Form Youth-Instruments

Youth—Instruments

Attachment B: System of Care Assessment

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx

System/Program__________________________

Interviewer___________________

Site ID#_________________________________

Date________________________

Respondent Data Entry#____________________

Assessment #_________________

P. Youth Respondent
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 0930-0307. Public reporting burden for this
collection of information is estimated to average 45 minutes per response, 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, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

Introduction
Hello, my name is
. Thank you for taking time today to help us. I’ll be asking
you questions about your experience with the services provided through (name of grant
program)
or about your involvement in program governance and management. This
information will help us understand what works best for young people and their families.
Before we start, I want to make sure that you know that the information you give me
today will be kept private and will not be shared with the (name of grant program) . In our report,
everybody’s answers will be combined and the people who gave us the information will
not be identified. While answering these questions, remember that you should
concentrate on things that have happened since you came to (name of grant program) .
[Note to interviewer: Review Assent or Consent form with respondent. Ascertain age of
respondent again to determine consent to participate with or without parental permission. Obtain
respondent signature before proceeding with the interview]

Introduction
1. Do you receive services through the (name of grant program) ?
1=No If no, go to Question 20
2=Yes If yes, continue
(NOTE TO INTERVIEWER: Question 2 skipped)

3.

Can you tell me why you become involved with
reasons the youth entered care.]
How did you learn about

(name of grant program) ?

[Probe for

(name of grant program) ?

Who referred you?
How long have you been receiving services through the program?

CMHS National Evaluation, Baseline Assessment
Youth (P), February 2011
Phase VI

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4.

What services do you currently receive through (name of grant program) ? [Probe for
examples such as counseling or therapy, mentoring, tutoring, support group,
respite care, transportation to appointments, etc.]
In addition to these, have you ever received any other services through (name of grant
program) ?

5.

In addition to the services received through (name of grant program) , have you received
services from or participated in activities sponsored by other providers,
organizations, programs or agencies? If yes, what were they? [Probe for examples
such as Boys and Girls Club, Big Brothers/Big Sisters, YMCA/YWCA, child welfare
or foster care caseworker, juvenile probation officer, school counselor or social
worker, drug treatment counselor, peer support program, etc.]

Entry into Services
Now I’d like for you to think back to when you first came to (name of grant program).
6.

How did you get started with
process]

(name of grant program)?

Was it difficult to get enrolled or started in

[Probe for details about the entry

(name of grant program) ?

(E.7.b.)

On a scale of 1 to 5, with 5 being the easiest and 1 being the hardest or most difficult,
how would you rate how easy or difficult it was for you or your family to get started in
the program?
Respondent’s rating
5=Entry process was not at all complicated/difficult. Very few
steps were involved.
4=Entry process was slightly complicated/difficult.
3=Entry process was somewhat complicated/difficult. Several
steps were involved.
2=Entry process was moderately complicated/difficult. Many steps
involved.
1=Entry process was extremely complicated/difficult. Very many
steps involved.

7.

Interviewer’s rating
5=Entry process was not at all complicated/difficult. Very few
steps were involved.
4=Entry process was slightly complicated/difficult.
3=Entry process was somewhat complicated/difficult. Several
steps were involved.
2=Entry process was moderately complicated/difficult. Many steps
involved.
1=Entry process was extremely complicated/difficult. Very many
steps involved.

How much time passed between when you first tried to get into (name of grant program) until
you actually started receiving services or participating in activies? Was this a good
timeframe for you, or did you want to receive services sooner? (E.7.c.)
On a scale of 1 to 5, with 5 being the least amount of time and 1 being the most amount
of time, how would you rate the length of time it took for your services to start?

Respondent’s rating
5=Timeframe was perfect, no changes needed
4=Timeframe was very fast, could use minor improvement
3=Timeframe pretty fast, could use some improvement
2=Timeframe pretty slow, could use quite a bit of improvement
1=Timeframe entirely too slow, needs a great deal of improvement

CMHS National Evaluation, Baseline Assessment
Youth (P), February 2011
Phase VI

Interviewer’s rating
5=Timeframe was perfect, no changes needed
4=Timeframe was very fast, could use minor improvement
3=Timeframe pretty fast, could use some improvement
2=Timeframe pretty slow, could use quite a bit of improvement
1=Timeframe entirely too slow, needs a great deal of improvement

2

8.

Were you treated with respect and made to feel comfortable throughout the
enrollment process? (E.2.a.)
Did the staff pay attention to and respect what you had to say?
On a scale from 1 to 5, with 5 being the best, how respected and comfortable did you
feel during the process for entering (name of grant program) ?

Respondent’s rating
5=Youth felt extremely respected and comfortable
4= Youth felt very respected and comfortable
3= Youth felt moderately respected and comfortable
2= Youth felt somewhat respected and comfortable
1= Youth felt extremely disrespected and uncomfortable

Interviewer’s rating
5= Youth felt extremely respected and comfortable
4= Youth felt very respected and comfortable
3= Youth felt moderately respected and comfortable
2= Youth felt somewhat respected and comfortable
1= Youth felt extremely disrespected and uncomfortable

Service Planning
Now I’d like to ask you some questions about what happened when you and the staff at
were deciding what services or activities would be best for you. We call
this the service planning process.

(name of grant program)

9.

Is there a main person at (name of grant program) who helps to decide what services or
activities you should receive or participate in? [Probe for the first name and
function (e.g., case manager/care coordinator or therapist) who worked with the
youth to plan services. Use that name where you see (name of case manager/therapist) ]

10.

Since entering (name of grant program) , have you been involved with staff from other
agencies such as child welfare, juvenile justice, education, etc.? If yes, which
agencies? (F.5.a.)
If yes, did anyone from any of these agencies work with you and (name of case
manager/therapist) to plan services for you? If so, who?

5=All involved agencies were present
4=Most involved agencies were present
3=Some involved agencies were present
2=Few of the involved agencies were present
1=One involved agency was present (but family involved with more than one)
666=Family involved with only one agency

11.

How well did the people who were working with you involve you in the service
planning process? (F.2.a.)
Did they encourage you to bring someone to the meeting with you, perhaps for
support?
Did they ask you whether there was anyone you did not want to be present in the
meeting?
Did they ask you to talk about what you thought were the most important concerns
for yourself?
Did they encourage you to help develop you own goals and objectives?

CMHS National Evaluation, Baseline Assessment
Youth (P), February 2011
Phase VI

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Did they give you a choice of services that you thought would be most helpful for
yourself?
Were you able to turn down services that you did not want to receive?
Overall, were you as involved in the service planning process as you think you should
have been?
5=Youth was involved in service planning in at least 6 ways AND respondent reported that involvement has been sufficient
4= Youth was involved in service planning in 5 ways OR involved in 6 ways but respondent reported that it could have been better
3= Youth was involved in service planning in 4 ways
2= Youth was involved in service planning in 3 ways
1= Youth was involved in service planning in fewer than 3 ways

12.

Was the service plan (plan of care) written down? Did you sign it? Did you receive a
copy of it?

13.

When you were working with (name of case manager/therapist) to plan services, did she/he talk
with you about your strengths (things you like to do, your interests, things you are good
at)? Would you mind giving me some examples of things you talked about? (F.3.b.)
How were your strengths used in planning your services? What could have been
done better?

5=Strengths explicitly discussed and at least three examples given of how strengths were incorporated into the service plan AND respondent
reported it could not have been better
4=Strengths explicitly discussed and two examples given of how strengths were incorporated into the service plan but respondent reported it
could have been better
3=Strengths explicitly discussed and one example given of how strengths were incorporated into the service plan
2=Strengths explicitly discussed but not (or very, very minimally) incorporated into the service plan
1=No discussion of strengths

Service Provision
14. Have you received all the services that were listed in your service or care plan? (G.3.a.)
If no, do you know why you did not receive all the services that were planned for you?
[Probe for reasons: lack of funds, no openings, waiting list, not in community,
etc.]
5=Child/youth received all of the services that were planned
4=Child/youth received most of the services that were planned
3=Child/youth received many of the services that were planned
2=Child/youth received a few of the services that were planned
1=Child/youth received no services outlined in the plan

Now I am going to ask you about the different people or service providers who work with
you.
15.

What have the different service providers you have worked with done to include you in
your services and treatment planning? (G.2.a.)
For example, have they usually encouraged you to offer your ideas about services
and treatments?

