Participant ID	Interview Type	Administration Date	Source	Action
{{adultQuestionnaire.participantNumber}}	{{adultQuestionnaire.interviewTypeDisplayName}}	{{adultQuestionnaire.administrationDate \| sparsDate }}	{{adultQuestionnaire.sourceDisplayName}}	Edit

Record Management

Study Design Group*

Participant ID*

Date of Survey Administration*

Interview Type* (Select One)

This section is disabled because you selected "Testing Services Only" in Interview Type.

A) Intervention Details

Type of Encounter* (select all that apply)

Intervention Name(s)

If the participant is receiving direct services from more than one intervention, please list each intervention below.

Intervention 1

Intervention 2

Intervention 3

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 interval)
minutes

B) Service Type(s)

Testing Services (select all that apply)

Health Care Services (select all that apply)

Individual Services (select all that apply)

Group Services (select all that apply)

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.

Please indicate the following:

Number of days in MAT

Type of medication received

Section 1: Facts About You

First, we'd like to ask some basic questions about you. Your answers will not be used to identify you in any way. Instead, your answers will help us understand how different groups (like people from different generations or from different backgrounds) feel about substance abuse and HIV prevention.

1. What is your date of birth

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

3. What is your race? (Select one or more)

4. How do you describe yourself?

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

6. Describe where you live.

7. Are you currently attending college?

8. Have you ever served in the Armed Forces, the Reserves, or the National Guard?

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

10. Are you on parole or probation?

11. 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?

12. 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?

13. Would you know where to go near where you live to see a health care professional regarding a drug or alcohol problem?

14. Would you know where to go near where you live to see a health care professional regarding HIV/AIDS or other sexually transmitted health issues?

15. Think about the household members who live with you right now. About how much income have you and your family members made in the last year before taxes? (Include child support and cash payments from the government—for example, welfare [TANF], SSI, or unemployment compensation)

Section 2: Attitudes & Knowledge

Next, we'd like to ask you how you feel about substance use and sexual behavior. Again, your answers are private and will not be used to identify you.

16. 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.)

17. 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.)

18. 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.)

19. What level of risk do you think people have of harming themselves physically if they share needles, syringes or other injection equipment when using drugs?

20. 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.)

21. 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® Percocet), hydrocodone (Vicodin®), codeine, morphine, methadone, tramadol, hydromorphone, oxymorphine, tapentadol.)

The next few questions ask about having SEX.

22. What level of risk do you think people have of harming themselves if they have sex (oral, vaginal, or anal) without a condom or dental dam?

23. What level of risk do you think people have of harming themselves if they have sex while high on drugs or under the influence of alcohol?

24. I could refuse if someone wanted to have sex without a condom or a dental dam

Section 3: 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...	Days	Don't know
25. Smoke cigarettes?		Don't know or can't say
26. Use other tobacco products?		Don't know or can't say
27. Use electronic vapor products?		Don't know or can't say
28. Drink alcohol? (any use at all)		Don't know or can't say
29. Binge drink?		Don't know or can't say
30. Use marijuana or hashish?		Don't know or can't say
31. Use prescription opioid drugs without orders given to you by your doctor?		Don't know or can't say
32. Use other prescription drugs without orders given to you by your doctor? Please exclude prescription opioid drugs.		Don't know or can't say
33. Use non-prescription opioid drugs?		Don't know or can't say
34. Use any other illegal drugs? Please exclude marijuana/hashish and non-prescription opioid drugs.		Don't know or can't say
35. Inject any drugs?		Don't know or can't say
36. Share injection equipment?		Don't know or can't say

Sexual Behavior

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

37. During the past 30 days, how many sexual partners have you had?

38. The following questions ask about unprotected sex. (Unprotected sex is vaginal, oral, or anal sex without a barrier such as a condom or dental dam.) During the past 30 days, have you had unprotected sex with...

A male	{{yesOrNo.description}}
A female	{{yesOrNo.description}}
A transgender individual	{{yesOrNo.description}}
A significant other in a monogamous relationship	{{yesOrNo.description}}
Multiple partners	{{yesOrNo.description}}
An HIV positive person	{{yesOrNo.description}}
A Hepatitis positive person	{{yesOrNo.description}}
A person who injects drugs	{{yesOrNo.description}}
A man who has sex with men	{{yesOrNo.description}}

39. Have you ever had sex (vaginal, anal, or oral) with someone in exchange for money, drugs, or shelter?

40. In the past 3 months, how often has anyone with whom you had an intimate relationship (sexual or not) abused you emotionally, physically, or sexually?

Adult Questionnaire