Form MAI Youth Question MAI Youth Question MAI Adult Questionnaire 2024

OMB No.: 0930-0357

Expiration Date: XX/XX/XXXX

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 AIDS Initiative (MAI) Substance Abuse/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 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 0930-0357. Public reporting burden for this collection of information is estimated to average .20 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, 5600 Fishers Lane}, Room 15E57-B, Rockville, MD 20857.

INSTRUCTIONS

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.

MARKING YOUR ANSWERS

• ^{Use a No. 2 black lead pencil.} EXAMPLES

• Do not use an ink or ballpoint pen.

• Make heavy dark marks that fill the circle completely. ^{Correct Marks: Incorrect Marks:}

• Erase cleanly any answer you wish to change. _  . _•

• Make no stray marks on this questionnaire.

Record Management Section: To Be Completed by Designated Staff

Grant ID

SP

Study Design Group (Select one)

• Intervention

• Comparison

Participant ID

Date of Survey Administration

| | | / | | | / | | | | |

Month Day Year

Interview Type (select one)

• Baseline

• Exit

• Follow-up

• Testing Services Only (skip to section B)

1. Intervention Details

Type of Encounter (select all that apply)

• Individual

• Group

Intervention Name(s) If the participant is receiving direct services from more than one intervention, please list each intervention below.

1.

2.

3.

Total Number of Direct Service Encounters Count each encounter once; if you provide multiple services during an encounter it still only counts as one encounter

direct service encounters

Average Duration of Encounter(s) Round time to nearest five

(5) minute interval)

minutes

2. Service Type(s) (select all that apply)

Testing Services

• HIV Testing

• Viral Hepatitis (VH) Testing

• Other STD Testing

Health Care Services

• VH Vaccination

• Primary Health Care Services

• Other Health Care Services

Individual Services

• Risk Reduction and/or Resiliency Strength Assessment

• Risk Reduction Counseling/Education

• HIV Testing Counseling

• Viral Hepatitis Testing Counseling

• Psycho-Social Counseling

• Substance Abuse Counseling

• Substance Abuse Education

• Opioid Prevention Education

• Opioid Prevention Counseling

• HIV Education

• STD Education

• Viral Hepatitis Education

• Mentoring (Peer or Other Type)

• Case Management Services

• All Other Individual Services

SPECIFY:

**Education may refer to population level information whereas counseling is clinical

Group Services

• Support Group

• Group Counseling/Therapy

• Skills Building Training/Education

• Health Education Classes/Sessions

• Viral Hepatitis Education

• HIV Education

• STD Education

• Substance Abuse Education

• Opioid Prevention Education

• Cultural Enhancement Activities

• Alternative Activities

• All Other Group Services

SPECIFY:

3. Referrals

Please mark any topic areas in which staff facilitated participant access to prevention, treatment, or recovery services. Select all that apply. If not applicable, leave blank.

• HIV Testing

• HIV Counseling

• HIV Treatment

• VH Testing

• VH Counseling

• VH Vaccination

• VH Treatment

• Substance Abuse Treatment

• Prescription Drugs/Opioid Treatment

• Mental Health Services (excluding HIV & VH counseling)

• Health Care Services (excluding SA, HIV, prescription drug/opioid, & VH treatment)

• Medicated-Assisted Treatment (MAT)

---Please indicate the following:

• Number of days in MAT

• Type of medication received (specify)

• Supportive Housing

• Other Social Support (e.g., job placement, public health care safety net, insurance programs, etc.)

SPECIFY:

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 12-year-olds have to say, and how that may be different from what 17-year-olds have to say.

Section One: Facts About You

1. What is your date of birth?

| | | / | | | | | Month Year

• Refused

2. Are you Hispanic, Latino/a, or Latinx?

• Yes

• No

• Refused

	Yes	No 5.
Central American	O	O
Cuban	O	O
Dominican	O	O
Mexican	O	O
Puerto Rican	O	O
South American	O	O

2a. [IF YES] What ethnic group do you consider yourself? You may say yes to more than one

Other (specify)

Refused O O

3. What is your race? You may indicate more than one.

Yes No

Black or African

American ^{O O}

White O O

American Indian or Alaska Native	O	O
Asian Indian	O	O
Chinese	O	O
Filipino	O	O
Japanese	O	O
Korean	O	O
Vietnamese	O	O
Other Asian	O	O
Native Hawaiian	O	O

Guamanian or

Chamorro ^{O O}

Samoan O O Other Pacific

Islander ^{O O}

Refused O O

4. What is your gender?

• Male

• Female

• Transgender

• Other (Specify)

• Refused

4a. [IF Yes to Transgender]

Do you consider yourself to be?

• Transgender, male to female

• Transgender, female to male

• Transgender, gender nonconforming

What is your sexual orientation?

• Straight/Heterosexual

• Gay/Lesbian

• Bisexual

• Queer, Pansexual, and/or Questioning

• Something Else? Please Specify

• Refused

6. 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

6. Who do you live with? (mark all that apply)

   • Alone

   • With parents

   • With relatives other than parents

   • With a foster family

   • With roommates

   • Other

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

• Yes

• No

6. In the past 30 days, how many times have you been arrested?

   • Times

   • Refused

   • Don’t know

6. Have you ever been informed of your HIV status (that is, whether or not you are HIV-positive) based on the result of an HIV test?

• Yes

• No

6. Have you ever been informed of your viral hepatitis (VH) status (that is, whether or not you are infected with a hepatitis virus) based on the result of a VH test?