CMHS National Evaluation, Baseline Assessment
Youth (P), February 2011
Phase VI

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Have they considered your ideas or input about your services and treatments?
Have they encouraged you to let them know when something was not working well?
Have they asked you for suggestions about changes that could be made to improve
your services or treatments?
Overall, could your service providers have done a better job in getting or using your
suggestions about the services and the treatments they are providing to you?
5=Youth was involved in service provision in 4 ways AND respondent reported that involvement has been sufficient
4= Youth was involved in service provision in 3 ways OR involved in 4 ways but respondent reported that it could have been better
3= Youth was involved in service provision in 2 ways
2= Youth was involved in service provision in 1 way
1= Youth was not involved in service provision

(NOTE TO INTERVIEWER: Questions 16-17 skipped)

Service Array
Now let’s talk about services that are available in your community.
18.

Is there a person you can talk to or a place you can go if you need support or help?
[Probe for advocacy organizations, support group, or mentoring relationship]
Who is this person or what group do you go to?

19.

Are you aware of any youth groups that support young people in your community?
Are you involved in such a youth group? Is it a part of the (name of grant program)?.
How did you become aware of this youth group?
What kinds of activities does this group do?

Governance
Now let’s talk about youth involvement in the governance of (name of grant program).
20.

Do you now or have you ever participated on the (governing body) to talk about the
(name of grant program)?
1=No If no, go to Question 25
2=Yes If yes, continue
How did you become involved and why?

21.

To what extent do you think youth, including yourself, have been actively involved
in the (governing body)? (A.2.a.)
a.

Which activities are youth generally involved in? [Probe for examples of
participation in the (governing body)’s functions such as committee

CMHS National Evaluation, Baseline Assessment
Youth (P), February 2011
Phase VI

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membership, strategic planning, budget discussions, service array
development]
5=Involved in all activities of the governing body
4=Involved in most activities of the governing body
3=Involved in some activities of the governing body
2=Involved in few activities of the governing body
1=Involved in no activities of the governing body

b.

How have youth been regarded and treated by other participants of the
(governing body)? (A.2.a.)
Has that been the same for all participants, or have some participants
demonstrated respect, acceptance, and value for youth input more than others?

5=All participants were very respectful, accepted, and highly valued family input
4=Most participants were very respectful and valued family input and the rest were moderately respectful
3=Some participants were very respectful and valued family input and the rest were moderately respectful
2=Few participants were very respectful and valued family input and most others were at least somewhat respectful
1=No or almost no participants were respectful or valued family input

c.

What percentage of (governing body) meetings have youth attended? (A.2.a.)

5=Attended 90% to 100% of meetings
4=Attended 75% to 89% of meetings
3=Attended 50% to 74% of meetings
2=Attended 25% to 49% of meetings
1=Attended less than 25% of meetings

22.

Are youth given information necessary to fulfill their role on the governing body? If yes, is
the information accurate, understandable, and complete? (governing body)? (A.2.b.)

5=Adequately informed all of the time
4=Adequately informed most of the time
3=Adequately informed some of the time
2=Adequately informed a few times
1=Adequately informed none of the time

23.

When and where have (governing body) meetings typically been held? How were these
times and locations determined? (A.2.c.)
Have the times and location been convenient for you and other youth? Why or why not?
Has the location or time of meetings ever prevented you or other youth from
attending?
On a scale of 1 to 5, with 5 being the most convenient, how would you rate the
convenience of the meetings?

Respondent’s rating
5=Extremely convenient
4=Very convenient
3=Moderately convenient
2=Somewhat convenient
1=Not at all convenient

CMHS National Evaluation, Baseline Assessment
Youth (P), February 2011
Phase VI

Interviewer’s rating
5=Extremely convenient
4=Very convenient
3=Moderately convenient
2=Somewhat convenient
1=Not at all convenient

6

24.

Since grant funds were received, has the (governing body) provided anything to youth to
make it easier for them to participate in the (governing body)? Please provide examples.
[Probe for whether transportation, stipends/compensation, food, childcare,
training, written/oral language interpretation or translation were provided]. (A.2.d.)
If yes, have these made a difference for youth?
If no, would it be helpful to youth if there were?
Is there anything else that could be done to make it easier for youth to participate?

5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal

Finally, let’s talk about management of the (name of grant program).
25.

Have efforts been made to involve youth in program operations such as providing
staff training, serving as volunteer or paid program staff, peer mentors, youth group
leaders, attending management meetings, etc? (B.2.a.)
1=No If no, go to Question 28
2=Yes If yes, continue
If yes, please describe all of the different ways youth have been involved.
[Note: Do not count involvement in governing body, evaluation, or conducting outreach activities.]

[Continue to probe for examples until the respondent reports no more.]
[Data entry: code ways]
5=Four examples of youth involvement in program operations
4=Three examples of youth involvement in program operations
3=Two examples of youth involvement in program operations
2=One example of youth involvement in program operations
1=No examples of youth involvement in program operations

26.

Has the (name of grant program) used youth to provide training to other youth or adults about
youth concerns/issues or how to work with youth?
What type of training was it and to whom was it given?

27.

Has the (name of grant program) provided any training to youth about the service system?
[Probe for training on how the system operates, its purpose, youth involvement
and development opportunities, and youth rights]

Summary
28.

On a scale from 1 to 5, with 5 being the best, how much would you say (name of grant
program) has helped young people?
5=Very much

CMHS National Evaluation, Baseline Assessment
Youth (P), February 2011
Phase VI

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4=A lot
3=Moderately
2=Somewhat
1=Not at all

29.

What is been the best thing about receiving services through

30.

Do you have any suggestions or recommendations for how (name of grant program) could
improve the way that it serves children, youth and families?

31.

On a scale from 1 to 5, with 5 being the best, how well do you think
meeting the needs of children, youth and families?

(name of grant program)?

(name of grant program)

is

5=Extremely well
4=Very well
3=Moderately well
2=Somewhat well
1=Not well at all

Those are all of the questions I have for you. Is there anything that I did not cover that you think
is important for us to know about (name of grant program)?

Thank you for taking the time to answer my questions. Do you have any questions for me?

CMHS National Evaluation, Baseline Assessment
Youth (P), February 2011
Phase VI

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Attachment D: Longitudinal Child and Family Outcome Study and Service
Experience Study

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
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 0930-0307. Public reporting burden for this
collection of information is estimated to average 8 minutes per response, 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, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

DELINQUENCY SURVEY, REVISED (DS–R)
/

DSRDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

1 = Intake
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

DSRINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

DSRMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

DSRLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Date last modified: December 2009

CHILD ID:

Delinquency Survey, Revised (DS–R)

Now I’d like to ask you about some things you may have done in the past 6 months. Some will not apply
to you, but these are standard questions we ask everyone. I’d like to repeat that your answers are
confidential and will not be connected to your name.

[CARD] [TIMELINE]
No times 1 time

2–5 times

6–10
times

More
than 10
times

In the past 6 months, how many times have you . . .
1.

been in trouble with the police for skipping
school?

1

2

3

4

5

2.

been in trouble with the police for running
away?

1

2

3

4

5

3.

taken something from a store without paying for
it?

1

2

3

4

5

4.

been a bully or threatened other people without
use of a weapon?

1

2

3

4

5

5.

participated in gang activities that involved
doing things that are against the law?

1

2

3

4

5

6.

been so loud or rowdy in public that you got in
trouble with the law?

1

2

3

4

5

7.

been so out of your parents’/caregivers’ control
that the police needed to get involved?

1

2

3

4

5

8.

purposely damaged or destroyed (other than
with fire) property that did not belong to you?

1

2

3

4

5

8a.

[IF DAMAGED PROPERTY] Please describe what kind of damage you did:
_________________________________________________________________________
_________________________________________________________________________

9.

hit someone or got into a physical fight?

1

2

3

4

5

10.

broken into a house or building to steal
something or just to look around?

1

2

3

4

5

11.

bought, received, possessed, or sold any stolen
goods?

1

2

3

4

5

12.

had sex with someone in exchange for favors,
gifts, or money?

1

2

3

4

5

13.

carried a weapon such as a knife or gun, or an
object that could be used as a weapon?

1

2

3

4

5

13a. [IF CARRIED A WEAPON] What type of weapon did you carry and what was the reason you
carried it?
_________________________________________________________________________
_________________________________________________________________________
For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
1

CHILD ID:

Delinquency Survey, Revised (DS–R)

No times 1 time

2–5 times

6–10
times

More
than 10
times

In the past 6 months, how many times have you . . .
14.

intentionally set a building, car, or other
property on fire?

