WERE ENROLLED:
Why did you leave?
What kind of work do you do?
(Do you work outside of your home?)
Have you always done that kind of
work?
IF NO: What other kind of work have
you done in the past?
What’s the longest you’ve worked at
one place?
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
SCID-5-RV Overview
3
Are you currently employed (getting
paid)?
PRIMARY EMPLOYMENT STATUS:
1 Full-time job
2 Part-time job
IF YES: Do you work part-time or fulltime?
3 Keeping house or care giving
full-time
IF PART-TIME: How many hours do
4 In school/training
you typically work each week?
5 Retired
(Why do you work part-time instead
6 Unemployed, looking for work
of full-time?)
7 Unemployed, not looking for
work
8 Disabled
IF NO: Why is that? When was the last
time you worked? How are you
supporting yourself now?
IF DISABLED: Are you currently
receiving disability payments?
What are you receiving disability
for?
IF EMPLOYED: How long have you
worked at your current job?
IF LESS THAN 6 MONTHS:
Why did you leave your last job?
IF UNKNOWN: Has there ever been a
period of time when you were unable to
work or go to school?
IF YES: Why was that?
Have you ever been arrested, involved in
a lawsuit, or had other legal trouble?
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
OV6
SCID-5-RV Overview
4
Current and Past Periods of Psychopathology
Have you ever seen anybody for
emotional or psychiatric problems?
IF YES: What was that for? (What
treatment did you get? Any
medications? When was that? When
was the first time you ever saw
someone for emotional or psychiatric
problems?)
______________________________
______________________________
______________________________
______________________________
Have you ever seen anybody for
problems with alcohol or drugs?
IF YES: What was that for? (What
treatment[s] did you get? Any
medications? When was that?)
Have you ever attended a self-help
group, like Alcoholics Anonymous,
Gamblers Anonymous, or Overeaters
Anonymous?
IF YES: What was that for? When was
that?
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
SCID-5-RV Overview
5
Hospitalization History
Have you ever been in a hospital for
treatment of a medical problem?
Number of previous hospitalizations
(Do not include transfers): ____
IF YES: What was that for?
Number of previous hospitalizations
(Do not include transfers): ____
______________________________
______________________________
Thinking back over your whole life, when
were you the most upset? (Why? What
was that like? How were you feeling?)
______________________________
______________________________
Other Current Problems
Have you had any problems in the past
month? (How are things going at work, at
home, and with other people?)
______________________________
______________________________
______________________________
What has your mood been like?
______________________________
______________________________
How has your physical health been?
(Have you had any medical problems?)
Do you take any medication, vitamins,
nutritional supplements, or natural
health remedies (other than those you’ve
already told me about?)
IF YES: How much and how often do
you take (MEDICATION)? (Has there
been any change in the amount you
have been taking?)
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
OV7
SCID-5-RV Overview
How have you been spending your free
time?
Who do you spend time with?
6
______________________________
______________________________
______________________________
______________________________
______________________________
Past Year Alcohol and Drug Use
Now I would like to ask you about your
alcohol use during the past year.
How much do you usually drink?
IF NEVER DRANK ALCOHOL IN THE
PAST YEAR, SKIP TO NEXT PAGE.
______________________________
______________________________
______________________________
Have there been any times in the past
year when you had five or more drinks?
______________________________
When in the past year were you drinking
the most?
______________________________
During that time. . .
how much were you drinking?
what were you drinking? Beer? Wine?
Hard liquor?
How often were you drinking this much?
______________________________
______________________________
______________________________
______________________________
During that time . . .
did your drinking cause problems for
you?
did anyone object to your drinking?
When you drink, who are you usually
with? (Are you usually alone or out with
other people?)
______________________________
______________________________
______________________________
SCID-5-RV Overview
Now I’d like to ask you about your
use of drugs or medicines during the
past 12 months.
During the past 12 months, have you
taken any pills to calm you down,
help you relax, or help you sleep?
(Drugs like Valium, Xanax, Ativan,
Klonopin, Ambien, Sonata, or
Lunesta?)
7
FOR EACH SPECIFIC DRUG IN THE
CLASS, INDICATE USE PATTERN (e.g.,
During the past 12 months, when were you
taking (SUBSTANCE) the most? How long did
that period last? During that time, how often
were you taking it? How much were you
using?)
Sedatives-hypnotics-anxiolytics:
1
3 OV8
____________________________________
____________________________________
____________________________________
IF PRESCRIBED: During the past 12
months, did you get hooked or
become dependent on (PRESCRIBED
DRUG)? (During the past 12 months)
did you take more of it than was
prescribed or run out of your
prescription early?) (During the past
12 months) did you have to go to
more than one doctor to make sure
you didn’t run out?)
During the past 12 months, have you
used marijuana (“pot,” “grass,”
“weed”), hashish (“hash”), THC, K2,
or “spice”?
Cannabis:
1
3 OV9
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
OV9a
IF OV9 = 3, WHICH DRUGS WERE
USED IN PAST YEAR?
1
2
3
1 = Did not use during past 12 months
Marijuana and/or hashish and/or
THC only
K2, and/or “spice” only
Both marijuana/hashish/THC and
K2/”spice”
3 = Did use during past 12 months
SCID-5-RV Overview
8
(During the past 12 months,) have
OV10
Stimulants:
1
3
you used any stimulants or “uppers”
___________________________________
to give you more energy, keep you
alert, lose weight, or help you focus?
___________________________________
(Drugs like speed, methamphetamine,
crystal meth, “crank,” Ritalin or
___________________________________
methylphenidate, Dexedrine, Adderall
___________________________________
or amphetamine or prescription diet
pills?)
___________________________________
IF PRESCRIBED: During the past 12
___________________________________
months, did you get hooked or
become dependent on (PRESCRIBED
___________________________________
DRUG)? (During the past 12 months)
did you take more of it than was
prescribed or run out of your
prescription early?) (During the past
12 months) did you have to go to
more than one doctor to make sure
you didn’t run out?)
How about cocaine or “crack”?
Have you used heroin, methadone, or
OV11
Opioids:
1
3
Fentanyl during the past 12 months?
___________________________________
How about prescription pain killers?
