Form Youth Questionnair Youth Questionnair Youth Questionnaire
Minority Substance Abuse/HIV Prevention Initiative
1.HIV shortened Youth Questionnaire_8-10-2015-OMB
Youth
OMB: 0930-0298
Form Approved
OMB No.:0930-0298
Expiration Date:
National Minority SA/HIV Prevention Initiative
Youth Questionnaire
TO BE FILLED OUT BY THE LOCAL GRANT SITE DATA COLLECTOR
Last Name , First Name M.I.
Participant ID #: |
RESPONDENT OR PARTICIPANT: Before answering any of the questions, please make sure your name is correct. If incorrect, make the change in the box above. Do not write your name on any other page in this questionnaire. Thank you.
National
Minority
SA/HIV
Prevention
Initiative
Youth Questionnaire
Funding for data collection supported by the
Center for Substance Abuse Prevention (CSAP),
Substance
Abuse
and Mental
Health
Services
Administration
(SAMHSA),
U.S.
Department
of
Health
and Human
Services
(HHS)
These questions are part of a data collection effort about how to prevent substance abuse and HIV infection. The questions are being asked of hundreds of other individuals throughout the United States. The data findings will be used to help prevention initiatives learn more about how to keep young people from using drugs and getting infected with HIV.
Completing this questionnaire is voluntary. If you do not want to answer any of the questions, you do not have to. If you decide not to participate in this survey, it will have no effect on your participation in direct service programs. However, your answers are very important to us. Please answer the questions honestly—based on what you really do, think, and feel. Your answers will not be told to anyone in your family or community. Do not write your name anywhere on this questionnaire.
We would like you to work fairly quickly, so that you can finish. Please work quietly by yourself. If you have any
questions or don’t understand something, let the data collector know.
We think you will find the questionnaire to be interesting and that you will like filling it out. Thank you very much for being an important part of this data collection effort!
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0298. 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 2-1057, Rockville, MD 20857. |
INSTRUCTIONS |
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1. Answer each question by marking one of the answer circles. Some questions allow you to mark more than one answer. If you don’t find an answer that fits exactly, choose the one that comes closest.
2. Mark your answers carefully so we can tell which answer circle you chose. Do not mark between the circles.
3. It is very important that you answer each question truthfully. Your responses will not be helpful unless you tell the truth.
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MARKING YOUR ANSWERS |
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EXAMPLES |
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Correct Marks:
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Record Management Section: To Be Completed by Designated Staff |
Grant ID
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P |
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Study Design Group (Select one)
Intervention Comparison
Participant
ID
Date of Survey Administration
/ /
Month Day Year
Interview Type (Select one)
Baseline Exit Follow-up
Service Duration (Select one)
Single-session (1 day or less duration)
Multiple-session brief (2 – 29 days’ duration)
Multiple-session long (30 days or longer duration)
Intervention Name(s)
(If the participant is receiving direct services from more than one intervention, please list each intervention below.)
1.
2.
3.
Section One: Facts About You |
First, we’d like to ask some questions about you. We are not going to use this information to identify you, but instead to talk about what different groups of people have to say. For example, what boys have to say, and how that may be different from what girls have to say. Or how 12-year-olds feel about different things, and how that might be different from what 17-year-olds feel. |
How would you describe yourself? (Gender)
Male
Female
Other (Specify________)
In what year were you born? (Enter all four digits of the year in the boxes below, and fill in corresponding circles)
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1 2 |
0 1 2 3 4 5 6 7 8 9 |
0 1 2 3 4 5 6 7 8 9 |
0 1 2 3 4 5 6 7 8 9 |
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Are you of Hispanic, Latino/a, or Spanish origin? (If yes, you may select one or more categories)
No, not of Hispanic, Latino/a, or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino/a, or Spanish origin
What is your race? (Select one or more)
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
How would you describe yourself? (Sexual orientation)
Straight or heterosexual
Bisexual
Gay or lesbian
Unsure
What is your primary spoken language?
