Form NOMs Instruments NOMs Instruments NOMs Instruments

National Outcome Measures for Substance Abuse Prevention

128Attachment B NOMs Instruments (FINAL)

CSAP/NOMs

OMB: 0930-0230

Document [docx]
Download: docx | pdf

Shape5

Form Approved

OMB No.: 09300230

     Expiration Date:  04/30/2012










Center for Substance Abuse Prevention

National Outcome Measures



Adult Community Form


(Adults ages 18 and older)


Use this Adult Community Form for communities in which data may be collected at a single point in time or at multiple time points, each time using different samples of individuals.


Shape1













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 0930-0230. Public reporting burden for this collection of information is estimated to average 0.4 hours per response. 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.


Center for Substance Abuse Prevention
National Outcome Measures

Adult Community Form


This form is voluntary. If you choose to take it, you may skip any question you don’t want to answer. If you decide not to fill out this form, it will have no effect on your participation in direct service programs.


This form asks about your experience and opinion on a number of topics related to alcohol, tobacco, and drug use. No one will connect your answers with your name or other identifying information. To help us protect the privacy of your answers, please do not write your name on this form.


The information in this form will be used to learn more about the effectiveness of programs in preventing substance abuse.


This is not a test, so there are no right or wrong answers. Some questions may ask you to select all of the answers that are relevant, and others ask you to select a single answer. If the question asks for a single answer and you don’t find an answer that exactly fits, choose one that comes closest.


Thank you for agreeing to participate.

Shape2

RECORD MANAGEMENT: Your form administrator will tell you what to fill in for these administrative questions. You may leave all but Date Completed blank if you are not given any instructions.

Shape3


Participant ID













Contract/Grant ID













Date Completed


/


/


Month


Day


Year


Program Name



Cohort Number





These questions ask for general information about you. Please mark the response that best describes you.

  1. What is your gender? (Check one)
    Male Female

  2. Are you Hispanic or Latino? (Check one)
    Yes No

  3. What is your race? (Select one or more)
    American Indian or Alaska Native
    Asian
    Black or African American
    Native Hawaiian or Other Pacific Islander
    White

  4. What is your date of birth?


    /


    Month


    Year

  5. Have you ever served in the Armed Forces, in the Reserves, or the National Guard [select all that apply]?

No, (Skip to #6]

Yes, in the Armed Forces

Yes, in the Reserves

Yes, in the National Guard



5a. Are you currently on active duty in the Armed Forces, in the Reserves, or the National Guard [select all that apply]?

Yes, in the Armed Forces

Yes, in the Reserves

Yes, in the National Guard

No, separated or retired from Armed Forces, Reserves, or National Guard

5b. Have you ever been deployed to a combat zone [select all that apply]?

Never deployed 

Iraq or Afghanistan (e.g., Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn)

Persian Gulf (Operation Desert Shield or Desert Storm)

Vietnam/Southeast Asia

Korea

WWII

Deployed to a combat zone not listed above (e.g., Somalia, Bosnia, Kosovo) 


  1. 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 Armed Forces, Reserves, or the National Guard?

Yes

Yes, more than one

No, (Skip to #8)


  1. If yes (answer for up to six people):

7a. What is the relationship of that person (Service Member) to you:

  Mother/Father

  Brother/Sister

  Spouse/Partner

  Child

  Other, Specify___________



The next few questions ask about your use of and attitudes toward tobacco,
alcohol, and other substances.

  1. Think back over the past 30 days and report how many days, if any, you used the following substances:




Fill in number of days
(0 – 30)

Check if don’t know or can’t say

Cigarettes: Include menthol and regular cigarettes and loose tobacco rolled into cigarettes

8a.

During the past 30 days, on how many days did you smoke part or all of a cigarette?




Other tobacco products: Include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe

8b.

During the past 30 days, on how many days did you use other tobacco products?




Alcoholic beverages: Include beer, wine, wine coolers, malt beverages, and liquor

8c.

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




Marijuana or hashish: Also known as grass, pot, hash, or hash oil

8d.

