NSDUH Questionnair NSDUH Questionnaire Change Flexibilities Screener

Attachment A

Recruitment Screener Criteria

AGE What is your age?

1 11 OR YOUNGER [NOT ELIGIBLE]

2 12-17 [NOT ELIGIBLE]

3 18-34

4 35-54

5 55 OR OLDER

GENDER What is your gender?

1. Male

2. Female

LANG Is your primary language English, Spanish, or another language?

1 English

2 Spanish

3 Other

FENTA During the past 12 months, have you used prescription fentanyl?

1 Yes

2 No

FENTB During the past 12 months, have you used fentanyl without a prescription?

1 Yes

2 No

METH During the past 12 months, have you used methamphetamine?

1 Yes

2 No

KRATOM During the past 12 months, have you used kratom?

1 Yes

2 No

DRTX During the past 12 months, have you received treatment or counseling for your use of alcohol or any drug, not counting cigarettes?

1 Yes

2 No

DRTXa [IF DRTX= 1] During the past 12 months when you received treatment, was the treatment for alcohol use only, drug use only, or both alcohol and drug use?

1 Alcohol use only

2 Drug use only

3 Both alcohol and drug use

MHTX During the past 12 months, have you received treatment or counseling for problems with emotions, nerves or mental health? Please do not include treatment for alcohol or drug use.

1 Yes

2 No

PROXY [IF AGE = 3-5] Do you have any children in your household between the ages of 12 – 17?

1 Yes

2 No

CNUM [IF PROXY = 1] How many children in your household are between the ages of 12 – 17?

1. 1

2. 2

3. 3

4. 4

5. 5

6. 6

7. 7

8. 8

CAGE [IF CNUM = 2-8: What are the ages of the children in your household who are between the ages of 12 – 17?/IF CNUM = 1: How old is this child?]

Child 1 1=12 years old

2=13 years old

3=14 years old

4=15 years old

5=16 years old

6=17 years old

Child 2 1=12 years old

2=13 years old

3=14 years old

4=15 years old

5=16 years old

6=17 years old

…

Child N [repeat for each subsequent child based on number of children indicated in CNUM]

CGENDER [IF CNUM = 1] Is this child male or female?

1. Male

2. Female

CGENDER2 [IF CNUM = 2-8] For each of your children aged 12-17, please indicate whether they are male or female.

Please select one response per row.	Male	Female
X-year-old child	1 	2 
X-year-old child	1 	2 
… [repeat for each child based on CAGE]	1 	2 

CLANG [IF CNUM = 1] Is your child’s primary language English, Spanish, or another language?

1 English

2 Spanish

3 Other

CLANG2 [IF CNUM = 2-8] For each of your children aged 12-17, please indicate if their primary language is English, Spanish, or another language.

Please select one response per row.	English	Spanish	Other
X-year-old child	1 	2 	3 
X-year-old child	1 	2 	3 
… [repeat for each child based on CAGE]	1 	2 	3 

CFENTA [IF CNUM = 1] During the past 12 months, has this child used prescription fentanyl?

1 Yes

2 No

CFENTA2 [IF CNUM = 2-8] During the past 12 months, have any of your children aged 12-17 used prescription fentanyl? Please indicate Yes or No for each child.

Please select one response per row.	Yes	No
X-year-old child	1 	2 
X-year-old child	1 	2 
… [repeat for each child based on CAGE]	1 	2 

CFENTB [IF CNUM = 1] During the past 12 months, has this child used fentanyl without a prescription?

1 Yes

2 No

CFENTB2 [IF CNUM = 2-8] During the past 12 months, have any of your children aged 12-17 used fentanyl without a prescription? Please indicate Yes or No for each child.

Please select one response per row.	Yes	No
X-year-old child	1 	2 
X-year-old child	1 	2 
… [repeat for each child based on CAGE]	1 	2 

CMETH [IF CNUM = 1] During the past 12 months, has this child used methamphetamine?