English
Spanish
Asian (Chinese, Japanese, or other)
American Indian (Apache, Blackfoot, Navajo, or other)
Other
How well do you speak English?
Very well
Well
Not well
Not at all
Do you have any health issues that affect your ability to see, hear, move around easily, or do self-care like dress yourself or brush your teeth?
Yes
No
With whom do you live? (Mark all that apply)
Alone
With parents
With relatives other than parents
With a foster family
With roommates
Other
Describe where you live.
In my own home or apartment
In a relative’s home
In a group home
In campus/dormitory housing
In a foster home
Homeless or in a shelter
Other
What is the highest level of education you have finished? (Mark the highest grade you have completed.)
Elementary school
Middle school
High school
Beyond high school
Have you ever been suspended from school for drug or alcohol use?
Yes
No
If you have ever been in juvenile/adult detention, jail, or prison for more than 3 days, how long has it been since you last got out?
Never in juvenile/adult detention, jail, or prison for more than 3 days
Less than two years
Two years or more
Is anyone in your family or someone close to you on active duty in the Armed Forces, in the Reserves or the National Guard, or separated or retired from the Armed Forces, the Reserves, or the National Guard?
No (Skip to #16)
Yes, 1 person
Yes, 2 people
Yes, 3 people
Yes, 4 people
Yes, 5 people
Yes, 6 or more people
If yes, answer the following questions for each person you marked in question 16 (up to six people).
-
Service Member #1
Service Member #2
Service Member #3
Service Member #4
Service Member #5
Service Member #6
Service member’s relationship to you:
Mother/father
Brother/sister
Spouse/Partner
Boyfriend/girlfriend
Other, specify
End of Section 1
Section Two: Attitudes & Knowledge |
In this section, we are going to ask how you feel about certain things, such as school, substance use, and sexual behavior. We are also going to ask what you know about HIV/AIDS. Remember, your answers are private and will not be used to identify you. |
What were your most recent grades in school?
I am not in school
Mostly As
Mostly Bs
Mostly Cs
Mostly Ds
Mostly Fs
How often do you feel that the school work you are assigned is meaningful and important?
I am not in school
Almost always
Often
Sometimes
Seldom
Never
How interesting are most of your classes to you?
I am not in school
Very interesting
Quite interesting
Fairly interesting
Slightly dull
Very dull
How important do you think things you are learning in school are going to be for you later in life?
I am not in school
Very important
Quite important
Fairly important
Slightly important
Not at all important
The next five questions (20 – 24) ask about your ETHNIC GROUP. An ethnic group is a cultural group that has a shared history, similar customs, traditions, and sometimes shared values.
I am active in organizations or social groups that include mostly members of my own ethnic group.
Strongly agree
Agree
Disagree
Strongly disagree
I think a lot about how my life is affected by my ethnic group’s history, traditions, and customs.
Strongly agree
Agree
Disagree
Strongly disagree
I have often talked to other people about my ethnic background.
Strongly agree
Agree
Disagree
Strongly disagree
I am interested in learning more about my ethnic background.
Strongly agree
Agree
Disagree
Strongly disagree
I participate in cultural practices of my own ethnic group, such as special food, music, or customs.
Strongly agree
Agree
Disagree
Strongly disagree
In general, how important are religious or spiritual beliefs in your day-to-day life?
Very important
Quite important
Fairly important
Slightly important
Not at all important
When you have problems or difficulties with your school (education), work, family, friends, or personal life, how often do you seek spiritual guidance and support?
Almost always
Often
Sometimes
Rarely
Never
Are there any adults in your life that you can talk to about an important problem that you wouldn't tell just anyone?
Yes
No
The next set of questions asks how you feel about someone your age using marijuana or drinking alcohol. Please tell us if you disapprove of their actions.
How do you feel about someone your age trying marijuana or hashish once or twice?
Neither approve nor disapprove
Somewhat disapprove
Strongly disapprove
Don’t know or can’t say
How do you feel about someone your age using marijuana once a month or more?