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




Other illegal drugs: Include substances like:

  • Heroin, crack or cocaine, methamphetamine

  • Hallucinogens (drugs that cause people to see or experience things that are not real) such as LSD (sometimes called acid), Ecstasy (sometimes called MDMA), PCP or peyote (sometimes called angel dust)

  • Inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to “feel good” or to get high)

  • Prescription drugs without a doctor’s orders, just to “feel good” or to get high

8e.

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




  1. Think back over your entire lifetime and try to remember whether you have EVER used any of the following substances. If so, what was your age the FIRST TIME you used the substance:




Check if NEVER

Fill in your age when you first used (in years)

Check if don’t know or can’t say

Cigarettes: Include menthol and regular cigarettes and loose tobacco rolled into cigarettes

9a.

Ever smoked part or all of a cigarette?






Other tobacco products: Include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe

9b.

Ever used any other tobacco product?






Alcoholic beverages: Include beer, wine, wine coolers, malt beverages, and liquor

9c.

Ever had a drink of an alcoholic beverage? Do NOT include any time when you only had a sip or two from a drink.






Marijuana or hashish: Also known as grass, pot, hash, or hash oil

9d.

Ever used marijuana or hashish?








Other illegal drugs: Include substances like:

  • Heroin, crack or cocaine, methamphetamine

  • Hallucinogens (drugs that cause people to see or experience things that are not real) such as LSD (sometimes called acid), Ecstasy (sometimes called MDMA), PCP or peyote (sometimes called angel dust)

  • Inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to “feel good” or to get high)

  • Prescription drugs without a doctor’s orders, just to “feel good” or to get high

9e.

Ever used any other illegal drug?






  1. For each of the three questions below check one box that shows HOW MUCH you think people RISK HARMING themselves physically or in other ways when they engage in the following behaviors:



No risk

Slight risk

Moderate risk

Great risk

Don’t know or can’t say

10a.

When they smoke one or more packs of CIGARETTES per day?

10b.

When they smoke MARIJUANA once or twice a week?

10c.

When they have five or more drinks of an ALCOHOLIC BEVERAGE once or twice a week?


This section asks just a few additional questions about your attitudes and experiences.


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


More likely

Less likely

Would make no difference

Don’t know or can’t say




  1. Now think about the past 12 months through today. DURING THE PAST 12 MONTHS, how many times have you talked with your child about the dangers or problems associated with the use of tobacco, alcohol, or drugs?

Don’t have any children

0 times

1 to 2 times

A few times

Many times

Don’t know or can’t say































Form Approved OMB No.: 09300230

     Expiration Date:  04/30/2012









Center for Substance Abuse Prevention

National Outcome Measures


Youth Community Form


(Youth ages 12-17)


Use this Youth Community Form for communities in which data may be collected at a single point in time or at multiple time points, each time using different samples of individuals.


Shape7














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 0930-0230. Public reporting burden for this collection of information is estimated to average 0.4 hours per response. 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.


Center for Substance Abuse Prevention

National Outcome Measures

Youth Community Form


This form is voluntary. If you choose to take it, you may skip any question you don’t want to answer. If you decide not to fill out this form, it will have no effect on your participation in direct service programs.


This form asks about your experience and opinion on a number of things related to alcohol, tobacco, and drug use. No one will connect your answers with your name or any other information about you that can identify who you are. To help us keep your answers secret, please do not write your name on this form.


The information in this form will be used to learn more about the effectiveness of programs in preventing substance abuse and protecting youth.


This is not a test, so there are no right or wrong answers. Some questions may ask you to select all of the answers that are relevant, and others ask you to select a single answer. If the question asks for a single answer and you don’t find an answer that exactly fits, choose one that comes closest.


Thank you for agreeing to participate.

Shape8

RECORD MANAGEMENT: Your form administrator will tell you what to fill in for these administrative questions. You may leave all but Date Completed blank if you are not given any instructions.

Shape9


Participant ID













Contract/Grant ID













Date Completed


/


/


Month


Day


Year


Program Name



Cohort Number





These questions ask for general information about you. Please mark the response that best describes you.


