Youth 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 24 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 questions about you. We are not going to use this information to identify you, but instead to talk about what different groups of people have to say. For example, what boys have to say, and how that may be different from what girls have to say. Or how 12-year-olds feel about different things, and how that might be different from what 17-year-olds feel.

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. What is your primary spoken language?

7. How well do you speak English?

8. Do you have any health issues that affect your ability to see, hear, move around easily, or do self-care like dress yourself or brush your teeth?

9. With whom do you live? (Select all that apply)

10. Describe where you live.

11. What is the highest level of education you have finished? (Select the highest grade you have completed.)

12. Have you ever been suspended from school for drug or alcohol use?

13. 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?

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

In this section, we are going to ask how you feel about certain things, such as school, substance use, and sexual behavior. We are also going to ask what you know about HIV/AIDS. Remember, your answers are private and will not be used to identify you.

16. What were your most recent grades in school?

17. How often do you feel that the school work you are assigned is meaningful and important?

18. How interesting are most of your classes to you?

19. How important do you think things you are learning in school are going to be for you later in life?

The next five questions (20 – 24) ask about your ETHNIC GROUP. An ethnic group is a cultural group that has a shared history, similar customs, traditions, and sometimes shared values.

20. I am active in organizations or social groups that include mostly members of my own ethnic group.

21. I think a lot about how my life is affected by my ethnic group’s history, traditions, and customs.

22. I have often talked to other people about my ethnic background.

23. I am interested in learning more about my ethnic background.

24. I participate in cultural practices of my own ethnic group, such as special food, music, or customs.

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

26. When you have problems or difficulties with your school (education), work, family, friends, or personal life, how often do you seek spiritual guidance and support?

27. Are there any adults in your life that you can talk to about an important problem that you wouldn't tell just anyone?

The next set of questions asks how you feel about someone your age using marijuana or drinking alcohol. Please tell us if you disapprove of their actions.

28. How do you feel about someone your age trying marijuana or hashish once or twice?

29. How do you feel about someone your age using marijuana once a month or more?

30. How do you feel about someone your age having one or two drinks of an alcoholic beverage nearly every day?

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

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

33. 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?

34. How much do you think people risk harming themselves physically if they have sex without a condom or dental dam?

35. How much do people risk harming themselves physically or in other ways when they inject illicit drugs for nonmedical reasons?

The next set of questions is about SEX.

In the next 3 months, how likely are you to...

36. Be sexually active?

37. Practice safe sex?

Please indicate how much you agree or disagree with the following statements.

38. I can get my boyfriend or girlfriend to use a condom, even if he or she does not want to.
(If you don’t have a boyfriend or girlfriend right now, suppose you had. How would you answer this question if you did?)

39. I would be able to say to my boyfriend or girlfriend that we should use a condom.
(If you don’t have a boyfriend or girlfriend right now, suppose you had. How would you answer this question if you did?)

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

41. I could say no if someone pressured me to have sex when I did not want to.

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

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

HIV/AIDS – What You Know

The next set of questions is about HIV/AIDS. Please indicate whether you think each of the following statements is true or false, or if you don’t know.

44. Only people who look sick can spread the HIV/AIDS virus.

45. Only people who have sex with gay (homosexual) people get HIV/AIDS.

46. Birth control pills protect women from getting the HIV/AIDS virus.

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

48. There is no cure for AIDS.

49. Young people under age 18 need their parents’ permission to get an HIV test.

50. Having another sexually transmitted disease like gonorrhea or herpes increases a person’s risk of becoming infected with HIV.

51. Sharing intravenous needles increases a person’s risk of becoming infected with HIV.

52. You can become infected with HIV by having unprotected oral sex.

In the next few questions, we are interested in knowing whether you have a regular place to go for health care and whether you believe you have been discriminated against.

53. Is there a doctor’s office, health center, or other similar place that you usually go to when you are sick?

54. Do you ever feel that you are treated with less respect than other people?

55. If yes, why do you think you are treated with less respect than other people?(Check all that apply. If none of these answers apply, check "None of these.")

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.

56. 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)

57. During the past 30 days, on how many days did you use other tobacco products?
(Includes tobacco product other than cigarettes, such as 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.

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

The next few 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 drank alcohol.

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

60. 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.)

61. During the past 30 days, on how many days have you been drunk or very high from drinking alcoholic beverages?

62. If you wanted to get some beer, wine, or hard liquor (for example, vodka, whiskey, or gin), how hard or easy would it be for you to get some?

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.

63. 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 report on how many days, if any, you used other illegal drugs.

64. 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 substances during the past 30 days.

65. 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)

66. 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?

67. During the past 30 days, on how many days did you inject any drugs?
(Count only injections without a doctor's orders—those you had just to feel good or to get high.)

The next few questions ask about the FIRST TIME you used a substance. Think back as to whether you have EVER used any of these substances. If so, tell us your age the FIRST TIME you used the following substances.

68. How old were you the first time you had a drink of an alcoholic beverage?
(Includes beer, wine, wine coolers, malt beverages, and liquor) DO NOT include any time when you only had a sip or two from a drink.

69. How old were you the first time you used marijuana or hashish? (Also known as grass, pot, hash, or hash oil)

70. How old were you the first time you used any other illegal drug?

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

72. 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, enter 0. Otherwise, enter Number of days in past 30 days

Sexual Behavior

These questions ask about your personal experience with sex.

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

74. How old were you when you had sex for the first time (include vaginal, oral, or anal sex)?

75. Now think about the last time you had sex (if you've ever had sex). At that time, did you and your partner use a condom?

76. During the last 3 months, with how many people did you have sex?

77. In the last 3 months, have you had sex after getting drunk or high?

Your Family and Friends

78. Now, think about the past 12 months through today. During the past 12 months, have you talked with at least one of your parents about the dangers of tobacco, alcohol, or drug use? (By PARENTS, we mean your biological parents, adoptive parents, stepparents, or adult guardians, whether or not they live with you.)

79. During the past 12 months, have you talked with at least one of your parents about the dangers of unprotected sex? (By PARENTS, we mean your biological parents, adoptive parents, stepparents, or adult guardians, whether or not they live with you.)

80. When I am not at home, one of my parents (or guardians) knows where I am.

81. When I am not at home, one of my parents (or guardians) knows who I am with.

82. Members of my family feel very close to each other.

How many of your friends...

83. Drink beer, wine, wine coolers, or hard liquor (besides a few sips)?

84. Smoke cigarettes?

85. Smoke marijuana or weed?

86. Get arrested?

87. Are sexually active?

88. Have been pregnant or gotten someone pregnant?

Prevention Education

You may get information about substance abuse, HIV/AIDS, or other health issues from many different sources. The next few questions ask about some of these sources.

89. During the past 12 months, do you recall hearing, reading, or watching an advertisement about prevention of substance abuse?

90. In the past 30 days, have you been in any classes or programs where they talked about preventing HIV or AIDS?

91. In the past 30 days, have you been in any classes or programs where they talked about prevention of drug and alcohol abuse?

The last question asks about your experience with this survey.

92. How truthful were you when answering the questions?