(Drugs like morphine, codeine,
___________________________________
Percocet, Percodan, Oxycontin,
Tylox, or oxycodone, Vicodin, Lortab, ___________________________________
Lorcet or hydrocodone, suboxone or
___________________________________
buprenorphine?)
___________________________________
IF PRESCRIBED: During the past 12
months, did you get hooked or
become dependent on (PRESCRIBED
DRUG)? (During the past 12 months)
did you take more of it than was
prescribed or run out of your
prescription early?) (During the past
12 months) did you have to go to
more than one doctor to make sure
you didn’t run out?)
1 = Did not use during past 12 months
3 = Did use during past 12 months
SCID-5-RV Overview
During the past 12 months, have
you used any drugs to “trip” or
heighten your senses? (Drugs like
LSD, “acid,” peyote, mescaline,
psilocybin, Ecstasy [MDMA,
“molly”], bath salts, DMT or other
hallucinogens?)
How about PCP (“angel dust,”
“peace pill”) or ketamine (“Special
K,” “Vitamin K”)?
9
Hallucinogens/PCP:
1
3
____________________________________
OV12
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
Have you used glue, paint, or
correction fluid, gasoline, or other
inhalants to get high during the
past 12 months?
Inhalants:
1
3
____________________________________
What about nitrous oxide (laughing
gas, “whippets”), nitrites (amyl
nitrite, butyl nitrite), “poppers,”
“snappers?
____________________________________
OV13
____________________________________
____________________________________
____________________________________
____________________________________
Module End Time: ____ ____ : ____ ____ AM/PM
1 = Did not use during past 12 months
3 = Did use during past 12 months
SCID-5-RV Overview
10
(This page is intentionally blank.)
1
SCID-5-RV SUD
SUBSTANCE USE DISORDERS
Module Start Time: ____ ____ : ____ ____ AM/PM
*PAST 12-MONTH ALCOHOL USE
DISORDER*
IF R HAS NOT DRUNK ON AT LEAST 1 OCCASION IN THE PAST YEAR, CIRCLE THE
1 AND SKIP TO *NON-ALCOHOL SUBSTANCE USE DISORDERS*, PAGE 7
3 SU1
1
IF R HAS DRUNK AT LEAST ONCE IN THE PAST YEAR, CIRCLE THE 3 AND CONTINUE
TO NEXT PAGE.
ALCOHOL USE DISORDER CRITERIA
I’d now like to ask you some more
questions about your drinking since
(1 YEAR AGO) . . .
A. A problematic pattern of
alcohol use, leading to
clinically significant
impairment or distress, as
manifested by at least two
of the following occurring
within a 12-month period:
NOTE: THE DSM-IV
EXAMPLES THAT WERE
OMITTED IN DSM-5 HAVE
BEEN RESTORED HERE.
During the past year, have you found that
once you started drinking you ended up
drinking much more than you intended to?
For example, you planned to have only one
or two drinks, but you ended up having
many more. (Tell me about that. How often
did this happen?)
1.
Alcohol is often taken in ?
larger amounts OR over
a longer period than
was intended.
1
2
3
IF NO: What about drinking for a
much longer period of time than
you were intending to?
__________________________________
__________________________________
__________________________________
?=Inadequate information
1=Absent or false
2=Subthreshold
3=Threshold or true
SU2
2
SCID-5-RV SUD
2.
There is a persistent
desire OR
unsuccessful efforts to
cut down or control
alcohol use.
?
1
2
3
SU3
3.
A great deal of time is
spent in activities
necessary to obtain
alcohol, use alcohol,
or recover from its
effects.
?
1
2
3
SU4
4.
Craving, or a strong
desire or urge to use
alcohol.
?
1
2
3
SU5
1=Absent or false
2=Subthreshold
During the past year, have you wanted to
stop, cut down, or control your drinking?
IF YES: How long did this desire to
stop, cut down, or control your drinking
last? Did you actually stop drinking
altogether?
IF NO: During the past year did you
ever try to cut down, stop, or control
your drinking? How successful were
you? (Did you make more than one
attempt to stop, cut down, or control
your drinking?)
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
Have you spent a lot of time drinking, being
drunk, or hung over? (How much time?)
__________________________________
__________________________________
__________________________________
Have you had a strong desire or urge to
drink in between those times when you
were drinking? (Has there been a time
when you had such strong urges to have a
drink that you had trouble thinking about
anything else?)
IF NO: How about having a strong
desire or urge to drink when you were
around bars or around people with
whom you go drinking?
__________________________________
__________________________________
__________________________________
?=Inadequate information
3=Threshold or true
3
SCID-5-RV SUD
During the past year, since (1 YEAR AGO),
have you missed work or school or often
arrived late because you were intoxicated,
high, or very hung over?
5.
IF NO: How about doing a bad job at
work or school, or failing courses or
flunking out of school because of your
drinking?
IF NO: How about getting in trouble
at work or school because of your
use of alcohol?
IF NO: How about not taking
care of things at home because
of your drinking, like (IF
YOUTH RESPONDENT WHO IS
NOT INDEPENDENT AND
DOES NOT HAVE OTHER
DEPENDENTS: watching kids
or babysitting, doing
household chores/ OTHERS:
making sure there is food and
clean clothes for your family
and making sure your children
go to school and get medical
care? How about not paying
your bills?)
Recurrent alcohol use ?
resulting in a failure to
fulfill major role
obligations at work,
school, or home [(e.g.,
repeated absences or
poor work
performance related to
alcohol use; alcoholrelated absences,
suspensions, or
expulsions from
school; neglect of
children or
household)].
1
2
3
SU6
IF YES TO ANY: How often?
_________________________________
_________________________________
_________________________________
_________________________________
?=Inadequate information
1=Absent or false
2=Subthreshold
3=Threshold or true
4
SCID-5-RV SUD
Has your drinking caused problems with
other people, such as family members,
friends, or people at work? (Have you
found yourself regularly getting into
arguments about what happens when you
drink too much? Have you gotten into
physical fights when you were drunk?)
6.
Continued alcohol use
despite having
persistent or recurrent
social or interpersonal
problems caused or
exacerbated by the
effects of alcohol
[(e.g., arguments with
spouse about
consequences of
intoxication, physical
fights)].
?
1
2
3
SU7
7.