1

2

3

4

5

15.

taken a car, truck, or motorcycle that didn’t
belong to you?

1

2

3

4

5

16.

sold, distributed, or helped make illegal drugs?

1

2

3

4

5

17.

threatened someone with a weapon or used a
weapon in a fight?

1

2

3

4

5

18.

hurt someone badly enough they needed
bandages or a doctor?

1

2

3

4

5

19.

taken a purse, money, or other things from
someone by force or threat?

1

2

3

4

5

20.

been physically cruel to animals?

1

2

3

4

5

21.

forced someone to have sex with you when they
did not want to?

1

2

3

4

5

22.

In the past 6 months, have you driven a motor vehicle (e.g., car, truck, or motorcycle)?
1 = No [GO TO QUESTION #23]
2 = Yes

No times 1 time

2–5 times

6–10
times

More
than 10
times

In the past 6 months, how many times have you . . .

23.

22a. gotten a ticket or citation for a traffic
violation (driving too fast, driving through
a red light, etc.)?

1

2

3

4

5

22b. driven a car or motorcycle while under the
influence of alcohol or illegal drugs?

1

2

3

4

5

22c. had a motor vehicle accident?

1

2

3

4

5

Have you ever been stopped or questioned by the police or legal authority because you were
suspected of committing a crime?
1 = No [GO TO QUESTION #24]
2 = Yes
23a. How many times in the past 6 months have you been stopped or questioned by the police or a
legal authority?
_____ times

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
2

CHILD ID:

24.

Delinquency Survey, Revised (DS–R)

Have you ever been arrested? By arrested, I mean that you were taken or held by a legal authority
because you were suspected of committing a criminal act.
1 = No [GO TO QUESTION #25]
2 = Yes
24a. How old were you the first time you were arrested?
_____ age
[NOTE TO INTERVIEWER: Prompt if age seems unreasonable, e.g., 1 year old.]
24b. In the past 6 months, how many times have you been arrested?
_____ times [IF ZERO, GO TO QUESTION #25]
24c. What were the offenses for which you were arrested in the past 6 months? [Describe all
offenses]
[NOTE TO INTERVIEWER: Record subject’s response verbatim, then code based on arrest
categories provided. Prompt if more information is needed to code the arrest charges correctly.]
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Arrest codes
25.

Have you ever been told to appear in court for something you were suspected of doing?
1 = No [GO TO QUESTION #26]
2 = Yes
25a. How many times in the past 6 months did you appear in court for something you were
suspected of doing?
_____ times [IF ZERO, GO TO QUESTION #26]
25b. What were the offenses for which you appeared in court in the past 6 months? [Describe all
offenses]
[NOTE TO INTERVIEWER: Record subject’s response verbatim, then immediately code the
offenses based on categories provided. Prompt if more information is needed to code the offenses
correctly.]
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Offense codes

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
3

CHILD ID:

26.

Delinquency Survey, Revised (DS–R)

Have you ever been convicted (found guilty or adjudicated) of a crime or offense in court? By
convicted, I mean found to be responsible for a crime by a jury or judge.
1 = No [GO TO QUESTION #27]
2 = Yes
26a. How old were you the first time you were found guilty or adjudicated of a crime or offense in
court?
_____ age
[NOTE TO INTERVIEWER: Prompt if age seems unreasonable, e.g., 1 year old.]
26b. In the past 6 months, have you been found guilty or adjudicated of a crime or offense in
court?
1 = No [GO TO QUESTION #27]
2 = Yes
26c. What were the offenses you were found guilty or adjudicated of in the past 6 months?
[Describe all offenses]
[NOTE TO INTERVIEWER: Record subject’s response verbatim, then immediately code the
offenses based on categories provided. Prompt if more information is needed to code the offenses
correctly.]
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Offense codes
27.

Have you been on probation in the past 6 months?
1 = No [END OF QUESTIONNAIRE]
2 = Yes
27a. Have you successfully followed your probation agreement?
1 = No
2 = Yes

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
4

CHILD ID:

28.

Delinquency Survey, Revised (DS–R)

[IF GREATER THAN ZERO TO #24b OR #25a, OR YES TO #26b OR #27] During the past 6
months, as a result of your contact with law enforcement (e.g., police, truant officers, court, judge),
which of the following did you do? [Select all that apply]
1 = Met with a probation officer or other person representing the juvenile justice
system
2 = Met with or talked to a mentor
3 = Attended crime prevention class or program
4 = Received mental health services
5 = Received substance abuse treatment
6 = Provided community service
7 = Returned property or paid money for stolen or damaged property
8 = Wore an electronic monitor
9 = Other—please specify ____________________________________________
[Probe for other outcomes]
10 = None of the above [END OF QUESTIONNAIRE]
28a. [IF ANY OF 1–9 SELECTED IN QUESTION #28] As a result of doing this activity/these
activities, did you avoid further involvement in the juvenile justice system? For example,
were you able to avoid going to court, being adjudicated in court (found guilty of a crime), or
being sent to juvenile jail?
1 = No [END OF QUESTIONNAIRE]
2 = Yes
28b. At what point during your involvement with the juvenile justice system did you do this
activity/these activities?
1 = After being arrested
2 = After meeting with a probation officer or other juvenile justice system
representative
3 = After appearing in court
4 = After being adjudicated or found guilty of a crime

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
5

Offense/Arrest List
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29

Vandalism, graffiti, or property destruction
Receiving, possessing, or selling stolen goods
Passing bad checks, forgery, or fraud
Shoplifting
Larceny or theft
Motor vehicle theft
Robbery
Simple assault or battery
Aggravated assault
Forcible rape
Murder, homicide, or non-negligent manslaughter
Arson
Driving under the influence
Drunkenness or other liquor law violation
Possession, dealing, distribution, or sale of drugs
Possession or use of drug paraphernalia
Possession or use of weapons
Prostitution, pimping, or commercialized sex
Probation or parole violations
Illegal gambling
Burglary or breaking and entering
Curfew violation
Truancy
Running away
Disorderly conduct
Gang involvement/activity
Domestic violence
Disturbing the peace
Other

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
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 0930-0307. Public reporting burden for this
collection of information is estimated to average 10 minutes per response, 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, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

BEHAVIORAL AND EMOTIONAL RATING
SCALE—Second Edition, Youth Rating Scale
(BERS–2Y)
/

BRYDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

1 = Intake
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

BRYINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

BRYMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

BRYLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Instructions to respondent: I am going to read you a list of statements that describe you in a positive way.
Some of the items will describe you very well. Other items will not describe you at all. After I read each
statement, tell me which description best describes you now or in the past 6 months. You must answer all
57 items. If you do not know the meaning of some of the words, ask me. Rate all 57 items by the
following criteria: the statement is very much like you, like you, not much like you, or not at all like you.
[CARD]

Date last modified: December 2009

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
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 0930-0307. Public reporting burden for this
collection of information is estimated to average 5 minutes per response, 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, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

GAIN QUICK–R: SUBSTANCE PROBLEM SCALE
(GAIN)
/

GQDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

1 = Intake
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

GQINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

GQMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

GQLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Date last modified: December 2009

CHILD ID:

GAIN Quick–R: Substance Problem Scale (GAIN)

Now I’m going to ask you some questions about things that you may have done, felt, or had happen to
you in the past 6 months as a result of using drugs or alcohol. We realize that this information is personal.
Please remember that the answers you give will be kept private [insert local confidentiality rules here]
and will never be linked to your name. For each question, answer “yes” or “no.” As I’m reading a
question, if I say something that applies to you, interrupt me and say “yes.” You don’t need to wait until
I’ve read the whole question. I’ll pause after each part of the question to give you a chance to answer.
Some of the questions are long or have difficult words. Please let me know if you want me to repeat a
question or explain what any of the words mean.
1.

During the past 6 months, have you used any alcohol, marijuana, cocaine, heroin, or other
substances?
0 = No [END OF QUESTIONNAIRE]
1 = Yes
During the past 6 months . . .
1a.

have you tried to hide that you were using alcohol, marijuana, or other drugs?
0 = No
1 = Yes

1b.

have your parents, family, partner, coworkers, classmates, or friends complained about your
alcohol, marijuana, or other drug use?
0 = No
1 = Yes

1c.

have you used alcohol, marijuana, or other drugs weekly?
0 = No
1 = Yes

1d.

has alcohol, marijuana, or other drug use caused you to feel depressed, nervous, suspicious,
uninterested in things, reduced your sexual desire, or caused other psychological problems?
0 = No
1 = Yes

1e.

has alcohol, marijuana, or other drug use caused you to have numbness, tingling, shakes,
blackouts, hepatitis, TB, sexually transmitted disease, or any other health problems?
0 = No
1 = Yes

2.