Neither approve nor disapprove
Somewhat disapprove
Strongly disapprove
Don’t know or can’t say
How do you feel about someone your age having one or two drinks of an alcoholic beverage nearly every day?
Neither approve nor disapprove
Somewhat disapprove
Strongly disapprove
Don’t know or can’t say
How much do people risk harming themselves physically or in other ways when they smoke one or more packs of cigarettes per day?
No risk
Slight risk
Moderate risk
Great risk
Don’t know or can’t say
How much do people risk harming themselves physically or in other ways when they smoke marijuana once or twice a week?
No risk
Slight risk
Moderate risk
Great risk
Don’t know or can’t say
How much do people risk harming themselves physically or in other ways when they have five or more drinks of an alcoholic beverage once or twice a week?
No risk
Slight risk
Moderate risk
Great risk
Don’t know or can’t say
How much do you think people risk harming themselves physically if they have sex without a condom or dental dam?
No risk
Slight risk
Moderate risk
Great risk
Don’t know or can’t say
How much do people risk harming themselves physically or in other ways when they inject illicit drugs for nonmedical reasons?
No risk
Slight risk
Moderate risk
Great risk
Don’t know or can’t say
The next set of questions is about SEX.
By sex or sexual activity, we mean a situation where two partners get sexually excited or aroused (turned on) by touching each other’s genitals (penis or vagina) or anus (butt) with their own genitals, hands, or mouth.
One question asks about sexual partners. A sexual partner is someone with whom you have sex, that is, engage in sexual activity.
When we ask about safe sex, we mean sex that is protected by using a condom. |
In the next 3 months, how likely are you to...
Be sexually active?
Not at all likely
A little likely
Somewhat likely
Very likely
Practice safe sex?
Not intending to have any sex during the next 3 months
Not at all likely
A little likely
Somewhat likely
Very likely
Please indicate how much you agree or disagree with the following statements. |
I can get my boyfriend or girlfriend to use a condom, even if he or she does not want to. (If you don’t have a boyfriend or girlfriend right now, suppose you had. How would you answer this question if you did?)
Strongly agree
Agree
Disagree
Strongly disagree
I would be able to say to my boyfriend or girlfriend that we should use a condom. (If you don’t have a boyfriend or girlfriend right now, suppose you had. How would you answer this question if you did?)
Strongly agree
Agree
Disagree
Strongly disagree
I could refuse if someone wanted to have sex without a condom.
Strongly agree
Agree
Disagree
Strongly disagree
I could say no if someone pressured me to have sex when I did not want to.
Strongly agree
Agree
Disagree
Strongly disagree
I would be able to say no if a friend offered me a drink of alcohol.
Strongly agree
Agree
Disagree
Strongly disagree
I would be able to refuse if a friend offered me drugs, including marijuana.
Strongly agree
Agree
Disagree
Strongly disagree
HIV/AIDS – What You Know |
The next set of questions is about HIV/AIDS. Please indicate whether you think each of the following statements is true or false, or if you don’t know. |
Only people who look sick can spread the HIV/AIDS virus.
True
False
Don’t know
Only people who have sex with gay (homosexual) people get HIV/AIDS.
True
False
Don’t know
Birth control pills protect women from getting the HIV/AIDS virus.
True
False
Don’t know
There are drugs available to treat HIV that can lengthen the life of a person infected with the virus.
True
False
Don’t know
There is no cure for AIDS.
True
False
Don’t know
Young people under age 18 need their parents’ permission to get an HIV test.
True
False
Don’t know
Having another sexually transmitted disease like gonorrhea or herpes increases a person’s risk of becoming infected with HIV.
True
False
Don’t know
Sharing intravenous needles increases a person’s risk of becoming infected with HIV.
True
False
Don’t know
You can become infected with HIV by having unprotected oral sex.
True
False
Don’t know
In the next few questions, we are interested in knowing whether you have a regular place to go for health care and whether you believe you have been discriminated against.
Is there a doctor’s office, health center, or other similar place that you usually go to when you are sick?