Important social,
occupational, or
recreational activities
given up or reduced
because of alcohol
use.
?
1
2
3
SU8
8.
Recurrent alcohol use
in situations in which it
is physically
hazardous (e.g.,
driving an automobile
or operating a
machine when
impaired by alcohol
use)
?
1
2
3
SU9
IF YES: Have you kept on drinking
anyway?
__________________________________
__________________________________
Have you had to give up or reduce the time
you spent at work or school, with family or
friends, or on things you like to do (like
sports, cooking, other hobbies) because
you were drinking or hungover?
__________________________________
__________________________________
__________________________________
During the past year, since (1 YEAR AGO),
have you ever had a few drinks right before
doing something that requires coordination
and concentration like driving, boating,
climbing on a ladder, or operating heavy
machinery?
IF YES: Would you say that the amount
you had to drink affected your
coordination or concentration so that it
was more likely that you or someone
else could have been hurt?
IF YES AND UNKNOWN: How
many times? (When?)
__________________________________
__________________________________
?=Inadequate information
1=Absent or false
2=Subthreshold
3=Threshold or true
5
SCID-5-RV SUD
Has your drinking caused you any
9.
problems like making you very depressed
or anxious? How about putting you in a
“mental fog,” making it difficult for you to
sleep, or making it so you couldn’t recall
what happened while you were drinking?
Has your drinking caused significant
physical problems or made a physical
problem worse, like stomach ulcers, liver
disease, or pancreatitis?
Alcohol use is continued
despite knowledge of
having a persistent or
recurrent physical or
psychological problem that
is likely to have been
caused or exacerbated by
alcohol [(e.g., continued
drinking despite
recognition that an ulcer
was made worse by
alcohol consumption)].
?
1
2
3
SU10
Tolerance, as defined by
either of the following:
?
1
2
3
SU11
IF YES TO EITHER OF ABOVE: Have
you kept on drinking anyway?
_________________________________
_________________________________
_________________________________
Have you found that you needed to drink
much more in order to get the feeling you
wanted than you did when you first
started drinking?
IF YES: How much more?
IF NO: What about finding that when
you drank the same amount, it had
much less effect than before? (How
much less?)
10
a. A need for markedly
increased amounts of
alcohol to achieve
intoxication or desired
effect.
b. Markedly diminished effect
with continued use of the
same amount of alcohol)
_________________________________
_________________________________
_________________________________
_________________________________
?=Inadequate information
1=Absent or false
2=Subthreshold
3=Threshold or true
6
SCID-5-RV SUD
During the past year, since (1 YEAR
AGO), have you had any withdrawal
symptoms, in other words, feeling sick
when you cut down or stopped drinking?
IF YES: What symptoms did you have?
(Sweating or a racing heart? Your
hand[s] shaking? Trouble sleeping?
Feeling nauseated or vomiting?
Feeling agitated? Feeling anxious?
How about having a seizure or seeing,
feeling, or hearing things that weren’t
really there?)
IF NO: During the past year, have you
ever started the day with a drink, or did
you often drink or take some other
drug or medication to keep yourself
from getting the shakes or becoming
sick?
_________________________________
_________________________________
_________________________________
_________________________________
11. Withdrawal, as manifested
by either of the following:
a.
?
1
2
3
SU12
At least TWO of the
following developing within
several hours to a few
days after the cessation of
(or reduction in) alcohol
use:
autonomic hyperactivity
(e.g., sweating or pulse
rate greater than 100
bpm)
increased hand tremor
insomnia
nausea or vomiting
psychomotor agitation
anxiety
generalized tonic-clonic
seizures
transient visual, tactile,
or auditory
hallucinations or
illusions
b. Alcohol (or a closely
related substance such as
a benzodiazepine) is taken
to relieve or avoid
withdrawal symptoms
_________________________________
SU13
AT LEAST TWO ALCOHOL
USE DISORDER ITEMS
CODED “3” DURING THE
PAST 12 MONTHS
SU14
?=Inadequate information
1=Absent or false
2=Subthreshold
3=Threshold or true
7
SCID-5-RV SUD
*PAST 12-MONTH NON-ALCOHOL SUBSTANCE USE DISORDER*
REVIEW HISTORY OF DRUG USE ON PAGES 7-9 OF OVERVIEW. IF R DENIES ANY PAST
YEAR DRUG USE AT ALL IN OVERVIEW, CHECK HERE ___ AND GO TO END OF
INTERVIEW MODULE
SU15
FOR ALL CLASSES IN WHICH THE DRUG HAS BEEN USED AT LEAST ONCE IN THE PAST
12 MONTHS (BASED ON OVERVIEW), CIRCLE THE APPROPRIATE ROW HEADER (DRUG
CLASS NAMES) ON PAGES 8 – 14.
?=Inadequate information
1=Absent or false
2=Subthreshold
3=Threshold or true
8
SCID-5-RV SUD
SUD CRITERIA
Now I'd now like to ask you some more
questions about your use of (DRUG
CLASS[ES] CIRCLED IN ROW HEADERS)
in the past 12 months, since (1 YEAR
AGO).
A. A maladaptive pattern of
substance use, leading to
clinically significant
impairment or distress, as
manifested by at least two of
the following occurring within
a twelve-month period:
During the past year, have you found
that once you started using (DRUG) you
ended up using much more than you
intended to? For example, you planned
to have (SMALL AMOUNT OF DRUG) but
you ended up having much more. (Tell
me about that. How often did that
happen?)
1. The substance is often taken SED ?
in larger amounts OR over a
longer period than was
CAN ?
intended.
STIM ?
1
2
3 SU16
1
2
3 SU17
1
2
3 SU18
OPI
?
1
2
3 SU19
HAL
?
1
2
3 SU20
INH
?
1
2
3 SU21
SED
?
1
2
3 SU22
CAN
?
1
2
3 SU23
IF YES: How long did this desire to
stop, cut down, or control your use
of (DRUG) last?
STIM ?
1
2
3 SU24
OPI
?
1
2
3 SU25
IF NO: During the past year, did you
ever try to cut down, stop, or control
your use of (DRUG)? How successful
were you? (Did you make more than
one attempt to stop, cut down, or
control your use of (DRUG)?
HAL
?
1
2
3 SU26
INH
?