During the past 6 months . . .
2a.

have you kept using alcohol, marijuana, or other drugs even though you knew it was keeping
you from meeting your responsibilities at work, school, or home?
0 = No
1 = Yes

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
1

CHILD ID:

GAIN Quick–R: Substance Problem Scale (GAIN)

2b.

have you used alcohol, marijuana, or other drugs where it made the situation unsafe or
dangerous for you, such as when you were driving a car, using a machine, or where you might
have been forced into sex or hurt?
0 = No
1 = Yes

2c.

has alcohol, marijuana, or other drug use caused you to have repeated problems with the law?
0 = No
1 = Yes

2d.

have you kept using alcohol, marijuana, or other drugs even after you knew it could get you
into fights or other kinds of legal trouble?
0 = No
1 = Yes

3.

During the past 6 months . . .
3a.

have you needed more alcohol, marijuana, or other drugs to get the same high or found that
the same amount did not get you as high as it used to?
0 = No
1 = Yes

3b.

have you had withdrawal problems from alcohol, marijuana, or other drugs like shaking
hands, throwing up, having trouble sitting still or sleeping, or have you used any alcohol,
marijuana, or other drugs to stop being sick or avoid withdrawal problems?
0 = No
1 = Yes

3c.

have you used alcohol, marijuana, or other drugs in larger amounts, more often, or for a
longer time than you meant to?
0 = No
1 = Yes

3d.

have you been unable to cut down or stop using alcohol, marijuana, or other drugs?
0 = No
1 = Yes

3e.

have you spent a lot of time either getting alcohol, marijuana, or other drugs, using them, or
feeling the effects of them (high, sick)?
0 = No
1 = Yes

3f.

has alcohol, marijuana, or other drugs caused you to give up, reduce, or have problems at
important activities at work, school, home, or social events?
0 = No
1 = Yes

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
2

CHILD ID:

3g.

GAIN Quick–R: Substance Problem Scale (GAIN)

have you kept using alcohol, marijuana, or other drugs even after you knew it was causing or
adding to medical, psychological, or emotional problems you were having?
0 = No
1 = Yes

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
3

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
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 0930-0307. Public reporting burden for this
collection of information is estimated to average 6 minutes per response, 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, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

SUBSTANCE USE SURVEY, REVISED (SUS–R)
/

SSRDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

1 = Intake
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

SSRINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

SSRMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

SSRLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Date last modified: December 2009

CHILD ID:

Substance Use Survey, Revised (SUS–R)

This set of questions deals with the use of alcohol, cigarettes, and other drugs. The information
respondents provide about their use of these substances is very important to the success of this study. We
recognize that this information is personal. Please remember that the answers you give will be kept
private [insert local confidentiality rules here] and will never be linked to your name.
Let’s talk about alcoholic beverages first. By an alcoholic beverage, we mean a can or bottle of beer, a
glass of wine, a wine cooler, a shot of liquor, or a mixed drink. We are not talking about little sips you
may have taken from another person’s beverage or wine you may have drunk in a religious ceremony.
1.

Have you ever had an alcoholic beverage?
1 = No [GO TO QUESTION #2]
2 = Yes
1a.

How old were you when you had your first alcoholic beverage? Please do not include any
times when you only had a sip or two from a drink.
_____ age

1b.

Have you ever been drunk?
1 = No [GO TO QUESTION #1d]
2 = Yes

1c.

How old were you when you first got drunk?
_____ age

1d.

How long has it been since you last drank an alcoholic beverage?
_____ days/weeks/months [IF MORE THAN 6 MONTHS, GO TO QUESTION #2]
(circle one)

[CARD] [TIMELINE]
1e.

In the past 6 months, how often did you drink an alcoholic beverage?
1 = Not at all [GO TO QUESTION #2]
2 = Less than once per month
3 = 1–3 times per month (for example, every other weekend)
4 = 1–2 times per week (for example, every weekend)
5 = 3–6 times per week
6 = Daily

1f.

During the past 30 days, that is, since [fill in date], on how many days did you drink one or
more alcoholic beverages?
_____ day(s) [IF 0, GO TO QUESTION #2]

1g.

During the past 30 days, that is, since [fill in date], 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.
_____ day(s)

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
1

CHILD ID:

2.

Substance Use Survey, Revised (SUS–R)

Have you ever smoked cigarettes?
1 = No [GO TO QUESTION #3]
2 = Yes
2a.

How old were you when you first smoked part or all of a cigarette?
_____ age

2b.

In the past 6 months, have you smoked part or all of a cigarette?
1 = No [GO TO QUESTION #3]
2 = Yes

2c.

During the past 30 days, that is, since [fill in date], on how many days did you smoke part or
all of a cigarette?
_____ day(s) [IF 0, GO TO QUESTION #3]

2d.

On the days you smoked cigarettes during the past 30 days, how many cigarettes did you
usually smoke per day?
_____ number

3.

Have you ever used chewing tobacco or snuff (sometimes called dip)?
1 = No [GO TO QUESTION #4]
2 = Yes
3a.

How old were you when you first used chewing tobacco or snuff?
_____ age

3b.

In the past 6 months, have you used chewing tobacco or snuff?
1 = No [GO TO QUESTION #4]
2 = Yes

3c.

In the past 30 days, on how many days did you use chewing tobacco or snuff?
_____ day(s)

4.

Have you ever, even once, used marijuana or hashish? Marijuana is also called “pot” or “weed.”
Hashish is also called “hash.”
1 = No [GO TO QUESTION #5]
2 = Yes
4a.

How old were you when you first used marijuana or hashish?
_____ age

4b.

In the past 6 months, have you used marijuana or hashish?
1 = No [GO TO QUESTION #5]
2 = Yes

4c.

In the past 30 days, on how many days did you use marijuana or hashish?
_____ day(s)

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
2

CHILD ID:

Substance Use Survey, Revised (SUS–R)

Now I’m going to ask you some questions about drugs you may have used. For each drug I say, please
tell me if you’ve ever used it, even if you only used it one time.
[NOTE TO INTERVIEWER: For each drug or drug class listed in the table, ask (a). For those that the
youth has used, ask (b) and (c). If they have used the drug in the past 6 months, ask (d).]

Substance

d.
In the past 30
c.
b.
days, on how
How old were In the past 6
a.
Have you ever, you when you months, have many days did
you used [drug you use [drug
first used
even once, used
name]?
name]?
[drug name]? [drug name]?
No

Yes

#

No

Yes

#

Cocaine, including all the
different forms of cocaine
sometimes called coke, crack,
or rock

1

2

______

1

2

______

Hallucinogens (These drugs
often cause people to see or
experience things that are not
real. Ex., LSD, mescaline,
peyote, Ashrooms,@ or
psilocybin)

1

2

______

1

2

______

7.

PCP

1

2

______

1

2

______

8.

Ketamine, or Special K

1

2

______

1

2

______

9.

MDMA, often called
“Ecstasy” or “X”

1

2

______

1

2

______

10.

GHB

1

2

______

1

2

______

11.

Inhalants

1

2

______

1

2

______

12.

Heroin

1

2

______

1

2

______

13.

Methamphetamine, crystal,
ice, glass, or other form of
methedrine

1

2

______

1

2

______

5.

6.

For these next drugs, please tell me if you’ve ever used them without a doctor’s prescription or if you
used more than was prescribed for you.
13a. Amphetamines or
stimulants (Also called
“uppers.” Ex.,
Benzedrine,
Biphetamine, Fastin, or
Phentermine)

For all variables and data elements:
Date last modified: December 2009

1

2

______

666 = Not Applicable
777 = Refused

1

2

______

888 = Don’t Know
999 = Missing
3

CHILD ID:

Substance Use Survey, Revised (SUS–R)

d.
In the past 30
c.
b.
days, on how
How old were In the past 6
a.
Have you ever, you when you months, have many days did
you used [drug you use [drug
first used
even once, used
name]?
name]?
[drug name]? [drug name]?

Substance

No

Yes

#

No

Yes

#

Pain killers (Ex., OxyContin,
Darvocet, Tylenol with
codeine, Percodan, Tylox,
Percocet, or Vicodin)

1

2

______

1

2

______

15.

