Adult Questionnaire

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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 and the expiration date is 3/31/2019. Public reporting burden for this collection of information is estimated to average 18 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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, Maryland, 20857.

Record Management

Survey Language*

Study Design Group*

Participant ID*

Date of Survey Administration*

Interview Type*

Service Duration*

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

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 men or women, or people of similar ages) feel about substance abuse and HIV prevention.

1. How would you describe yourself? (Gender)

2. In what year were you born?

3. Are you of Hispanic, Latino/a, or Spanish origin? (If yes, you may select one or more categories)

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

5. How would you describe yourself? (Sexual orientation)

6. How well do you speak English?

7. What is your primary spoken language?

8. What is the highest level of education you have finished, whether or not you received a degree? (Select the highest grade you have completed.)

9. Are you currently attending college?

10. Which of the following best describes you? (Select the one that fits best)

11. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone—such as visiting a doctor’s office or shopping?

12. If you have ever been in juvenile/adult detention, jail, or prison for more than 3 days, how long has it been since you last got out?

13. Have you ever served in the Armed Forces, in the Reserves, or the National Guard? (Select all that apply)

13a. Are you currently on active duty in the Armed Forces, in the Reserves, or the National Guard?

13b. Have you ever been deployed to a combat zone? (Select all that apply)

14. Is anyone in your family or someone close to you on active duty in the Armed Forces, in the Reserves or the National Guard, or separated or retired from the Armed Forces, the Reserves, or the National Guard?

15. If YES to question 14, answer the following questions for each person you marked in question 14 (up to six people).

Service Member #1: Service member's relationship to you:

Service Member #2: Service member's relationship to you:

Service Member #3: Service member's relationship to you:

Service Member #4: Service member's relationship to you:

Service Member #5: Service member's relationship to you:

Service Member #6: Service member's relationship to you:

Section 2: Attitudes & Knowledge

Next, we’d like to ask you how you feel about substance use and sexual behavior, as well as what you know about HIV/AIDS. Again, your answers are private and will not be used to identify you.

16. How much do people risk harming themselves physically or in other ways when they smoke one or more packs of cigarettes per day?

17. How much do people risk harming themselves physically or in other ways when they smoke marijuana once or twice a week?

18. How much do people risk harming themselves physically or in other ways when they have five or more drinks of an alcoholic beverage once or twice a week?

19. How many of your friends and acquaintances often have 5 or more drinks in one sitting?

20. How would you feel about your close friends frequently having 5 or more drinks in one sitting?

21. How would you feel about your close friends regularly engaging in unprotected sexual activity?

The next questions are about your beliefs and attitudes toward SEX.

We start by asking you some questions about how risky you believe certain behaviors are.
How much do you think people risk harming themselves physically:

22. If they have sex (oral, vaginal, or anal) without a condom or dental dam?

23. If they have sex while high on drugs or under the influence of alcohol?

24. If they share unsanitized needles or works when using drugs?

Now think about your relationship with your PRIMARY (MAIN) partner. How confident are you that you could...

25. Refuse to have sex with your partner because you weren’t in the mood?

26. Ask your partner to wait while you got a condom or dental dam?

27. Tell your partner how to treat you sexually?

28. Refuse to engage in sexual practices you didn’t like?

29. Ask your partner to use a condom or dental dam?

30. Refuse to have sex because your partner did not want to use a condom or dental dam?

HIV/AIDS - What You Know

In Questions 31-35, please indicate whether you think each of the following two statements about HIV/AIDS is true or false or if you don’t know.

31. Only people who look sick can spread HIV/AIDS?

32. Only people who have sexual intercourse with gay (homosexual) people get HIV/AIDS.

33. Birth control pills protect women from getting HIV/AIDS.

34. There are drugs available to treat HIV that can lengthen the life of a person infected with the virus.

35. There is no cure for AIDS.

36. 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?

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

38. When you need medical help, generally how difficult is it for you to get to a service provider? Would you say it is:

39. In your day-to-day life, do you ever feel that you are treated with less respect or receive poorer services than other people?

39a. What do you think is the main reason for these experiences? (Check all that apply to you. If none of the answers apply, check "None of the above.")

40. 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?

41. Now we would like you to think about all the people you know. Are there certain people you could go to when you want to talk about personal matters that you wouldn't tell just anyone?

42. In general, how important are religious or spiritual beliefs in your day-to-day life?

Section 3: Behavior & Relationships

The next two questions are about CIGARETTES and OTHER TOBACCO PRODUCTS.

Think back over the past 30 days and record on how many days, if any, you used cigarettes, other tobacco products, or both.