  1. What is your gender? (Check one)
    Male Female

  2. Are you Hispanic or Latino? (Check one)
    Yes No

  3. What is your race? (Select one or more)
    American Indian or Alaska Native
    Asian
    Black or African American
    Native Hawaiian or Other Pacific Islander
    White

  4. What is your date of birth?


    /


    Month


    Year

  5. 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 Armed Forces, Reserves, or the National Guard?

Yes

Yes, more than one

No, (Skip to #7)


  1. If yes (answer for up to six people):

6a. What is the relationship of that person (Service Member) to you:

Mother

Father

Brother/Sister

Aunt/Uncle

Grandparent

Other, Specify_____________



The next few questions ask about your use of and attitudes toward tobacco,
alcohol, and other substances.





  1. Think back over the past 30 days and report how many days, if any, you used the following substances:




    Fill in number of days
    (0 – 30)

    Check if don’t know or can’t say

    Cigarettes: Include menthol and regular cigarettes and loose tobacco rolled into cigarettes

    7a.

    During the past 30 days, on how many days did you smoke part or all of a cigarette?




    Other tobacco products: Include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe

    7b.

    During the past 30 days, on how many days did you use other tobacco products?




    Alcoholic beverages: Include beer, wine, wine coolers, malt beverages, and liquor

    7c.

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




    Marijuana or hashish: Also known as grass, pot, hash, or hash oil

    7d.

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




    Other illegal drugs: Include substances like:

    • Heroin, crack or cocaine, methamphetamine

    • Hallucinogens (drugs that cause people to see or experience things that are not real) such as LSD (sometimes called acid), Ecstasy (sometimes called MDMA), PCP or peyote (sometimes called angel dust)

    • Inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to “feel good” or to get high)

    • Prescription drugs without a doctor’s orders, just to “feel good” or to get high

    7e.

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




  2. Think back over your entire lifetime and try to remember whether you have EVER used any of the following substances. If so, what was your age the FIRST TIME you used the substance:




    Check if NEVER

    Fill in your age when you first used (in years)

    Check if don’t know or can’t say

    Cigarettes: Include menthol and regular cigarettes and loose tobacco rolled into cigarettes

    8a.

    Ever smoked part or all of a cigarette?






    Other tobacco products: Include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe

    8b.

    Ever used any other tobacco product?






    Alcoholic beverages: Include beer, wine, wine coolers, malt beverages, and liquor

    8c.

    Ever had a drink of an alcoholic beverage? Do NOT include any time when you only had a sip or two from a drink.






    Marijuana or hashish: Also known as grass, pot, hash, or hash oil

    8d.

    Ever used marijuana or hashish?








    Other illegal drugs: Include substances like:

    • Heroin, crack or cocaine, methamphetamine

    • Hallucinogens (drugs that cause people to see or experience things that are not real) such as LSD (sometimes called acid), Ecstasy (sometimes called MDMA), PCP or peyote (sometimes called angel dust)

    • Inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to “feel good” or to get high)

    • Prescription drugs without a doctor’s orders, just to “feel good” or to get high

    8e.

    Ever used any other illegal drug?





  3. For each of the following five questions below check the box that shows how YOU think or feel.



Neither approve nor disapprove

Somewhat disapprove

Strongly disapprove

Don’t know or can’t say

9a.


How do you feel about someone your age smoking one or more packs of cigarettes a day?

9b.

How do you think your close friends would feel about YOU smoking one or more packs of cigarettes a day?

9c.


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

9d.


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

9e.


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


  1. For each of the three questions below check one box that shows HOW MUCH you think people RISK HARMING themselves physically or in other ways when they do the following things:



No risk

Slight risk

Moderate risk

Great risk

Don’t know or can’t say

10a.

When they smoke one or more packs of CIGARETTES per day?

10b.

When they smoke MARIJUANA once or twice a week?

10c.

When they have five or more drinks of an ALCOHOLIC BEVERAGE once or twice a week?





This section asks just a few additional questions about your attitudes and experiences.



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



More likely

Less likely

Would make no difference

Don’t know or can’t say

  1. 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.