Ritalin, Adderall, or Desoxyn

1

2

______

1

2

______

16.

Tranquilizers or anti-anxiety
drugs (Ex., Valium, Xanax, or
Atarax)

1

2

______

1

2

______

Barbiturates or sedatives (Also
called “downers.” Ex.,
Seconol or Nembutal)

1

2

______

1

2

______

Have you ever used
nonprescription/over-thecounter drugs for the feeling
they cause or taken more than
is recommended? (Ex., diet
pills, pep pills like No-Doz,
and cold or cough medicine
that says DM or Tuss on the
bottle)

1

2

______

1

2

______

Have you used any other
drugs?

1

2

______

1

2

______

1

2

______

1

2

______

14.

17.

18.

19.

19a. If yes, what drugs have
you used?
________________________
________________________
________________________
20.

Have you ever gone to a group meeting or self-help group because of your drinking, smoking, or
drug use?
1 = No [END OF QUESTIONNAIRE]
2 = Yes
20a. Have you gone to a group meeting or self-help group in the past 6 months?
1 = No
2 = Yes

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
4

DRUG IDENTIFICATION LIST
NOTE TO INTERVIEWER: For your purposes only, here are some additional formal and slang names
for the drugs you ask youth about in the Substance Use Survey. Before beginning to administer this
questionnaire, please identify local names for the drugs and use these local names in addition to, or
instead of, the names provided here. Useful Web sites for helping to expand the list provided below
include
http://www.whitehousedrugpolicy.gov/streetterms/
http://www.erowid.org/psychoactives/slang/slang3.shtml
Marijuana
Marijuana, hashish, weed, pot or dope, hash oil, grass, blunts
Cocaine
Powder, Crack, Free Base, Coca paste, rock
Heroin
Hallucinogens
LSD (also called ‘acid’), PCP (also called ‘angel dust’ or phencyclidine), Peyote, Mescaline, Psilocybin
Ecstasy (MDMA)
E, X, XTC
Inhalants
Amyl nitrite, “poppers,” “rush,” correction fluid, degreaser, cleaning fluid, gasoline, lighter fluid, glue,
shoe polish, toluene, Halothane, ether, other anesthetics, lacquer thinner, other paint solvents, lighter
gases (such as butane or propane), nitrous oxide, “whippets,” spray paints, other aerosol sprays
Pain relievers
Darvocet, Darvon, Tylenol with codeine, Percocet, Percodan, Tylox, Vicodin, Lortab, Lorcet, Codeine,
Demerol, Dilaudid, Fioricet, Fiorinal, Hydrocodone, Methadone, Morphine, OxyContin, Phenaphen with
Codeine, Propoxyphene, Stadol, Talacen, Talwin, Talwin NX, Tramadol, Ultram
Tranquilizers
Klonopin, Clonazepam, Xanax, Alprazolam, Ativan, Lorazepam, Valium, Diazepam, Atarax, BuSpar,
Equanil, Flexeril, Librium, Limbitrol, Meprobamate, Miltown, Rohypnol, Serax, Soma, Tranxene,
Vistaril
Prescription stimulants
Desoxyn, Methedrine, Prescription diet pills (such as Amphetamines, Benzedrine, Biphetamine, Fastin, or
Phentermine), Ritalin, Methylphenidate, Cylert, Dexedrine, Dextroamphetamine, Didrex, Eskatrol,
Ionamin, Mazanor, Obedrin - L.A., Plegine, Preludin, Sanorex, Tenuate
Nonprescription stimulants
Uppers, ups, speed, bennies, dexies, pep pills, diet pills, Methamphetamine, meth or crystal meth
Ketamine
Special K, Cat Valium, Vitamin K, Kit kat

Sedatives or barbiturates
(downs, downers, goofballs, yellows, reds, blues, rainbows or sleeping pills) Methaqualone, Sopor,
Quaalude, Barbiturates (such as Nembutal, Pentobarbital, Seconal, Secobarbital, or Butalbital), Restoril,
Temazepam, Amytal, Butisol, Chloral Hydrate, Dalmane, Halcion, Phenobarbital, Placidyl, Tuinal,
Luminal, Debutal
Nonprescription drugs
Prolamine, Wake, Caffedrine, imitation speed, look-alikes, Dextromethorphan, or DXM (says DM or
Tuss on the bottle)
Steroids
Gamma hydroxybutyrate
GHB, Georgia Home Boy, Grievous bodily harm

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
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 0930-0307. Public reporting burden for this
collection of information is estimated to average 4 minutes per response, 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, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

REVISED CHILDREN’S MANIFEST ANXIETY
SCALE, Second Edition (RCMAS–2)
/

RCDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

1 = Intake
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

RCINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

RCMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

RCLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Instructions to respondent: I am going to read you some sentences that tell how some people think and
feel about themselves. Listen to each sentence carefully. Tell me “yes” if you think the sentence is true
about you. Tell me “no” if you think it is not true about you. Tell me an answer for every sentence, even
if it is hard to choose one that fits you. There are no right or wrong answers. Only you can tell us how you
think and feel about yourself. Remember, after I read each sentence, ask yourself, “Is it true about me?” If
it is, say “yes.” If it is not, say “no.”

Date last modified: December 2009

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
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 0930-0307. Public reporting burden for this
collection of information is estimated to average 3 minutes per response, 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, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

REYNOLDS ADOLESCENT DEPRESSION SCALE,
Second Edition (RADS–2)
/

RADSDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

1 = Intake
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

RADSINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

RADSMETH (Method of administering interview) 1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted
RADSLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Instructions to respondent: This questionnaire is about how you feel. I’m going to read you some
sentences and you’ll decide how often you feel this way. Decide if you feel this way almost never, hardly
ever, sometimes, or most of the time. For each sentence, tell me the answer that best describes how you
really feel. Remember, there are no right or wrong answers. Just choose the answer that tells how you
usually feel. [CARD]

Date last modified: December 2009

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
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 0930-0307. Public reporting burden for this
collection of information is estimated to average 15 minutes per response, 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, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

YOUTH INFORMATION QUESTIONNAIRE,
REVISED—Intake (YIQ–R–I)
/

YIQDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

1 = Intake

YIQINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

YIQMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

YIQLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Date last modified: December 2009

CHILD ID:

Youth Information Questionnaire, Revised—Intake (YIQ–R–I)

I am going to be asking you questions on a range of topics, including things about your health,
relationships, safety, and things you may do. It may seem like the questions are unrelated, but all of them
are important for understanding youth and their problems. I will begin by asking you about languages you
speak and then ask some questions about how you spend your time.
[NOTE TO INTERVIEWER: For Questions #1–1b, do not read the response options to the youth.]
1.

What language or languages do you speak? [Select all that apply]
1 = English
2 = Spanish
3 = Other—please specify __________________________
1a.

What language do you usually speak with your family?
1 = English
2 = Spanish
3 = Other—please specify __________________________

1b.

What language do you usually speak with your friends?
1 = English
2 = Spanish
3 = Other—please specify __________________________

2.

In the past 6 months, have you had a job, including formal jobs (e.g., working in a restaurant or
store) or done other work for which you were paid (e.g., babysitting, mowing lawns)?
1 = No [GO TO QUESTION #2g]
2 = Yes
2a.

In how many of the past 6 months have you worked?
_____ months

2b.

In an average month, about how many weeks do you work?
_____ weeks

2c.

In an average week, about how many days do you work?
_____ days

2d.

In an average day, about how many hours do you work?
_____ hours

2e.

About how much money do you make per week?
$__________

2f.

How many days in the past 6 months did you miss work due to your emotional and behavioral
problems, if any?
_____ days [GO TO QUESTION #3]

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
1

CHILD ID:

2g.

Youth Information Questionnaire, Revised—Intake (YIQ–R–I)

Are you at least 14 years old?
1 = No [GO TO QUESTION #3]
2 = Yes

2h.

Which of the following best describes why you have not worked in the past 6 months?
1 = I was trying to find a job but could not find one.
2 = I do not have time to work.
3 = My caregivers do not want me to work.
4 = I do not want to work.
5 = I am attending school.
6 = I am not able to work for physical or emotional reasons.
7 = Other—please specify ____________________________________________

2i.

What are other reasons, if any, why you have not worked in the past 6 months? [Select all
that apply]
1 = I was trying to find a job but could not find one.
2 = I do not have time to work.
3 = My caregivers do not want me to work.
4 = I do not want to work.
5 = I am attending school.
6 = I am not able to work for physical or emotional reasons.
7 = Other—please specify ____________________________________________

3.