1
2
3 SU27
IF NO: What about using (DRUG)
over a much longer period of time
than you were intending to?
__________________________________
__________________________________
__________________________________
During the past year, have you wanted
to stop or cut down using (DRUG), or
control your use of (DRUG)?
2.
There is a persistent desire
OR unsuccessful efforts to
cut down or control
substance use.
__________________________________
__________________________________
__________________________________
?=Inadequate information
1=Absent or false
2=Subthreshold
3=Threshold or true
9
SCID-5-RV SUD
During the past 12 months, have you
spent a lot of time getting (DRUG) or
has it taken a lot of time for you to get
over the effects of (DRUG)? (How much
time?)
__________________________________
3.
?
1
2
3 SU28
?
1
2
3 SU29
?
1
2
3 SU30
?
1
2
3 SU31
HAL
?
1
2
3 SU32
INH
?
1
2
3 SU33
Craving, or a strong desire SED
or urge to use the
CAN
substance
?
1
2
3 SU34
?
1
2
3 SU35
STIM
?
1
2
3 SU36
OPI
?
1
2
3 SU37
HAL
?
1
2
3 SU38
INH
?
1
2
3 SU39
A great deal of time is
SED
spent in activities
necessary to obtain the
CAN
substance, use the
substance, or recover from STIM
its effects.
OPI
__________________________________
__________________________________
Have you had a strong desire or urge to
use (DRUG) in between those times
when you were using (DRUG)? (Has
there been a time when you had such
strong urges to use (DRUG) that you
had trouble thinking about anything
else?)
4.
IF NO: How about having a strong
desire or urge to use (DRUG) when
you were around people with whom
you used (DRUG)?
__________________________________
__________________________________
__________________________________
?=Inadequate information
1=Absent or false
2=Subthreshold
3=Threshold or true
10
SCID-5-RV SUD
During the past year, have you missed
work or school or often arrived late
because you were intoxicated, high, or
recovering from the night before?
IF NO: How about doing a bad job at
work or school, or failing courses or
flunking out of school because of
your use of (DRUG)?
IF NO: How about getting into
trouble at work or school because
of your use of (DRUG)?
5.
Recurrent substance use
resulting in a failure to fulfill
major role obligations at
work school, or home
[(e.g., repeated absences
or poor work performance
related to substance use;
substance-related
absences, suspensions, or
expulsions from school;
neglect of children or
household)].
SED
?
1
2
3 SU40
CAN
?
1
2
3 SU41
STIM
?
1
2
3 SU42
OPI
?
1
2
3 SU43
HAL
?
1
2
3 SU44
INH
?
1
2
3 SU45
IF NO: How about not taking care
of things at home because of
your use of (DRUG), like (IF
YOUTH RESPONDENT WHO IS
NOT INDEPENDENT AND DOES
NOT HAVE OTHER
DEPENDENTS: watching kids or
babysitting, doing household
chores/OTHERS: making sure
there is food and clean clothes
for your family and making sure
your children go to school and
get medical care? How about not
paying your bills?)
IF YES TO ANY: How often?
__________________________________
__________________________________
__________________________________
?=Inadequate information
1=Absent or false
2=Subthreshold
3=Threshold or true
11
SCID-5-RV SUD
During the past year, has your use of
(DRUG) caused problems with other
people, such as with family members,
friends, or people at work? (Have you
found yourself regularly getting into
arguments about your [DRUG] use?
Have you gotten into physical fights
when you were taking [DRUG]?)
6.
IF YES: Have you kept on using
(DRUG) anyway?
__________________________________
Continued substance use
despite having persistent or
recurrent social or
interpersonal problems
caused or exacerbated by
the effects of the substance
[(e.g., arguments with
spouse about
consequences of
intoxication, physical
fights)].
SED
?
1
2
3 SU46
CAN
?
1
2
3 SU47
STIM
?
1
2
3 SU48
OPI
?
1
2
3 SU49
HAL
?
1
2
3 SU50
INH
?
1
2
3 SU51
?
1
2
3 SU52
?
1
2
3 SU53
?
1
2
3 SU54
__________________________________
__________________________________
Have you had to give up or reduce the
time you spent at work or school, with
family or friends, or on your hobbies
because you were using (DRUG)
instead?
7.
Important social,
SED
occupational, or
recreational activities given CAN
up or reduced because of
substance use.
STIM
__________________________________
OPI
?
1
2
3 SU55
__________________________________
HAL
?
1
2
3 SU56
__________________________________
INH
?
1
2
3 SU57
?=Inadequate information
1=Absent or false
2=Subthreshold
3=Threshold or true
12
SCID-5-RV SUD
During the past year, have you ever
gotten high before doing something that
requires coordination and concentration
like driving, boating, climbing on a
ladder, or operating heavy machinery?
8.
IF YES: (FOR SUBSTANCES OTHER
THAN STIMULANTS): Would you say
that your use of (DRUG) affected
your coordination or concentration
so that it was more likely that you or
someone else could have been hurt?
Recurrent substance use in
situations in which it is
physically hazardous [(e.g.,
driving an automobile or
operating a machine when
impaired by substance
use)].
SED
?
1
2
3 SU58
CAN
?
1
2
3 SU59
STIM
?
1
2
3 SU60
OPI
?
1
2
3 SU61
HAL
?
1
2
3 SU62
INH
?
1
2
3 SU63
SED
?
1
2
3 SU64
CAN
?
1
2
3 SU65
STIM
?
1
2
3 SU66
OPI
?
1
2
3 SU67
HAL
?
1
2
3 SU68
INH
?
1
2
3 SU69
IF YES: (FOR STIMULANTS ONLY):
Would you say that your being high
on (STIMULANT) made you drive
recklessly like driving very fast or
taking unnecessary risks?
IF YES TO EITHER AND
UNKNOWN: How many times?
__________________________________
__________________________________
__________________________________
Has your use of (DRUG) during the past
year caused you any problems like
making you very depressed, irritable,
anxious, paranoid, or extremely
agitated? What about triggering panic
attacks, making it difficult for you to fall
or stay asleep, putting you into a
“mental fog,” or making it so you
couldn’t recall what happened while you
were using (DRUG)?