Yes
No
Do you ever feel that you are treated with less respect than other people?
No (Skip to #56)
Yes
If yes, why do you think you are treated with less respect than other people? (Check all that apply. If none of these answers apply, check “None of the above.”)
Your skin color
Your religion
Your gender
Your sexual orientation
None of these
End of Section Two
Section Three: Behavior & Relationships |
The next two questions are about CIGARETTES and OTHER TOBACCO PRODUCTS.
Think back over the past 30 days and record on how many days, if any, you used cigarettes, other tobacco products, or both. |
During the past 30 days, on how many days did you smoke part or all of a cigarette? (Includes menthol and regular cigarettes and loose tobacco rolled into cigarettes)
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
During the past 30 days, on how many days did you use other tobacco products? (Includes tobacco products other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe)
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
The next question asks about ELECTRONIC |
During the past 30 days, on how many days did you use electronic vapor products?
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
The next few questions are about ALCOHOL. By alcohol, we mean BEER, WINE, WINE COOLERS, MALT BEVERAGES, or HARD LIQUOR.
Different groups of people in the United States may use alcohol for religious reasons. For example, some churches serve wine during a church service. If you drink wine at church or for some other religious reason, do not count these times in your answers to the questions below.
Think back over the past 30 days and record on how many days, if any, you drank alcohol. |
During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage?
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
During the past 30 days, on how many days did you have 5 or more drinks on the same occasion? [By “occasion,” we mean at the same time or within a couple of hours of each other.]
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
During the past 30 days, on how many days have you been drunk or very high from drinking alcoholic beverages?
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
If you wanted to get some beer, wine, or hard liquor (for example, vodka, whiskey, or gin), how hard or easy would it be for you to get some?
Very hard
Sort of hard
Sort of easy
Very easy
The next question is about MARIJUANA or HASHISH. Marijuana is sometimes called weed, blunt, hydro, grass, or pot. Hashish is sometimes called hash or hash oil. Think back over the past 30 days and record on how many days, if any, you used marijuana or hashish. |
During the past 30 days, on how many days did you use marijuana or hashish?
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
The next question is about OTHER ILLEGAL DRUGS, excluding marijuana or hashish. These include substances like inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to feel good or get high); 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 (MDMA), peyote, and PCP (sometimes called angel dust); and prescription drugs used without a doctor’s orders, just to feel good or get high. Now we would like to ask you about some specific substances. Think back over the past 30 days and report on how many days, if any, you used other illegal drugs. |
During the past 30 days, on how many days did you use any other illegal drug?
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
Now we would like to ask about your use of three specific substances during the past 30 days.
During the past 30 days, on how many days did you use synthetic marijuana (also called K2, Spice, fake weed, King Kong, Yucatan Fire, Skunk, or Moon Rocks)?
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
During the past 30 days, on how many days have you used prescription drugs without a doctor’s orders, in order to feel good or to get high?
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
During the past 30 days, on how many days did you inject any drugs? (Count only injections without a doctor’s orders—those you had just to feel good or to get high.)
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
The next few questions ask about the FIRST TIME you used a substance. Think back as to whether you have EVER used any of these substances. If so, tell us your age the FIRST TIME you used the following substances.
How old were you the first time you had a drink of an alcoholic beverage? (Includes beer, wine, wine coolers, malt beverages, and liquor) DO NOT include any time when you only had a sip or two from a drink.
I have never had a drink of an alcoholic beverage
-
5 years old or younger
14 years old
6 years old
15 years old
7 years old
16 years old
8 years old
17 years old
9 years old
18 years old
10 years old
19 years
11 years old
or older
12 years old
Don’t know
13 years old
or can’t say
How old were you the first time you used marijuana or hashish? (Also known as grass, pot, hash, or hash oil)
I have never used marijuana or hashish
-
5 years old or younger
14 years old
6 years old
15 years old
7 years old
16 years old
8 years old
17 years old
9 years old
18 years old
10 years old
19 years
11 years old
or older
12 years old
Don’t know
13 years old
or can’t say
How old were you the first time you used any other illegal drug?