In the past 6 months, have you done volunteer work?
1 = No [GO TO QUESTION #4]
2 = Yes
3a.

In how many of the past 6 months did you do volunteer work?
_____ months

4.

Do you have a Social Security number?
1 = No
2 = Yes

Now I would like to ask you about the people outside your family and relatives that you know. I’d like
you to think about close friends and other people you know, including both kids your age and adults.

[CARD 1]
Rarely, Less More than Usually,
almost than half half the almost
always Always
time
Never never the time
5.

How often can you depend on having
someone your own age to talk to?

1

2

3

4

5

6

6.

How often can you depend on having an
adult to talk to?

1

2

3

4

5

6

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
2

CHILD ID:

Youth Information Questionnaire, Revised—Intake (YIQ–R–I)

Rarely, Less More than Usually,
almost than half half the almost
Never never the time
time
always Always
7.

8.

9.

If a problem or emergency arises, how
often can you depend on having someone
your own age to turn to for help and
support?

1

2

3

4

5

6

If a problem or emergency arises, how
often can you depend on having an adult
to turn to for help and support?

1

2

3

4

5

6

How often do you have someone your
own age to have fun or hang out with
when you want to?

1

2

3

4

5

6

1

2

3

4

5

6

10. How often do you have an adult to have
fun or hang out with when you want to?

Now I am going to read you some statements. For each of these statements, please tell me whether the
statement is True or False in describing your experience.
True

False

11.

I felt free to do what I wanted about getting mental health treatment for
myself.

1

2

12.

I chose to get mental health treatment for myself.

1

2

13.

It was my idea to get mental health treatment for myself.

1

2

14.

I had a lot of control over whether I got mental health treatment.

1

2

15.

I had more influence than anyone else on whether I got mental health
treatment.

1

2

These next questions are about problems you may have experienced. I know it may be difficult or
upsetting to answer some of these questions, but they provide information that is very important for
understanding what youth like you are experiencing and for providing services that can help youth.

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
3

CHILD ID:

16.

Youth Information Questionnaire, Revised—Intake (YIQ–R–I)

What were the emotional or behavioral symptoms that led to you receiving services?
[NOTE TO INTERVIEWER: Write down all the problems that the youth says and then select all
that apply. Do not read the response options.]
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
1 = Suicide-related problems (including suicide ideation, suicide attempt, self-injury)
2 = Depression-related problems (including major depression, dysthymia, sleep disorders,
somatic complaints)
3 = Anxiety-related problems (including fears and phobias, generalized anxiety, social
avoidance, obsessive–compulsive behavior, posttraumatic stress disorder)
4 = Hyperactive and attention-related problems (including hyperactive, impulsive, attentional
difficulties)
5 = Conduct/delinquency-related problems (including physical aggression, extreme verbal abuse,
noncompliance, sexual acting out, property damage, theft, running away, sexual assault, fire
setting, cruelty to animals, truancy, police contact)
6 = Substance use, abuse, and dependence-related problems
7 = Adjustment-related problems (including changes in behaviors or emotions in reaction to a
significant life stress)
8 = Psychotic behaviors (including hallucinations, delusions, strange or odd behaviors)
9 = Pervasive developmental disabilities (including autistic behaviors, extreme social avoidance,
stereotypes, perseverative behavior)
10 = Specific developmental disabilities (including enuresis, encopresis, expressive or receptive
speech and language delay)
11 = Learning disabilities
12 = School performance problems not related to learning disabilities
13 = Eating disorders (including anorexia, bulimia)
14 = Other problems—please specify problems __________________________

17.

Have you ever intentionally harmed yourself?
1 = No [GO TO QUESTION #18]
2 = Yes
17a. In the past 6 months, have you intentionally harmed yourself?
1 = No [GO TO QUESTION #18]
2 = Yes
17b. In the past 6 months, did you receive treatment for harming yourself?
1 = No
2 = Yes

18.

Have you ever thought about killing yourself?
1 = No [GO TO QUESTION #19]
2 = Yes

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
4

CHILD ID:

Youth Information Questionnaire, Revised—Intake (YIQ–R–I)

18a. In the past 6 months, have you thought about killing yourself?
1 = No [GO TO QUESTION #19]
2 = Yes
18b. In the past 6 months, did you receive treatment for thinking about killing yourself?
1 = No
2 = Yes
19.

Have you ever tried to kill yourself?
1 = No [GO TO QUESTION #20]
2 = Yes
19a. How many times have you tried to kill yourself?
_____ times
19b. In the past 6 months, have you tried to kill yourself?
1 = No [GO TO QUESTION #20]
2 = Yes
19c. In the past 6 months, did you receive treatment for trying to kill yourself?
1 = No
2 = Yes

Now I would like to ask you about safety and violence in your neighborhood and social groups.
20.

When you’re in your neighborhood, do you feel safe?
1 = No
2 = Yes

21.

In the past 6 months, have you seen any non-violent crime in your neighborhood, such as someone
selling drugs or stealing?
1 = No
2 = Yes

22.

In the past 6 months, have you seen any violent crimes taking place in your neighborhood, such as
someone getting beat up?
1 = No
2 = Yes

23.

In the past 6 months, have you known someone other than yourself who was a victim of a violent
crime in your neighborhood?
1 = No
2 = Yes

24.

In the past 6 months, have you been a victim of a violent crime in your neighborhood?
1 = No
2 = Yes

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
5

CHILD ID:

25.

Youth Information Questionnaire, Revised—Intake (YIQ–R–I)

In the past 6 months, have you been bullied at school or in your neighborhood?
1 = No
2 = Yes

26.

In the past 6 months, have you experienced online bullying or threats (cyber-bullying)?
1 = No
2 = Yes

Now I’m going to ask you some questions about medications that you may be taking for your emotional
or behavioral symptoms.
27.

Now or in the past 6 months, have you taken any prescribed medication for your emotional or
behavioral symptoms?
1 = No [GO TO QUESTION #28]
2 = Yes
27a. In the past 6 months, have these medications helped you feel better?
1 = No [GO TO QUESTION #27c]
2 = Yes
27b. In what ways have they helped you feel better?
_________________________________________________________________________
_________________________________________________________________________
27c. In the past 6 months, have you had any bad side effects from these medications?
1 = No [GO TO QUESTION #27e]
2 = Yes
27d. What were the bad side effects?
_________________________________________________________________________
_________________________________________________________________________

I will now read you several statements. These statements are about any medications that you currently
take, or have taken in the past 6 months, for your emotional or behavioral symptoms. For each of the
statements, please tell me how strongly you agree that the statement reflects your experience.

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
6

CHILD ID:

Youth Information Questionnaire, Revised—Intake (YIQ–R–I)

[CARD 2]
Strongly
Strongly
disagree Disagree Undecided Agree
agree
27e. I understand why I take my medication.

1

2

3

4

5

27f. I know what my medication is supposed
to do for me.

1

2

3

4

5

27g. I had a choice in the medication that I
take.

1

2

3

4

5

27h. I take my medication the way I’m
supposed to.

1

2

3

4

5

27i. I feel comfortable about taking
medication.

1

2

3

4

5

I will now read you several statements. These statements are about things you know and can do in your
daily living. For each of the statements, please indicate how well the statement describes you.

[CARD 3]
Not like Somewhat Very much
me
like me
like me
28.

I can arrange for new telephone service and utilities (such as gas,
water, electricity).

1

2

3

29.

I can complete a rental agreement or lease.

1

2

3

30.

I can calculate the start-up costs for new living arrangements (for
instance, rental deposits, rent, utilities, furnishings).

1

2

3

31.

I can explain how to prevent pregnancy.

1

2

3

32.

I can explain two ways to prevent sexually transmitted diseases
(STDs) such as HIV/AIDS and syphilis.

1

2

3

33.

I can explain what happens to your body if you smoke or chew
tobacco, drink alcohol, or use illegal drugs.

1

2

3

34.

I can explain how I am feeling (like angry, happy, worried, or
depressed).

1

2

3

35.

I can get help if my feelings bother me.

1

2

3

36.

I ask for help when I need it.

1

2

3

37.

I am polite to others.

1

2

3

38.

I show appreciation for things others do for me.

1

2

3

39.

I respect other people’s things.

1

2

3

40.

I get my work done on time.

1

2

3

41.

I get to school or work on time.

1

2

3

42.