Has your use of (DRUG) caused physical
problems, like heart palpitations,
coughing or trouble breathing,
constipation, or skin infections?
9.
Substance use is continued
despite knowledge of
having a persistent or
recurrent physical or
psychological problem that
is likely to have been
caused or exacerbated by
the substance [(e.g.,
recurrent cocaine use
despite recognition of
cocaine-related
depression)].
IF YES TO EITHER OF ABOVE: Have
you kept on using (DRUG) anyway?
__________________________________
__________________________________
__________________________________
?=Inadequate information
1=Absent or false
2=Subthreshold
3=Threshold or true
13
SCID-5-RV SUD
Have you found that you needed to use
much more (DRUG) in order to get the
feeling you wanted than when you first
started using it?
IF YES: How much more?
IF NO: What about finding that when
you used the same amount, it had
much less effect than before?
?
1
2
3 SU70
CAN
A need for markedly
increased amounts of the
STIM
substance to achieve
intoxication or desired
OPI
effect.
?
1
2
3 SU71
?
1
2
3 SU72
?
1
2
3 SU73
Markedly diminished
HAL
effect with continued use
of the same amount of
INH
the substance.
?
1
2
3 SU74
?
1
2
3 SU75
?
1
2
3 SU76
CAN
?
1
2
3 SU77
STIM
?
1
2
3 SU78
?
1
2
3 SU79
10. Tolerance, as defined by
either of the following:
a.
b.
SED
IF PRESCRIBED MEDICATION: Were you
taking (DRUG) exactly as your doctor
told you to? (Did you ever take more of Note: If opioids,
it than was prescribed or run out of your
sedative/hypnotic/anxiolytic
prescription early? Did you ever go to
medications, or stimulant
more than one doctor in order to get the
medications are taken
amount of medication you wanted?)
solely under appropriate
medical supervision, this
__________________________________
criterion is not considered
to be met.
__________________________________
__________________________________
THE FOLLOWING ITEM DOES NOT
APPLY TO INHALANTS, OR
HALLUCINOGENS/PCP.
During the past year, have you had any
withdrawal symptoms, in other words
felt sick when you cut down or stopped
using (DRUG)?
IF YES: What symptoms did you
have? REFER TO LIST OF
WITHDRAWAL SYMPTOMS ON
PAGES 15-16.
11. Withdrawal, as manifested
SED
by either of the following:
a. The characteristic
withdrawal syndrome for
the substance (see pages
15-16).
OPI
b. The same (or a closely
related) substance is taken
to relieve or avoid
withdrawal symptoms
IF NO: After not using (DRUG) for a
few hours or more, did you
sometimes use it or something like it Note: This criterion does not
apply to inhalants, PCP, or
to keep yourself from getting sick
hallucinogens.
with (WITHDRAWAL SXS)?
Note: If opioids,
__________________________________
sedatives/hypnotics/anxioly
tics medications, or
__________________________________
stimulant medications are
taken solely under
__________________________________
appropriate medical
supervision, this criterion is
not considered to be met.
?=Inadequate information
1=Absent or false
2=Subthreshold
3=Threshold or true
14
SCID-5-RV SUD
PAST YEAR SUBSTANCE USE
DISORDER
AT LEAST TWO SUBSTANCE
USE DUSORDER ITEMS
CODED “3” FOR THE PAST 12
MONTHS
SED
1
3
SU80
CAN
1
3
SU81
STIM
1
3
SU82
OPI
1
3
SU83
HAL
1
3
SU84
INH
1
3
SU85
Substance Use
Disorder
FOR EACH DRUG CLASS CODED AS 3, INDICATE SEVERITY:
3 = Severe (6+ sxs.); 2 = Moderate (4-5 sxs.); 1 = Mild (2-3 sxs.)
SED
CAN
STIM
OPI
HAL
INH
3
3
3
3
3
3
2
2
2
2
2
2
1
1
1
1
1
1
SU86
SU87
SU89
SU90
SU91
SU88
Module End Time: ____ ____ : ____ ____ AM/PM
?=Inadequate information
1=Absent or false
2=Subthreshold
3=Threshold or true
15
SCID-5-RV SUD
LIST OF WITHDRAWAL SYMPTOMS (FROM DSM-5 CRITERIA)
Listed below are the characteristic withdrawal symptoms for those classes of psychoactive
substances for which a withdrawal syndrome has been identified. (NOTE: A specific
withdrawal syndrome has not been identified for HALLUCINOGENS/PCP OR INHALANTS).
Withdrawal symptoms may occur following the cessation of prolonged moderate or heavy
use of a psychoactive substance or a reduction in the amount used.
SEDATIVES, HYPNOTICS, AND ANXIOLYTICS:
Two (or more) of the following, developing within several hours to a few days after cessation
(or reduction) of sedative, hypnotic, or anxiolytic use, that has been prolonged:
(1) Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100)
(2) Hand tremor
(3) Insomnia
(4) Nausea or vomiting
(5) Transient visual, tactile, or auditory hallucinations or illusions
(6) Psychomotor agitation
(7) Anxiety
(8) Grand mal seizures
CANNABIS:
Three (or more) of the following signs and symptoms developing within approximately one
week after cessation of cannabis use that has been heavy and prolonged (i.e., usually daily
or almost daily use over a period of at least a few months):
(1) Irritability, anger, or aggression.
(2) Nervousness or anxiety.
(3) Sleep difficulty (e.g., insomnia, disturbing dreams).
(4) Decreased appetite or weight loss.
(5) Restlessness.
(6) Depressed mood.
(7) At least one of the following physical symptoms causing significant discomfort:
abdominal pain, shakiness/tremors, sweating, fever, chills, or headache.