43. During the past 30 days, on how many days did you smoke part or all of a cigarette?
(Includes menthol and regular cigarettes and loose tobacco rolled into cigarettes)

44. During the past 30 days, on how many days did you use other tobacco products?
(Includes tobacco product other than cigarettes, such as dipping snuff, chewing tobacco, and smoking tobacco from a pipe)

The next question asks about ELECTRONIC VAPOR PRODUCTS, such as blu, NJOY, or Starbuzz. Electronic vapor products include e cigarettes, e cigars, e-pipes, vape pipes, vaping pens, e hookahs, and hookah pens.

45. During the past 30 days, on how many days did you use electronic vapor products?

The next two questions are about ALCOHOL.

By alcohol, we mean BEER, WINE, WINE COOLERS, MALT BEVERAGES, or HARD LIQUOR

Think back over the past 30 days and record on how many days, if any, you consumed alcohol.

46. During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage?

47. During the past 30 days, on how many days did you have 5 or more drinks on the same occasion?
(By "occasion", we mean at the same time or within a couple of hours of each other.)

The next question is about MARIJUANA or HASHISH. Marijuana is sometimes called weed, blunt, hydro, grass, or pot. Hashish is sometimes called hash or hash oil.

Think back over the past 30 days and record on how many days, if any, you used marijuana or hashish.

48. During the past 30 days, on how many days did you use marijuana or hashish?

The next question is about OTHER ILLEGAL DRUGS, excluding marijuana or hashish.

Think back over the past 30 days and record on how many days, if any, you used other illegal drugs.

49. During the past 30 days, on how many days did you use any other illegal drug?

Now we would like to ask about your use of three specific drugs during the past 30 days.

50. During the past 30 days, on how many days have you used prescription drugs without a doctor's orders, in order to feel good or to get high?

51. During the past 30 days, on how many days did you use synthetic marijuana?
(also called K2, Spice, fake weed, King Kong, Yucatan Fire, Skunk, or Moon Rocks)

52. This question is SPECIFICALLY ABOUT INJECTED DRUGS. During the past 30 days, on how many days have you injected any drugs?
(Count only injections without a doctor’s orders—ones you used to feel good or to get high.)

The next five questions are about your specific experiences with alcohol use. If you have never used alcohol, you should respond to these questions by marking "No".

53. Have you ever felt you should cut down on your drinking?

54. Have people annoyed you by criticizing your drinking?

55. Have you ever felt bad or guilty about your drinking?

56. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?

57. During the past 30 days, has your use of alcohol or drugs caused you to have emotional problems?

58. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health NOT good?
Responses: IF "none," choose 0. Otherwise, enter number of days in past 30 days.

Sexual Behavior

Now we’d like to ask you about your experience with sex. If you cannot remember what we mean by sex, please refer to the definitions on section 2. Remember, your answers will be kept private.

59. Have you ever had sex (vaginal, oral, or anal)?

60. Have you had sex (vaginal, oral, or anal) in the past 30 days?

61. The last time you had sex (vaginal, oral, or anal), was it protected or unprotected?

62. Have you ever had sex with a man?

63. Have you ever had sex with a woman?

64. During the past 3 months, how many sexual partners have you had?

65. If you have ever had unprotected sex (vaginal, anal, or oral) with someone in exchange for money, drugs, or shelter, when was the last time you did?

66. If you have ever had unprotected sex (vaginal, anal, or oral) with a partner you knew had, or suspected of having, HIV/AIDS or another sexually transmitted disease (STD), when was the last time you did?

67. If you have ever had unprotected sex (vaginal, anal, or oral) with someone who you knew was, or whom you suspected of being, an injected drug user, when was the last time you did?

68. If you have ever had sex while you were under the influence of drugs or alcohol, when was the last time you did?

The next two questions ask about abuse you might have experienced.

69. 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?

70. During the past 12 months, how many times have you had unwanted sex (vaginal, oral, or anal) either because someone physically forced you or because you were too drunk or out of it to know what was happening?

Family, Relationships, and Work

71. Describe your current relationship status

72. With whom do you live? (Select the answer that describes you best)

73. Describe where you live.

74. If you have children, during the past 12 months, how many times have you talked with your children about the dangers or problems associated with the use of tobacco, alcohol, or drugs?

75. 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)

The next question is about medical or health care insurance and where you obtained it.

As you may know, new state and federal health insurance marketplaces can be used to shop for health insurance and compare prices and benefits. These marketplaces can also be used to enroll in Medicaid or Medical Assistance. You may know the marketplace as Healthcare.gov or “Obamacare,” or your state may have a special name for its health insurance marketplace. If you have medical or health care insurance, we are interested in learning whether or not you obtained it from such a marketplace.

76. Do you have medical or health care insurance?

77. Would you be more or less likely to want to work for an employer that tests its employees for drug or alcohol use on a random basis? Would you say more likely, less likely, or would it make no difference to you?
(Select one)

The last question asks about your experience with this survey.

78. How truthful were you when answering the questions?