I prepare for exams and presentations.

1

2

3

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
7

CHILD ID:

Youth Information Questionnaire, Revised—Intake (YIQ–R–I)

Not like Somewhat Very much
me
like me
like me
43.

I use things in the kitchen, like the microwave, electric mixer,
and oven.

1

2

3

44.

I fix meals for myself on my own.

1

2

3

45.

I store food so it doesn’t spoil or go bad.

1

2

3

46.

With which gender do you identify? [Select only one]
1 = Male
2 = Female
3 = Transgender (male to female)
4 = Transgender (female to male)
5 = I don’t know/I’m not sure
6 = Other—please specify ____________________________________________

47.

How would you describe your sexual orientation? [Select only one]
1 = Heterosexual/straight (attracted only to persons of the opposite sex)
2 = Mostly heterosexual/straight (attracted mostly to persons of the opposite sex)
3 = Bisexual (attracted to both males and females)
4 = Mostly homosexual/gay or lesbian (attracted mostly to persons of the same sex)
5 = Homosexual/gay or lesbian (attracted only to persons of the same sex)
6 = Other—please specify __________________________
7 = I don’t know/I am not sure
8 = I don’t understand this question

I will now read you several statements. These statements are about how you manage your emotions and
mental health, how you manage services and supports, and how you help change or improve service
systems. For each of the statements, please indicate how true it is for you.

[CARD 4]
Never or
almost
never

Always
or almost
Rarely Sometimes Mostly always

48.

When problems arise with my mental health or
emotions, I handle them pretty well.

1

2

3

4

5

49.

I make changes in my life so I can live
successfully with my emotional or mental
health challenges.

1

2

3

4

5

50.

I know how to take care of my mental or
emotional health.

1

2

3

4

5

51.

I work with providers to adjust my services or
supports so they fit my needs.

1

2

3

4

5

52.

When a service or support is not working for
me, I take steps to get it changed.

1

2

3

4

5

53.

I tell service providers what I think about
services I get from them.

1

2

3

4

5

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
8

CHILD ID:

Youth Information Questionnaire, Revised—Intake (YIQ–R–I)

Never or
almost
never

Always
or almost
Rarely Sometimes Mostly always

54.

I help other young people learn about services
or supports that might help them.

1

2

3

4

5

55.

I tell people in agencies and schools how
services for young people can be improved.

1

2

3

4

5

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
9

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
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 0930-0307. Public reporting burden for this
collection of information is estimated to average 15 minutes per response, 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, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

YOUTH INFORMATION QUESTIONNAIRE,
REVISED—Follow-Up (YIQ–R–F)
/

YIQDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

YIQINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

YIQMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

YIQLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Date last modified: December 2009

CHILD ID:

Youth Information Questionnaire, Revised—Follow-Up (YIQ–R–F)

I am going to be asking you questions on a range of topics, including things about your health,
relationships, safety, and things you may do. It may seem like the questions are unrelated, but all of them
are important for understanding youth and their problems.
[NOTE TO INTERVIEWER: Questions #1–1b are skipped, as they are not applicable at follow-up.]
First, I would like to ask you some questions about how you spend your time.
2.

In the past 6 months, have you had a job, including formal jobs (e.g., working in a restaurant or
store) or done other work for which you were paid (e.g., babysitting, mowing lawns)?
1 = No [GO TO QUESTION #2g]
2 = Yes
2a.

In how many of the past 6 months have you worked?
_____ months

2b.

In an average month, about how many weeks do you work?
_____ weeks

2c.

In an average week, about how many days do you work?
_____ days

2d.

In an average day, about how many hours do you work?
_____ hours

2e.

About how much money do you make per week?
$__________

2f.

How many days in the past 6 months did you miss work due to your emotional and behavioral
problems, if any?
_____ days [GO TO QUESTION #3]

2g.

Are you at least 14 years old?
1 = No [GO TO QUESTION #3]
2 = Yes

2h.

Which of the following best describes why you have not worked in the past 6 months?
1 = I was trying to find a job but could not find one.
2 = I do not have time to work.
3 = My caregivers do not want me to work.
4 = I do not want to work.
5 = I am attending school.
6 = I am not able to work for physical or emotional reasons.
7 = Other—please specify ____________________________________________

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
1

CHILD ID:

2i.

Youth Information Questionnaire, Revised—Follow-Up (YIQ–R–F)

What are other reasons, if any, why you have not worked in the past 6 months? [Select all
that apply]
1 = I was trying to find a job but could not find one.
2 = I do not have time to work.
3 = My caregivers do not want me to work.
4 = I do not want to work.
5 = I am attending school.
6 = I am not able to work for physical or emotional reasons.
7 = Other—please specify ____________________________________________

3.

In the past 6 months, have you done volunteer work?
1 = No [GO TO QUESTION #5]
2 = Yes
3a.

In how many of the past 6 months did you do volunteer work?
_____ months

[NOTE TO INTERVIEWER: Question #4 is skipped, as it is not applicable at follow-up.]
Now I would like to ask you about the people outside your family and relatives that you know. I’d like
you to think about close friends and other people you know, including both kids your age and adults.

[CARD 1]
Rarely, Less More than Usually,
almost than half half the almost
Never never the time
time
always Always
5.

How often can you depend on having
someone your own age to talk to?

1

2

3

4

5

6

6.

How often can you depend on having an
adult to talk to?

1

2

3

4

5

6

7.

If a problem or emergency arises, how
often can you depend on having someone
your own age to turn to for help and
support?

1

2

3

4

5

6

If a problem or emergency arises, how
often can you depend on having an adult
to turn to for help and support?

1

2

3

4

5

6

How often do you have someone your
own age to have fun or hang out with
when you want to?

1

2

3

4

5

6

1

2

3

4

5

6

8.

9.

10. How often do you have an adult to have
fun or hang out with when you want to?

[NOTE TO INTERVIEWER: Questions #11–14 are skipped, as they are not applicable at follow-up.]

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
2

CHILD ID:

Youth Information Questionnaire, Revised—Follow-Up (YIQ–R–F)

Now I would like to ask you some questions about the services you have received from {insert system of
care program name} over the past 6 months. For each of these statements, please tell me whether the
statement is True or False in describing your experience.
True

False

14a. The services I received from {insert system of care program name}
were due mostly to the requests I made and not anyone else.

1

2

14b. My involvement in {insert system of care program name} has
benefitted me.

1

2

[NOTE TO INTERVIEWER: Questions #15–17 are skipped, as they are not applicable at follow-up.]
These next questions are about problems you may have experienced. I know it may be difficult or
upsetting to answer some of these questions, but they provide information that is very important for
understanding what youth like you are experiencing and for providing services that can help youth.
17a. In the past 6 months, have you intentionally harmed yourself?
1 = No [GO TO QUESTION #18a]
2 = Yes
17b. In the past 6 months, did you receive treatment for harming yourself?
1 = No
2 = Yes
[NOTE TO INTERVIEWER: Question #18 is skipped, as it is not applicable at follow-up.]
18a. In the past 6 months, have you thought about killing yourself?
1 = No [GO TO QUESTION #19b]
2 = Yes
18b. In the past 6 months, did you receive treatment for thinking about killing yourself?
1 = No
2 = Yes
[NOTE TO INTERVIEWER: Questions #19 and #19a are skipped, as they are not applicable at followup.]
19b. In the past 6 months, have you tried to kill yourself?
1 = No [GO TO QUESTION #20]
2 = Yes
19c. In the past 6 months, did you receive treatment for trying to kill yourself?
1 = No
2 = Yes

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
3

CHILD ID:

Youth Information Questionnaire, Revised—Follow-Up (YIQ–R–F)

Now I would like to ask you about safety and violence in your neighborhood and social groups.
20.

When you’re in your neighborhood, do you feel safe?
1 = No
2 = Yes

21.

In the past 6 months, have you seen any non-violent crime in your neighborhood, such as someone
selling drugs or stealing?
1 = No
2 = Yes

22.

In the past 6 months, have you seen any violent crimes taking place in your neighborhood, such as
someone getting beat up?
1 = No
2 = Yes

23.

In the past 6 months, have you known someone other than yourself who was a victim of a violent
crime in your neighborhood?
1 = No
2 = Yes

24.

In the past 6 months, have you been a victim of a violent crime in your neighborhood?
1 = No
2 = Yes

25.

In the past 6 months, have you been bullied at school or in your neighborhood?
1 = No
2 = Yes

26.

