Form Approved
OMB No.: 0930-0357
Expiration Date: 11/30/2024

National Minority AIDS Initiative (MAI) Substance Abuse/HIV Prevention Initiative

Adult 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.

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