1 Yes

2 No

CMETH2 [IF CNUM = 2-8] During the past 12 months, have any of your children age 12-17 used methamphetamine? Please indicate Yes or No for each child.

Please select one response per row.	Yes	No
X-year-old child	1 	2 
X-year-old child	1 	2 
… [repeat for each child based on CAGE]	1 	2 

CKRATOM [IF CNUM = 1] During the past 12 months, has this child used kratom?

1 Yes

2 No

CKRATOM2 [IF CNUM = 2-8] During the past 12 months, have any of your children aged 12-17 used kratom? Please indicate Yes or No for each child.

Please select one response per row.	Yes	No
X-year-old child	1 	2 
X-year-old child	1 	2 
… [repeat for each child based on CAGE]	1 	2 

CDRTX [IF CNUM = 1] During the past 12 months, has this child received treatment or counseling for their use of alcohol or any drug, not counting cigarettes??

1 Yes

2 No

CDRTXa [IF CDRTX = 1] During the past 12 months when this child received treatment, was the treatment for alcohol use only, drug use only, or both alcohol and drug use?

1 Alcohol use only

2 Drug use only

3 Both alcohol and drug use

CDRTX2 [IF CNUM = 2-8] During the past 12 months, have any of your children aged 12-17 received treatment or counseling for their use of alcohol or any drug, not counting cigarettes? Please indicate Yes or No for each child.

Please select one response per row.	Yes	No
X-year-old child	1 	2 
X-year-old child	1 	2 
… [repeat for each child based on CAGE]	1 	2 

CDRTX2a [IF CDRTX2= 1] During the past 12 months when any of your children aged 12-17 received treatment, was the treatment for alcohol use only, drug use only, or both alcohol and drug use? Please indicate your response below for each child.

Please select one response per row.	Alcohol Use Only	Drug Use Only	Both Alcohol and Drug Use
X-year-old child	1 	2 	3 
X-year-old child	1 	2 	3 
… [repeat for each child based on CAGE AND CDRTX2]	1 	2 	3 

CMHTX [IF CNUM = 1] During the past 12 months, has this child received treatment or counseling for problems with emotions, nerves or mental health? Please do not include treatment for alcohol or drug use?

1 Yes

2 No

CMHTX2 [IF CNUM = 2-8] During the past 12 months, have any of your children aged 12-17 received treatment or counseling for problems with emotions, nerves or mental health? Please do not include treatment for alcohol or drug use Please indicate Yes or No for each child.

Please select one response per row.	Yes	No
X-year-old child	1 	2 
X-year-old child	1 	2 
… [repeat for each child based on CAGE]	1 	2 

Eligibility Determination

Spanish speakers: IF LANG = 2 OR CLANG = 2 OR ANY CLANG2 = 2

Fentanyl users: IF FENTA = 1 OR FENTB = 1 OR CFENTA = 1 OR CFENTB = 1 OR ANY CFENTA2 = 1 OR OR ANY CFENTB2 = 1

Methamphetamine users: IF METH=1 OR CMETH =1 OR ANY CMETH2 = 1

Kratom users: IF KRATOM=1 OR CKRATOM = 1 OR ANY CKRATOM2 = 1

Drug treatment: IF DRTX = 1 OR CDRTX = 1 OR ANY CDRTX2 = 1

Mental health treatment: IF MHTX = 1 OR CMHTX = 1 OR CMHTX2 = 1

Youth: IF PROXY=1

General Population: IF (AGE = 3-5 AND FENTA = 2 AND FENTB = 2 AND METH = 2 AND KRATOM = 2 AND DRTX = 2 AND MHTX = 2) OR (PROXY = 2 AND CFENTA = 2 AND ALL CFENTA2 = 2 AND CFENTB = 2 AND ALL CFENTB2 = 2 AND CMETH = 2 AND ALL CMETH2 = 2 AND CKRATOM = 2 AND ALL CKRATOM2 = 2 AND CDRTX = 2 AND ALL CDRTX2 = 2 AND CMHTX = 2 AND ALL CMHTX2 = 2)

11