In the past 6 months, have you experienced online bullying or threats (cyber-bullying)?
1 = No
2 = Yes

Now I’m going to ask you some questions about medications that you may be taking for your emotional
or behavioral symptoms.
27.

Now or in the past 6 months, have you taken any prescribed medication for your emotional or
behavioral symptoms?
1 = No [GO TO QUESTION #28]
2 = Yes
27a. In the past 6 months, have these medications helped you feel better?
1 = No [GO TO QUESTION #27c]
2 = Yes

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
4

CHILD ID:

Youth Information Questionnaire, Revised—Follow-Up (YIQ–R–F)

27b. In what ways have they helped you feel better?
_________________________________________________________________________
_________________________________________________________________________
27c. In the past 6 months, have you had any bad side effects from these medications?
1 = No [GO TO QUESTION #27e]
2 = Yes
27d. What were the bad side effects?
_________________________________________________________________________
_________________________________________________________________________
I will now read you several statements. These statements are about any medications that you currently
take, or have taken in the past 6 months, for your emotional or behavioral symptoms. For each of the
statements, please tell me how strongly you agree that the statement reflects your experience.

[CARD 2]
Strongly
Strongly
disagree Disagree Undecided Agree
agree
27e. I understand why I take my medication.

1

2

3

4

5

27f. I know what my medication is supposed
to do for me.

1

2

3

4

5

27g. I had a choice in the medication that I
take.

1

2

3

4

5

27h. I take my medication the way I’m
supposed to.

1

2

3

4

5

27i. I feel comfortable about taking
medication.

1

2

3

4

5

I will now read you several statements. These statements are about things you know and can do in your
daily living. For each of the statements, please indicate how well the statement describes you.

[CARD 3]
Not like Somewhat Very much
me
like me
like me
28.

I can arrange for new telephone service and utilities (such as gas,
water, electricity).

1

2

3

29.

I can complete a rental agreement or lease.

1

2

3

30.

I can calculate the start-up costs for new living arrangements (for
instance, rental deposits, rent, utilities, furnishings).

1

2

3

31.

I can explain how to prevent pregnancy.

1

2

3

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
5

CHILD ID:

Youth Information Questionnaire, Revised—Follow-Up (YIQ–R–F)

Not like Somewhat Very much
me
like me
like me
32.

I can explain two ways to prevent sexually transmitted diseases
(STDs) such as HIV/AIDS and syphilis.

1

2

3

33.

I can explain what happens to your body if you smoke or chew
tobacco, drink alcohol, or use illegal drugs.

1

2

3

34.

I can explain how I am feeling (like angry, happy, worried, or
depressed).

1

2

3

35.

I can get help if my feelings bother me.

1

2

3

36.

I ask for help when I need it.

1

2

3

37.

I am polite to others.

1

2

3

38.

I show appreciation for things others do for me.

1

2

3

39.

I respect other people’s things.

1

2

3

40.

I get my work done on time.

1

2

3

41.

I get to school or work on time.

1

2

3

42.

I prepare for exams and presentations.

1

2

3

43.

I use things in the kitchen, like the microwave, electric mixer,
and oven.

1

2

3

44.

I fix meals for myself on my own.

1

2

3

45.

I store food so it doesn’t spoil or go bad.

1

2

3

46.

With which gender do you identify? [Select only one]
1 = Male
2 = Female
3 = Transgender (male to female)
4 = Transgender (female to male)
5 = I don’t know/I’m not sure
6 = Other—please specify ____________________________________________

47.

How would you describe your sexual orientation? [Select only one]
1 = Heterosexual/straight (attracted only to persons of the opposite sex)
2 = Mostly heterosexual/straight (attracted mostly to persons of the opposite sex)
3 = Bisexual (attracted to both males and females)
4 = Mostly homosexual/gay or lesbian (attracted mostly to persons of the same sex)
5 = Homosexual/gay or lesbian (attracted only to persons of the same sex)
6 = Other—please specify __________________________
7 = I don’t know/I am not sure
8 = I don’t understand this question

I will now read you several statements. These statements are about how you manage your emotions and
mental health, how you manage services and supports, and how you help change or improve service
systems. For each of the statements, please indicate how true it is for you.

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
6

CHILD ID:

Youth Information Questionnaire, Revised—Follow-Up (YIQ–R–F)

[CARD 4]
Never or
almost
never

Always
or almost
Rarely Sometimes Mostly always

48.

When problems arise with my mental health or
emotions, I handle them pretty well.

1

2

3

4

5

49.

I make changes in my life so I can live
successfully with my emotional or mental
health challenges.

1

2

3

4

5

50.

I know how to take care of my mental or
emotional health.

1

2

3

4

5

51.

I work with providers to adjust my services or
supports so they fit my needs.

1

2

3

4

5

52.

When a service or support is not working for
me, I take steps to get it changed.

1

2

3

4

5

53.

I tell service providers what I think about
services I get from them.

1

2

3

4

5

54.

I help other young people learn about services
or supports that might help them.

1

2

3

4

5

55.

I tell people in agencies and schools how
services for young people can be improved.

1

2

3

4

5

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
7

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
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 0930-0307. Public reporting burden for this
collection of information is estimated to average 5 minutes per response, 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, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

YOUTH SERVICES SURVEY
Abbreviated Version (YSS)
/

YSSDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

YSSINTV (Who administered interview)

2 = Data collector

YSSMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

YSSLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Date last modified: December 2009

CHILD ID:

Youth Services Survey, Abbreviated Version (YSS)

Please think about all the services you and your family received over the past 6 months. These services
may include treatment received from a therapist or clinician such as individual therapy, or support such
as case management, or transportation. These services may also include help you and your family
received through your school, a child welfare agency, the police, and the courts. All of these services are
part of the service system in your community that works with children and families.
Have you or your family received any services like these in the past 6 months?
1 = No [END OF QUESTIONNAIRE]
2 = Yes
We are interested in knowing what you think about the services you and your family received during the
past 6 months.
Your opinions are important, so please be honest and tell us what you think. We want to know how you
felt, good or bad! Remember that what you say will be kept confidential. People who provide services to
you and your family will never find out what you have told us.
I will read you several statements. For each of the statements, please tell me the extent to which you
disagree or agree that the statement describes your experience.

[CARD]
Strongly
Strongly
disagree Disagree Undecided Agree
agree
1.

Overall, I am satisfied with the services I
received.

1

2

3

4

5

2.

I helped to choose my services.

1

2

3

4

5

3.

I helped to choose my treatment goals.

1

2

3

4

5

4.

The people helping me stuck with me no matter
what.

1

2

3

4

5

5.

I felt I had someone to talk to when I was
troubled.

1

2

3

4

5

6.

I participated in my own treatment.

1

2

3

4

5

7.

I received services that were right for me.

1

2

3

4

5

8.

The location of services was convenient.

1

2

3

4

5

9.

Services were available at times that were
convenient for me.

1

2

3

4

5

10.

I got the help I wanted.

1

2

3

4

5

11.

I got as much help as I needed.

1

2

3

4

5

12.

Staff treated me with respect.

1

2

3

4

5

13.

Staff respected my family’s religious and
spiritual beliefs.

1

2

3

4

5

14.

Staff spoke with me in a way that I understood.

1

2

3

4

5

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
1

CHILD ID:

Youth Services Survey, Abbreviated Version (YSS)

Strongly
Strongly
disagree Disagree Undecided Agree
agree
15.

Staff were sensitive to my cultural and ethnic
background.

1

2

3

4

5

As a result of the services I received:
16.

I am better at handling daily life.

1

2

3

4

5

17.

I get along better with family members.

1

2

3

4

5

18.

I get along better with friends and other people.

1

2

3

4

5

19.

I am doing better in school and/or work.

1

2

3

4

5

20.

I am better able to cope when things go wrong.

1

2

3

4

5

21.

I am satisfied with my family life right now.

1

2

3

4

5

22.

I am better able to do the things I want to do.

1

2

3

4

5

As a result of the services I received: please answer for relationships with persons other than your mental
health or other provider(s)
23.

I know people who will listen and understand
me when I need to talk.

1

2

3

4

5

24.

I have people whom I am comfortable talking
with about my problems.

1

2

3

4

5

25.

In a crisis, I would have the support I need from
family and friends.

1

2

3

4

5

26.

I have people with whom I can do enjoyable
things.

1

2

3

4

5

27.

What has been the most helpful thing about the services you received over the past 6 months?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

*Developed by Brunk et al. (1999)

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
2