Yes

No

Don’t know or can’t say


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

Yes

No

Don’t know or can’t say




















Form Approved

OMB No.: 09300230

     Expiration Date:  04/30/2012








Center for Substance Abuse Prevention

National Outcome Measures



Adult Programs Form


(Adult participants ages 18 and older)


Use this Adult Programs Form for participants in prevention interventions who are expected to complete forms at baseline, exit, and followup periods.


Shape13
















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 0930-0230. Public reporting burden for this collection of information is estimated to average 0.4 hours per response. 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


Center for Substance Abuse Prevention

National Outcome Measures


Adult Programs Form


This form is voluntary. If you choose to take it, you may skip any question you don’t want to answer. If you decide not to fill out this form, it will have no effect on your participation in direct service programs.


This form asks about your experience and opinion on a number of topics related to alcohol, tobacco, and drug use. No one will connect your answers with your name or other identifying information. To help us protect the privacy of your answers, please do not write your name on this form.


The information in this form will be used to learn more about the effectiveness of programs in preventing substance abuse.


This is not a test, so there are no right or wrong answers. Some questions may ask you to select all of the answers that are relevant, and others ask you to select a single answer. If the question asks for a single answer and you don’t find an answer that exactly fits, choose one that comes closest.

Thank you for agreeing to participate.

Shape16

RECORD MANAGEMENT: Your form administrator will tell you what to fill in for these administrative questions. You may leave all but Date Completed blank if you are not given any instructions.

Shape17

Participant ID












Contract/Grant ID













Date Completed


/


/


Month


Day


Year


Form Type (Check one)

Baseline Exit First followup after exit Second followup


Program Name


­­­­­­­­­­Cohort Number




These questions ask for general information about you. Please mark the response that best describes you.

  1. What is your gender? (Check one)
    Male Female

  2. Are you Hispanic or Latino? (Check one)
    Yes No

  3. What is your race? (Select one or more)
    American Indian or Alaska Native
    Asian
    Black or African American
    Native Hawaiian or Other Pacific Islander
    White

  4. What is your date of birth?


    /


    Month


    Year

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

No, (Skip to #6]

Yes, in the Armed Forces

Yes, in the Reserves

Yes, in the National Guard

5b. Are you currently on active duty in the Armed Forces, in the Reserves, or the National Guard [select all that apply]?

Yes, in the Armed Forces

Yes, in the Reserves

Yes, in the National Guard

No, separated or retired from Armed Forces, Reserves, or National Guard


5c. Have you ever been deployed to a combat zone [select all that apply]?

Never deployed 

Iraq or Afghanistan (e.g., Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn)

Persian Gulf (Operation Desert Shield or Desert Storm)

Vietnam/Southeast Asia

Korea

WWII

Deployed to a combat zone not listed above (e.g., Somalia, Bosnia, Kosovo) 


  1. 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 Armed Forces, Reserves, or the National Guard?


Yes

Yes, more than one

No, (Skip to #8)


  1. If yes (answer for up to six people):

7a. What is the relationship of that person (Service Member) to you:

  Mother/Father

  Brother/Sister

  Spouse/Partner

  Child

  Other, Specify___________



The next few questions ask about your use of and attitudes toward tobacco, alcohol, and other substances.



  1. Think back over the past 30 days and report how many days, if any, you used the following substances:




Fill in number of days (0 – 30)


Check if don’t know or can’t say

Cigarettes: Include menthol and regular cigarettes and loose tobacco rolled into cigarettes

8a.

During the past 30 days, on how many days did you smoke part or all of a cigarette?







Other tobacco products: Include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe

8b.

During the past 30 days, on how many days did you use other tobacco products?







Alcoholic beverages: Include beer, wine, wine coolers, malt beverages, and liquor

8c.

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







Marijuana or hashish: Also known as grass, pot, hash, or hash oil

8d.

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







Other illegal drugs: Include substances like:

  • Heroin, crack or cocaine, methamphetamine

  • Hallucinogens (drugs that cause people to see or experience things that are not real) such as LSD (sometimes called acid), Ecstasy (sometimes called MDMA), PCP or peyote (sometimes called angel dust)

  • Inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to “feel good” or to get high)

  • Prescription drugs without a doctor’s orders, just to “feel good” or to get high

8e.