STIMULANTS/COCAINE
Dysphoric mood AND two (or more) of the following physiological changes, developing
within a few hours to several days after cessation (or reduction of substance use which has
been heavy and prolonged):
(1) Fatigue
(2) Vivid, unpleasant dreams
(3) Insomnia or hypersomnia
(4) Increased appetite
(5) Psychomotor retardation or agitation
?=Inadequate information
1=Absent or false
2=Subthreshold
3=Threshold or true
16
SCID-5-RV SUD
OPIOIDS:
Three (or more) of the following, developing within minutes to several days after cessation of
(or reduction in) opioid use which has been heavy and prolonged (i.e., several weeks or
longer) or after administration of an opioid antagonist after a period of opioid use:
(1) Dysphoric mood
(2) Nausea or vomiting
(3) Muscle aches
(4) Lacrimation or rhinorrhea (runny nose)
(5) Pupillary dilation, piloerection (“goose bumps”), or sweating
(6) Diarrhea
(7) Yawning
(8) Fever
(9) Insomnia
?=Inadequate information
1=Absent or false
2=Subthreshold
3=Threshold or true
End of Interview/Interviewer Debriefing Module
1
Module Start Time: ____ ____ : ____ ____ AM/PM
That was my last question. Thank you for your time and cooperation in completing this
interview.
Sometimes the personal issues we’ve discussed cause people to become upset and in
need of speaking with a counselor. If you are feeling upset or disturbed by the personal
issues we have discussed in this interview and would like to talk with someone about
your feelings, we suggest you call your doctor, counselor, or other treatment provider if
you are currently under someone’s care. If not, there is also a National Lifeline Network
number you can call. This number is on the receipt for the $30 you received for this
interview from the interviewer who met with you earlier. Do you still have that receipt?
IF NO: We would like to give you the hotline number for the National Lifeline Network,
where counselors are available to talk at any time of the day or night. They can also give
you information about (additional) mental health services in your area. Their toll-free
number is 1-800-273-8255.
IF YES: OK. Please know that counselors at the National Lifeline Network are available to
talk at any time of the day or night. They can also give you information about mental
health services in your area if you request that information.
Do you have any additional questions you’d like to ask me before we end our call?
Thank you again for your time and have a good (day/afternoon/evening).
Module End Time: ____ ____ : ____ ____ AM/PM
End of Interview/Interviewer Debriefing Module
2
INTERVIEWER DEBRIEFING SECTION
Distressed Respondent Protocol
Was the Distressed Respondent Protocol used?
No
Yes
1
3
EI1
EI2
Specify problems:
_____________________________________________________
_____________________________________________________
_____________________________________________________
Cognitive Impairment Screener
Was the Short-Blessed Scale used?
No
Yes
1
3
EI3
IF EI3 = 1,
SKIP EI4
and EI4a
EI4
Specify problems:
_____________________________________________________
_____________________________________________________
_____________________________________________________
Indicate score on the Short-Blessed Scale.
________
(0-28)
EI4a
End of Interview/Interviewer Debriefing Module
3
Comprehension Rating
Estimate the respondent’s understanding of the interview:
Circle
Response
No difficulty—no language or comprehension problem
1
Just a little difficulty—almost no language or comprehension
problems
2
A fair amount of difficulty—some language or comprehension
problems
3
A lot of difficulty—considerable language or comprehension
problems
4
Extreme problems with language or comprehension
5
EI5
EI6
Specify problems:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Cooperation Rating
Rate how cooperative the respondent was during the interview:
Circle
Response
Very cooperative
1
Fairly cooperative
2
Not very cooperative
3
Uncooperative
4
Openly hostile
5
Specify problems:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
EI7
EI8
End of Interview/Interviewer Debriefing Module
4
Privacy Rating
Indicate on a scale of 1 through 5 how private the interview was:
Circle
Response
Completely private—no one who could overhear any part of the
interview appeared present
1
Minor distractions—other person(s) seemed present or listening
for less than 1/3 of the time
2
Moderate distractions—others seemed present about 1/3 of the
time
3
Severe distractions—interruptions of privacy more than half the
time
4
Constant presence of other person(s)
5
EI9
EI10
Specify problems:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Global Validity Rating
Rate the overall validity of the interview:
Circle
Response
Excellent—no reason to suspect invalid responses
1
Good—factors present that may adversely affect validity
2
Fair—factors present that definitely reduce validity
3
Poor—substantially reduced validity
4
Invalid responses, severely impaired mental status, or possible
deliberate “faking bad” or “faking good”
5
Specify problems:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
EI11
EI12
End of Interview/Interviewer Debriefing Module
5
CLINICAL SUPERVISOR’S RATINGS
Clinical Supervisor: Global Validity Rating
Rate the overall validity of the interview:
Circle
Response
Excellent—no reason to suspect invalid responses
1
Good—factors present that may adversely affect validity
2
Fair—factors present that definitely reduce validity
3
Poor—substantially reduced validity
4
Invalid responses, severely impaired mental status, or possible
deliberate “faking bad” or “faking good”
5
Specify problems:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
EI13
EI14
This page has been intentionally left blank.
2020 NSDUH Clinical Validation Study (CVS)
Attachment CVS-2 – Follow-Up Clinical
Interview Recruitment Scripts
NSDUH Clinical Validation Study Recruitment Scripts
NSDUH Clinical Validation Study (CVS) recruitment occurs at the end of the main
NSDUH interview. If a respondent is selected for the CVS, the following recruitment
instructions and scripts appear on the laptop and are read to the respondent by the field
interviewer.
Adult CVS Recruitment Script in Main Interview (Age 18+)
You have been selected to participate in one additional study for the U.S. Department of
Health and Human Services. For this study, we are interested in interviewing a wide
variety of individuals to learn more about how different people think and talk about their
use or non-use of alcohol and drugs. The interview will include additional questions
about your knowledge of and experiences with alcohol and drugs. It will be conducted
over the telephone and will take about an hour. Participation in this interview is
voluntary and all of your answers will be kept private and confidential.
HAND ADULT FOLLOW-UP STUDY DESCRIPTION TO RESPONDENT. Please read
this statement. It describes the survey and how federal law keeps your answers private
and confidential. Any data you provide will only be used by authorized personnel for
statistical purposes. We hope that protecting your privacy will help you to give accurate
answers.
If you agree to participate, I will give you an additional $30 today. Within the next two
weeks, a different interviewer will call you to explain more about the interview and to
schedule a convenient time to complete it. If you wish, you may complete the full
interview when the interviewer calls.
IF ASKED “WHY WAS I SELECTED”: Anyone who participates in the National Survey
on Drug Use and Health this year may be chosen for this special study. This study is
sponsored by the Substance Abuse and Mental Health Services Administration
(SAMHSA), part of the U.S. Department of Health and Human Services (DHHS).
