Participant ID	Interview Type	Administration Date	Source	Action
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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)

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

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 2: 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.)

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.)

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.)

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.)

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.)

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

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

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

The next two questions are about SEX.

21. What level of risk do you think people have of harming themselves if they have sex without a condom?

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

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
23. Use tobacco?		Don't know or can't say
24. Use electronic vapor products?		Don't know or can't say
25. Drink alcohol? (any use at all)		Don't know or can't say
26. Binge drink?		Don't know or can't say
27. Use marijuana or hashish?		Don't know or can't say
28. Use prescription opioid drugs without orders given to you by your doctor?		Don't know or can't say
29. Use other prescription drugs without orders given to you by your doctor? Please exclude prescription opioid drugs.		Don't know or can't say
30. Use non-prescription opioid drugs?		Don't know or can't say
31. Use any other illegal drugs? Please exclude marijuana/hashish and non-prescription opioid drugs.		Don't know or can't say
32. Inject any drugs?		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.

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

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

35. 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

Youth Questionnaire