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)

Question Title

* 1. Organization

Question Title

* 2. First two Initials of your First Name?

Question Title

* 3. First two Initials of your Last Name?

Question Title

* 4. What is your Email Address?

SECTION ONE: Facts About You
First, we'd like to ask some basic questions about you. Your answers will not be used to identify you in any way. Instead, your answers will help us understand how different groups (like people from different generations or from different backgrounds) feel about substance abuse and HIV prevention.

Question Title

* 5. What is your date of birth?

Date

Question Title

* 6. Are you of Hispanic, Latino/a, or Latin X?

Question Title

* 7. [IF YES] What ethnic group do you consider yourself? You may select more than one.

Question Title

* 8. What is your origin race? You may choose more than one.

Question Title

* 9. What is your gender?

Question Title

* 10. [IF YES] To Transgender which, do you consider yourself to be?

Question Title

* 11. Which one of the following do you consider yourself to be?

Question Title

* 12. Describe where you live.

Question Title

* 13. Are you currently attending college?

Question Title

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

Question Title

* 15. In the past 30 days, have you been arrested?

Question Title

* 16. Are you on parole or probation?

Question Title

* 17. Have you ever been informed of your HIV status (whether or not you are HIV-negative or positive) based on the result of an HIV test?

Question Title

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

Question Title

* 19. Would you know where to go (near where you live) to see a healthcare professional regarding a drug or alcohol problem?

Question Title

* 20. Would you know where to go (near where you live) to see a healthcare professional regarding HIV/AIDS or other sexually transmitted health issues?

Question Title

* 21. Think about the household members who live with you right now. About how much income have you and your family made in the last tax year before taxes? (Including child support and cash payments from the government- for example, welfare [TANF], SSI, or unemployment compensation.)

Section Two: Attitudes & Knowledge
Next, we'd like to ask you how you feel about substance use and sexual behavior. Again, your answers are private and will not be used to identify you.

Question Title

* 22. 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, snuff, chewing tobacco, dipping tobacco and others.

Question Title

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

Question Title

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

Question Title

* 25. What level of risk do you think people have of harming themselves physically if they share needles, syringes or other injection equipment when using drugs?

Question Title

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

Question Title

* 27. 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 order 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.

The next two questions are about sex. Specifically sexual activity, meaning a situation where two partners get sexually excited or aroused by touching each other's genitals (penis or vagina) or anal with their own genitals, hands or mouth.

Question Title

* 28. What level of risk do you think people have of harming themselves if they have sex (oral, vaginal or anal) without a condom or dental dam?

Question Title

* 29. What level of risk do you think people have of harming themselves if they have sex while high on drugs or under the influence of alcohol?

Question Title

* 30. I could refuse if someone wanted to have sex without a condom or a dental dam.

Section Three: Behavior, 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 activities.

Question Title

* 31. Over the past 30 days, how many days, if any, did you use tobacco?

Question Title

* 32. Over the past 30 days, how many days, if any, did you use electronic vapor products?

Question Title

* 33. Over the past 30 days, how many days, if any, did you drink alcohol? (any use at all)

Question Title

* 34. Over the past 30 days, how many days, if any, did you binge drink? (any use at all)

Question Title

* 35. Over the past 30 days, how many days, if any, use marijuana or hash?

Question Title

* 36. Over the past 30 days, how many days, if any, have you used prescription opioid drugs without orders given to you by your doctor?

Question Title

* 37. Over the past 30 days, how many days, if any, have you use other prescription drugs without orders given to you by your doctor?

Question Title

* 38. Over the past 30 days, how many days, if any, have you used non-prescription opioid drugs?

Question Title

* 39. Over the past 30 days, how many days, if any, use any other illegal drugs? Please exclude marijuana/hash and non-prescription opioid drugs.

Question Title

* 40. Over the past 30 days, how many days, if any, inject any drugs? Count only injections without orders from your doctor-those you had just to feel good or to get high.

Question Title

* 41. Over the past 30 days, how many days, if any, share injection equipment? By injection equipment, we mean needle and drug paraphernalia.

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

Question Title

* 42. During the past 30 days, how many sexual partners have you had?

Question Title

* 43. During the past 30 days, have you had unprotected sex with....

  Yes No Don't Know
A Male
A Female
A Transgender Male
A Transgender Female
Significant Other in a Monogamous Relationship
Multiple Partners
An HIV POZ Person
A Hepatitis POZ Person
A Person Who Injects Drugs
A Man Who Has Sex With Men

Question Title

* 44. Have you ever had sex (vaginal, anal or oral) with someone in exchange for money, drugs or shelter?

Question Title

* 45. In the past 3 months, how often has anyone with whom you had an intimate relationship (sexual or not) abused you emotionally, physically, or sexually?

YOU ARE DONE! Thank you for your help!

T