Knowledge gained from the study will improve our ability to describe and understand
alcohol and drug use in the United States.
IF ASKED “HOW IS THIS INTERVIEW DIFFERENT”: To be certain the questions
asked during the first interview accurately collect data as intended, we must periodically
conduct special studies to evaluate new questions. The follow-up study will ask
questions similar to those just answered, but in a different way through an interview
conducted over the phone.
1
2
3
RESPONDENT AGREES TO RECONTACT
RESPONDENT DOES NOT AGREE TO RECONTACT
RESPONDENT IS NOT AVAILABLE DURING THE SPECIFIED TIME
PERIOD
---------1
IF RESPONDENT IS NOT AVAILABLE IN THE NEXT TWO WEEKS
To accommodate your schedule, an interviewer will be available to call you about this
study and schedule a convenient time to complete the interview within the next four
weeks.
INDICATE YES OR NO IN COMPUTER TO INDICATE IF ADULT AGREES TO
PARTICIPATE IN CVS FOLLOW-UP INTERVIEW.
1
2
3
RESPONDENT AGREES TO RECONTACT
RESPONDENT DOES NOT AGREE TO RECONTACT
RESPONDENT IS NOT AVAILABLE DURING THE SPECIFIED TIME
PERIOD
---------IF RESPONDENT IS AVAILABLE WITHIN THE NEXT TWO OR FOUR WEEKS
Since another interviewer will be completing the follow-up interview, may I have your
first name and phone number so the interviewer can call you?
ENTER FIRST NAME ONLY AND PHONE NUMBER.
---------To check that I entered the number correctly, please repeat the phone number.
CONFIRM NUMBER. AS NEEDED, READ THE CONTACT INFORMATION ENTERED
TO THE RESPONDENT AND CONFIRM IT IS CORRECT.
---------Is there another number where the telephone interviewer could contact you about the
follow-up interview?
IF YES: RECORD PHONE NUMBER AND TYPE (CELL, WORK, ETC) IN THE
NOTES FIELD. REPEAT ABOVE STEPS TO CONFIRM THE NUMBER. YOU MAY
ENTER UP TO 50 CHARACTERS.
IF NO: CONTINUE
---------IF RESPONDENT PROVIDES CONTACT INFORMATION
Please also let me know the best days and times when you will be available in the next
[two/four] weeks. I will give this information to the interviewer, and he or she will try to
contact you during one of these times.
ENTER BEST DAYS/TIMES. AS NEEDED, PROBE FOR ADDITIONAL BEST
DAYS/TIMES.
2
READ THE INFORMATION ENTERED TO THE RESPONDENT AND CONFIRM IT IS
CORRECT.
---------COMPLETE A REMINDER CARD AND HAND TO THE RESPONDENT.
I have entered these days and times in the computer and recorded them on this card.
Please note the interviewer may try to reach you at other times as well.
---------IF RESPONDENT HAS PROVIDED CONTACT INFORMATION
HAND RESPONDENT $30 CASH.
ON THE FOLLOW-UP INTERVIEW INCENTIVE RECEIPT:
MARK THE APPROPRIATE “CASH ACCEPTANCE” BOX
SIGN AND DATE
ENTER THE CASE ID
GIVE TOP COPY TO RESPONDENT.
I have signed this form to indicate that I have given you $30 for the follow-up interview.
At the bottom of this form, we have included national hotline numbers that you can call if
you ever feel you need to talk to someone about mental health or drug use issues.
Thank you in advance for your participation.
---------IF RESPONDENT REFUSES TO PARTICIPATE
Since this additional study is designed to help us improve future NSDUH surveys, it is
important to understand why people might not want to participate. Would you please
tell me why you do not want to participate?
ENTER COMMENT
3
Youth Clinical Validation Study Recruitment Script (Age 12-17)
To Youth:
You have been chosen to take part in one additional study for the U.S. Department of
Health and Human Services. Before I explain more about the study to you, I need to
get permission from your parent or guardian for you to participate.
ASK TO SPEAK TO PARENT OR GUARDIAN WHO HAS LEGAL CUSTODY.
To Parent:
Your child has been selected to participate in one additional study for the U.S.
Department of Health and Human Services. Are you the parent who has legal custody
of this child or are you [HIS/HER] legal guardian?
IF NOT, ASK TO SPEAK TO THE PARENT OR GUARDIAN WHO HAS LEGAL
CUSTODY.
For this study, we are interested in interviewing a wide variety of individuals to learn
more about how different people think and talk about their use or non-use of alcohol and
drugs. The interview will include additional questions about your child’s knowledge of
and experiences with alcohol and drugs. It will be conducted over the telephone and will
take about an hour. Participation in this interview is voluntary and all of [HIS/HER]
answers will be kept confidential.
Within the next few weeks, a different interviewer will call you and your child to explain
more about the interview and to schedule a convenient time to complete it. If you wish,
[HE/SHE] may complete the full interview when the interviewer calls.
All of your child’s answers will be private and confidential and used only for statistical
purposes. There are two exceptions to this promise. If [HE/SHE] tells the interviewer
that [HE/SHE] intends to seriously harm [HIMSELF/HERSELF] or someone else, the
interviewer may need to notify you or a mental health professional or another authority.
If your child tells the interviewer that [HE/SHE] is at risk of serious harm by someone
else, the interviewer may also need to notify you or another authority.
Your child may consider some of the questions to be sensitive and some of the
questions may also make [HIM/HER] feel certain emotions, such as sadness. [HE/SHE]
can refuse to answer any questions that [HE/SHE] does not want to answer and can
stop the interview at any time. If your child becomes upset during the interview and
wishes to speak to a mental health professional about how [HE/SHE] is feeling, the
interviewer will provide [HIM/HER] with toll-free hotline numbers.
HAND YOUTH FOLLOW-UP STUDY DESCRIPTION TO PARENT/GUARDIAN.
Please read this statement. It describes the survey and how federal law keeps any
information your child provides private.
If you agree to allow your child to participate, I will give [HIM/HER] an additional $30
today.
IF ASKED “WHY WAS MY CHILD SELECTED”: Anyone who participates in the
National Survey on Drug Use and Health this year may be chosen for this special study.