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








  1. Think back over your entire lifetime and try to remember whether you have EVER used any of the following substances. If so, what was your age the FIRST TIME you used the substance:






Check if NEVER

Fill in your age when you first used (in years )

Check if don’t know or can’t say

Cigarettes: Include menthol and regular cigarettes and loose tobacco rolled into cigarettes

9a.

Ever smoked part or all of a cigarette?






Other tobacco products: Include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe

9b.

Ever used any other tobacco product?







Alcoholic beverages: Include beer, wine, wine coolers, malt beverages, and liquor

9c.

Ever had a drink of an alcoholic beverage? Do NOT include any time when you only had a sip or two from a drink.





Marijuana or hashish: Also known as grass, pot, hash, or hash oil

9d.

Ever used marijuana or hashish?





Other illegal drugs: Include substances like:

  • Heroin, crack or cocaine, methamphetamine

  • Hallucinogens (drugs that cause people to see or experience things that are not real) such as LSD (sometimes called acid), Ecstasy (sometimes called MDMA), PCP or peyote (sometimes called angel dust)

  • Inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to “feel good” or to get high)

  • Prescription drugs without a doctor’s orders, just to “feel good” or to get high

9e.

Ever used any other illegal drug?










  1. For each of the three questions below check one box that shows HOW MUCH you think people RISK HARMING themselves physically or in other ways when they engage in the following behaviors:




No risk


Slight risk

Moderate risk

Great risk

Don’t know or can’t say

10a.

When they smoke one or more packs of CIGARETTES per day?







10b.

When they smoke MARIJUANA once or twice a week?







10c.

When they have five or more drinks of an ALCOHOLIC BEVERAGE once or twice a week?







This section asks just a few additional questions about your attitudes and experiences.


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

More likely

Less likely

Would make no difference

Don’t know or can’t say


  1. DURING THE PAST 12 MONTHS, have you
    driven a vehicle while you were under the influence of alcohol?

Yes

No

Don’t know or can’t say




  1. Now think about the past 12 months through today. DURING THE PAST 12 MONTHS, how many times have you talked with your child about the dangers or problems associated with the use of tobacco, alcohol, or drugs?

Don’t have any children


0 times


1 to 2 times

A few times

Many times

Don’t know or can’t say

































Form Approved

OMB No.: 09300230

     Expiration Date: 04/30/2012










Center for Substance Abuse Prevention

National Outcome Measures


Youth Programs Form


(Participants ages 12-17)


Use this Youth Programs Form for participants in prevention interventions who are expected to complete forms at baseline, exit, and followup periods.


Shape18
















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 0930-0230. Public reporting burden for this collection of information is estimated to average 0.4 hours per response. 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.



Center for Substance Abuse Prevention

National Outcome Measures



Youth Programs Form


This form is voluntary. If you choose to take it, you may skip any question you don’t want to answer. If you decide not to fill out this form, it will have no effect on your participation in direct service programs.


This form asks about your experience and opinion on a number of things related to alcohol, tobacco, and drug use. No one will connect your answers with your name or any other information about you that can identify who you are. To help us keep your answers secret, please do not write your name on this form.


The information in this form will be used to learn more about the effectiveness of programs in preventing substance abuse and protecting youth.


This is not a test, so there are no right or wrong answers. Some questions may ask you to select all of the answers that are relevant, and others ask you to select a single answer. If the question asks for a single answer and you don’t find an answer that exactly fits, choose one that comes closest.


Thank you for agreeing to participate.

Shape19

RECORD MANAGEMENT: Your form administrator will tell you what to fill in for these administrative questions. You may leave all but Date Completed blank if you are not given any instructions.

Shape20


Participant ID












Contract/Grant ID













Date Completed


/


/


Month


Day


Year


Form Type (Check one)

Baseline Exit First follow-up after exit Second follow-up


Program Name


­­­­­­­­­­Cohort Number



These questions ask for general information about you. Please mark the response that best describes you.

  1. What is your gender? (Check one)
    Male Female

  2. Are you Hispanic or Latino? (Check one)
    Yes No

  3. What is your race? (Select one or more)
    American Indian or Alaska Native
    Asian
    Black or African American
    Native Hawaiian or Other Pacific Islander

White

  1. What is your date of birth?


    /


    Month


    Year


  2. 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 Armed Forces, Reserves, or the National Guard?