I have never used other illegal drugs
-
5 years old or younger
14 years old
6 years old
15 years old
7 years old
16 years old
8 years old
17 years old
9 years old
18 years old
10 years old
19 years
11 years old
or older
12 years old
Don’t know
13 years old
or can’t say
During the past 30 days, has your use of alcohol or drugs caused you to have emotional problems?
I have not used alcohol or drugs in the past 30 days
Not at all
Somewhat
Considerably
Extremely
Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health NOT good?
Responses: If none, enter 0. Otherwise, enter
Number of days in past 30 days
-
0 days
12 days
24 days
1 day
13 days
25 days
2 days
14 days
26 days
3 days
15 days
27 days
4 days
16 days
28 days
5 days
17 days
29 days
6 days
18 days
30 days
7 days
19 days
Don’t know
8 days
20 days
or can’t say
9 days
21 days
10 days
22 days
11 days
23 days
Sexual Behavior |
These questions ask about your personal experience with sex. By sex, we mean a situation where two partners get sexually excited or aroused (turned on) by touching each other’s genitals (penis or vagina) or anus (butt) with their own genitals, hands, or mouth. When a male inserts his penis into his female partner’s vagina, the partners are considered to be having vaginal sex. When one partner’s mouth touches the other partner’s genitals (penis or vagina) or anus during sex, the partners are considered to be having oral sex. When a male’s penis is inserted into his male or female partner’s anus, the partners are considered to be having anal sex. |
Have you ever had sex (either vaginal, oral, or anal)?
No, I’ve never had sex.
Yes, the last time was within the past 30 days
Yes, the last time was within the past 3 months
Yes, the last time was more than 3 months ago
How old were you when you had sex for the first time (include vaginal, oral, or anal
sex)?
I have never had sex
Under 5 years old
Between 5 and 10 years old
Between 11 and 14 years old
Between 15 and 18 years old
Over 18 years old
Now think about the last time you had sex (if you've ever had sex). At that time, did you and your partner use a condom?
I’ve never had sex
Yes, the last time I had sex we used a condom.
No, the last time I had sex, we did not use a condom.
During the last 3 months, with how many people did you have sex?
0 people
1 person
2 people
3 people
4 people
5 people
6 or more people
In the last 3 months, have you had sex after getting drunk or high?
Yes
No
Your Family and Friends |
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
During the past 12 months, have you talked with at least one of your parents about the dangers of unprotected sex? (By PARENTS, we mean your biological parents, adoptive parents, stepparents, or adult guardians, whether or not they live with you.)
Yes
No
Don’t know or can’t say
When I am not at home, one of my parents (or guardians) knows where I am.
Yes
No
When I am not at home, one of my parents (or guardians) knows who I am with.
Yes
No
Members of my family feel very close to each other.
I don’t have any family
Not true
Sometimes true
Usually true
Always true
How many of your friends…
Drink beer, wine, wine coolers, or hard liquor (besides a few sips)?
None
A few
Some
Most
All
Smoke cigarettes?
None
A few
Some
Most
All
Smoke marijuana or weed?
None
A few
Some
Most
All
Get arrested?
None
A few
Some
Most
All
Are sexually active?
None
A few
Some
Most
All
Have been pregnant or gotten someone pregnant?
None
A few
Some
Most
All
Prevention Education |
You may get information about substance abuse, HIV/AIDS, or other health issues from many different sources. The next few questions ask about some of these sources.
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
In the past 30 days, have you been in any classes or programs where they talked about preventing HIV or AIDS?
Yes
No
In the past 30 days, have you been in any classes or programs where they talked about prevention of drug and alcohol abuse?
Yes
No
The last question asks about your experience with this survey.
How truthful were you when answering the questions?
Very truthful
Somewhat truthful
Somewhat untruthful
Very untruthful
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Cross-Site Evaluation of the Minority Substance Abuse/HIV Prevention Program |
| Author | Calverton |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |
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