• Yes

• No

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

• Yes

• No

Section Two: Attitudes & Knowledge

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

6. What level of risk do you think people have of harming themselves physically or in other ways when they use tobacco once or twice a week? By tobacco, we mean menthol cigarettes, regular cigarettes, loose tobacco rolled into cigarettes or cigars, pipe tobacco, snuff, chewing tobacco, dipping tobacco, snus, and others.

• No risk

• Slight risk

• Moderate risk

• Great risk

• Don’t know or can’t say

6. What level of risk do you think people have of harming themselves physically or in other ways when they binge drink alcoholic beverages once or twice a week? Binge drinking is 5 or more alcoholic beverages at the same time or within a couple of hours of each other for males; 4 or more for females. By alcoholic beverage, we mean beer, wine, wine coolers, malt beverages, or hard liquor.

• No risk

• Slight risk

• Moderate risk

• Great risk

• Don’t know or can’t say

6. What level of risk do you think people have of harming themselves physically or in other ways when they use marijuana or hashish once or twice a week? Marijuana is sometimes called weed, blunt, hydro, grass, or pot. Hashish is sometimes called hash or hash oil.

• No risk

• Slight risk

• Moderate risk

• Great risk

• Don’t know or can’t say

6. What level of risk do you think people have of harming themselves physically or in other ways when they use non-prescription opioid drugs once or twice a week? By non- prescription opioid drugs we mean the illegal drug heroin and illicitly made synthetic opioids such as fentanyl.

• No risk

• Slight risk

• Moderate risk

• Great risk

• Don’t know or can’t say

6. What level of risk do you think people have of harming themselves physically or in other ways when they take prescription opioid drugs without a doctor’s orders once or twice a week? By prescription opioid drugs, we mean pain relievers such as oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, morphine, methadone, tramadol, hydromorphone, oxymorphine, tapentadol.

• No risk

• Slight risk

• Moderate risk

• Great risk

• Don’t know or can’t say

6. What level of risk do you think people have of harming themselves physically when they inject drugs for nonmedical reasons?

• No risk

• Slight risk

• Moderate risk

• Great risk

• Don’t know or can’t say

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

• Strongly agree

• Agree

• Disagree

• Strongly disagree

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

• Strongly agree

• Agree

• Disagree

• Strongly disagree

The next two questions are 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.

6. What level of risk do you think people have of harming themselves if they have sex without a condom?

• No risk

• Slight risk

• Moderate risk

• Great risk

• Don’t know or can’t say

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

• Strongly agree

• Agree

• Disagree

• Strongly disagree

Section Three: Behavior

In this section we are going to ask you about substance use and sexual behavior. Remember, your answers will be kept private.

Tobacco, Alcohol, and Drugs

Think back over the past 30 days and record on how many days, if any, you did any of the following.

Over the past 30 days, how many days, if any, did you…		Definitions
23. Use tobacco?	| | | Days Don’t know or can’t say	By tobacco, we mean menthol cigarettes, regular cigarettes, loose tobacco rolled into cigarettes or cigars, pipe tobacco, snuff, chewing tobacco, dipping tobacco, snus, and others.
24. Use electronic vapor products?	| | | Days Don’t know or can’t say	By electronic vapor products we mean Vapes, vaporizers, vape pens, hookah pens, electronic cigarettes (e-cigarettes or e-cigs), e-pipes or electronic nicotine delivery systems (ENDS).
25. Drink alcohol? (any use at all)	| | | Days Don’t know or can’t say	By alcohol, we mean beer, wine, wine coolers, malt beverages, or hard liquor.
26. Binge drink?	| | | Days Don’t know or can’t say	Binge drinking is 5 or more alcoholic beverages at the same time or within a couple of hours of each other for males; 4 or more for females.
27. Use marijuana or hashish?	| | | Days Don’t know or can’t say	Marijuana is sometimes called cannabis, weed, blunt, hydro, grass, or pot. Hashish is sometimes called hash or hash oil.
28. Use prescription opioid drugs without orders given to you by your doctor?	| | | Days Don’t know or can’t say	By prescription opioid drugs, we mean pain relievers such as oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, morphine, methadone, tramadol, hydromorphone, oxymorphine, tapentadol.
29. Use other prescription drugs without orders given to you by your doctor? Please exclude prescription opioid drugs.	| | | Days Don’t know or can’t say	By other prescription drugs, we mean substances like barbiturates, sedatives, hypnotics, non-benzo tranquilizers.
30. Use non-prescription opioid drugs?	| | | Days Don’t know or can’t say	By non-prescription opioid drugs we mean the illegal drug heroin and illicitly made synthetic opioids such as fentanyl.
31. Use any other illegal drugs? Please exclude marijuana/hashish and non-prescription opioid drugs.	| | | Days Don’t know or can’t say	By other illegal drugs, we mean substances like crack or cocaine, amphetamine or methamphetamine, hallucinogens (such as LSD/acid, Ecstasy/MDMA, PCP/angel dust, peyote), inhalants (sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, shoe polish).
32. Inject any drugs?	| | | Days Don’t know or can’t say	Count only injections without orders from your doctor – those you had just to feel good or to get high.

Sexual Behavior

Now we’d like to ask you about your experience with sex. Remember, your answers will be kept private.

33. During the past 3 months, how people did you have sex with?

• None

• 1 person

• 2 people

• 3 people

• 4 people

• 5 people

• 6 or more people

33. In the past 30 days, have you had sex after getting drunk or high?

• Yes

• No

33. During the past 30 days, have you had unprotected sex? If yes, select all that apply. Unprotected sex, is vaginal, oral, or anal sex without a barrier such as a condom

• No

• Yes,unprotected oral sex

• Yes,unprotected vaginal sex

• Yes,unprotected anal sex

YOU ARE DONE!

Thank you for your help!