This study is sponsored by the Substance Abuse and Mental Health Services
Administration (SAMHSA), part of the U.S. Department of Health and Human Services
(DHHS). Knowledge gained from the study will improve our ability to describe and
understand alcohol and drug use in the United States.
IF ASKED “HOW IS THIS INTERVIEW DIFFERENT”: To be certain the questions
asked during the first interview accurately collect data as intended, we must periodically
conduct special studies to evaluate new questions. The follow-up study will ask
questions similar to those just answered, but in a different way through an interview
conducted over the phone.
Do I have your permission to ask your child to participate in this study?
IF PARENT AGREES TO ALLOW YOUTH TO PARTICIPATE
To Youth:
You have been chosen to take part in one additional study for the U.S. Department of
Health and Human Services. For this study, we are interested in interviewing a wide
variety of individuals to learn more about how different people think and talk about their
use or non-use of alcohol and drugs. The interview will include additional questions
about your knowledge of and experiences with alcohol and drugs. It will take place over
the telephone and will take about an hour. Your parent said you can do this interview if
you want to. It is your choice whether or not you do the interview. All your answers will
be kept private and confidential.
HAND YOUTH FOLLOW-UP STUDY DESCRIPTION TO RESPONDENT.
Please read this statement. It describes the survey and how federal law keeps your
answers private and confidential. Any data you provide will only be used by authorized
personnel for statistical purposes. We hope that protecting your privacy will help you to
give honest answers.
If you agree to participate, I will give you an additional $30 today. Within the next two
weeks, a different interviewer will call you and your parent to explain more about the
interview and to schedule a convenient time to complete it. If you wish, you may
complete the full interview when the interviewer calls.
IF ASKED “WHY WAS I SELECTED”: Anyone who participates in the National Survey
on Drug Use and Health this year may be chosen for this special study. This study is
sponsored by the Substance Abuse and Mental Health Services Administration
(SAMHSA), part of the U.S. Department of Health and Human Services (DHHS).
Knowledge gained from the study will improve our ability to describe and understand
alcohol and drug use in the United States.
IF ASKED “HOW IS THIS INTERVIEW DIFFERENT”: To be certain the questions
asked during the first interview accurately collect data as intended, we must periodically
conduct special studies to evaluate new questions. The follow-up study will ask
questions similar to those just answered, but in a different way through an interview
conducted over the phone.
Do you want to participate in this additional study?
IF YOUTH AGREES TO PARTICIPATE
ASK TO SPEAK TO THE PARENT AGAIN
Are you and your child available to speak with an interviewer in the next two weeks?
1
2
3
AGREES TO RECONTACT
DOES NOT AGREE TO RECONTACT
NOT AVAILABLE DURING THE SPECIFIED TIME PERIOD
---------IF NOT AVAILABLE IN THE NEXT TWO WEEKS
To accommodate your schedule, an interviewer will be available to call you and your
child about this study and schedule a convenient time to complete [HIS/HER] interview
within the next four weeks.
1
2
3
AGREES TO RECONTACT
DOES NOT AGREE TO RECONTACT
NOT AVAILABLE DURING THE SPECIFIED TIME PERIOD
---------IF AVAILABLE WITHIN THE NEXT TWO OR FOUR WEEKS
Since another interviewer will be completing the follow-up interview, may I have your
first name, your phone number and your child’s first name so the interviewer can call
you? Please do not provide the number for any personal cell phone your child may
have.
ENTER FIRST NAMES ONLY AND PHONE NUMBER. DO NOT COLLECT
TELEPHONE NUMBER FOR A YOUTH’S PERSONAL CELL PHONE.
---------To check that I entered the number correctly, please repeat the phone number.
CONFIRM NUMBER. AS NEEDED, READ THE CONTACT INFORMATION ENTERED
TO THE PARENT AND CONFIRM IT IS CORRECT.
Is there another number where the telephone interviewer could contact you and your
child about the follow-up interview? Again, please do not provide the number for any
personal cell phone your child may have.
IF YES: RECORD PHONE NUMBER AND TYPE (CELL, WORK, ETC) IN THE
NOTES FIELD. DO NOT COLLECT TELEPHONE NUMBER FOR A YOUTH’S
PERSONAL CELL PHONE. REPEAT ABOVE STEPS TO CONFIRM THE NUMBER.
YOU MAY ENTER UP TO 50 CHARACTERS.
IF NO: CONTINUE
---------IF PARENT PROVIDED CONTACT INFORMATION
Please also let me know the best days and times when you and your child will be
available in the next [TWO/FOUR] weeks. I will give this information to the interviewer,
and they will try to contact you during one of these times.
ENTER BEST DAYS/TIMES. AS NEEDED, PROBE FOR ADDITIONAL BEST
DAYS/TIMES.
READ THE INFORMATION ENTERED TO THE PARENT AND CONFIRM IT IS
CORRECT.
---------IF PARENT PROVIDED CONTACT INFORMATION
COMPLETE A REMINDER CARD AND HAND TO THE PARENT.
I have entered these days and times in the computer and recorded them on this card.
Please note the interviewer may try to reach you at other times as well.
HAND YOUTH $30.
ON THE FOLLOW-UP INTERVIEW INCENTIVE RECEIPT:
MARK THE APPROPRIATE “CASH ACCEPTANCE” BOX
SIGN AND DATE
ENTER THE CASE ID
GIVE TOP COPY TO YOUTH.
I have signed this form to indicate that I have given you $30 for the follow-up interview.
At the bottom of this form, we have included national hotline numbers that you can call if
you ever feel you need to talk to someone about mental health or drug use issues.
Thank you in advance for your participation.
---------IF PARENT OR YOUTH REFUSES TO PARTICIPATE
Since this additional study is designed to help us understand important issues about
alcohol and drug use, it is important to know why people might not want to participate.
Would you please tell me why you do not want [YOUR CHILD] to participate?
ENTER COMMENT
IF PARENT/GUARDIAN UNAVAILABLE
Without parent or guardian permission to talk with you about the study, we will need to
continue and finish your interview.
CONTINUE
| File Type | application/pdf |
| File Title | Microsoft Word - Electronic Attachment Dividers_CVS PDF 1.doc |
| Author | lchilds |
| File Modified | 2019-09-04 |
| File Created | 2019-09-04 |