Yes

Yes, more than one

No, (Skip to #7)


  1. If yes (answer for up to six people above):

6a. What is the relationship of that person (Service Member) to you:

Mother

Father

Brother/Sister

Aunt/Uncle

Grandparent

Other, Specify_____________





The next few questions ask about your use of and attitudes toward tobacco, alcohol, and other substances.



  1. Think back over the past 30 days and report how many days, if any, you used the following substances:




Fill in number of days (0 – 30)


Check if don’t know or can’t say

Cigarettes: Include menthol and regular cigarettes and loose tobacco rolled into cigarettes

7a.

During the past 30 days, on how many days did you smoke part or all of a cigarette?







Other tobacco products: Include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe

7b.

During the past 30 days, on how many days did you use other tobacco products?







Alcoholic beverages: Include beer, wine, wine coolers, malt beverages, and liquor

7c.

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







Marijuana or hashish: Also known as grass, pot, hash, or hash oil

7d.

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







Other illegal drugs: Include substances like:

  • Heroin, crack or cocaine, methamphetamine

  • Hallucinogens (drugs that cause people to see or experience things that are not real) such as LSD (sometimes called acid), Ecstasy (sometimes called MDMA), PCP or peyote (sometimes called angel dust)

  • Inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to “feel good” or to get high)

  • Prescription drugs without a doctor’s orders, just to “feel good” or to get high

7e.

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








  1. Think back over your entire lifetime and try to remember whether you have EVER used any of the following substances. If so, what was your age the FIRST TIME you used the substance:






Check if NEVER

Fill in your age when you first used (in years)

Check if don’t know or can’t say

Cigarettes: Include menthol and regular cigarettes and loose tobacco rolled into cigarettes

8a.

Ever smoked part or all of a cigarette?






Other tobacco products: Include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe

8b.

Ever used any other tobacco product?







Alcoholic beverages: Include beer, wine, wine coolers, malt beverages, and liquor

8c.

Ever had a drink of an alcoholic beverage? Do NOT include any time when you only had a sip or two from a drink.





Marijuana or hashish: Also known as grass, pot, hash, or hash oil

8d.

Ever used marijuana or hashish?





Other illegal drugs: Include substances like:

  • Heroin, crack or cocaine, methamphetamine

  • Hallucinogens (drugs that cause people to see or experience things that are not real) such as LSD (sometimes called acid), Ecstasy (sometimes called MDMA), PCP or peyote (sometimes called angel dust)

  • Inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to “feel good” or to get high)

  • Prescription drugs without a doctor’s orders, just to “feel good” or to get high

8e.

Ever used any other illegal drug?










  1. For each of the following five questions below check the box that shows how YOU think or feel.




Neither approve nor disapprove



Somewhat disapprove



Strongly disapprove

Don’t know or can’t say

9a.


How do you feel about someone your age smoking one or more packs of cigarettes a day?

9b.

How do you think your close friends would feel about YOU smoking one or more packs of cigarettes a day?

9c.


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

9d.


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

9e.


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


  1. For each of the three questions below check one box that shows HOW MUCH you think people RISK HARMING themselves physically or in other ways when they do the following things:



No risk

Slight risk

Moderate risk

Great risk

Don’t know or can’t say

10a.

When they smoke one or more packs of CIGARETTES per day?






10b.

When they smoke MARIJUANA once or twice a week?






10c.

When they have five or more drinks of an ALCOHOLIC BEVERAGE once or twice a week?







This section asks just a few additional questions about your attitudes and experiences.


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

More likely

Less likely

Would make no difference

Don’t know or can’t say


  1. DURING THE PAST 12 MONTHS, have you driven a vehicle while you were under the influence of alcohol?


Yes

No

Don’t know or can’t say



  1. 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.

Yes

No

Don’t know or can’t say


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

Yes

No

Don’t know or can’t say






Shape6

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleSection One: Demographics
Authorfsabel
File Modified0000-00-00
File Created2021-01-29

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