Web Recruitment Screener

Web Screener (Adult)

INTRO1 The purpose of the study is to get feedback on how easy or difficult different questions about alcohol and drug use are to answer. These questions will be presented on a laptop computer. We are doing this research to improve the questions about past drug and alcohol use in a large national survey, called the National Survey on Drug Use and Health, which is given to about 70,000 people every year.

The survey is conducted by RTI International, and is funded by the Substance Abuse and Mental Health Services Administration or SAMHSA. The interview will take about 60 minutes and be conducted at RTI International’s office at [LOCATION] between [DATE] and [DATE]. If you qualify and take part in the interviews, you will receive $40 cash for completing the interviews.

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NOTICE: Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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, Paperwork Reduction Project (0930-0290); Room 2-1057; 1 Choke Cherry Road, Rockville, MD 20857. 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 0930-0290, expiration date 5/31/17.

Instrument Version: 22.XX

INTRO2 To determine if you are eligible, we must ask you a few questions about your alcohol and drug use as well as your background. All responses to the survey will remain private and confidential. We will not share information you give us with anyone other than project staff.

If you are eligible for the study, a staff person will call or email you to schedule a time for the interview.

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AGE What is your age?

1 11 or younger [GO TO TERM]

2 12-17 [GO TO TERM]

3 18-34

4 35-54

5 55 or older

GEO In what geographic area do you currently live?

1 Raleigh, Durham, Chapel Hill area

2 Washington, DC metro area

3 Chicago, IL metro area

4 Portland, OR metro area

5 Other [GO TO TERM1]

HEAR How did you hear about this study?

1 I saw an advertisement on www.craiglist.com

2 I saw an advertisement at a treatment center

3 I heard about it from a friend

4 Other

ALCOHOL This question is about alcoholic beverages, such as beer, wine, brandy, and mixed drinks. How long has it been since you last drank an alcoholic beverage?

1 I have never had an alcoholic beverage

2 Within the past 30 days

3 More than 30 days ago but within the past 12 months

4 More than 12 months ago but with the past 5 years

5 More than 5 years ago

ALC_AMT [IF ALCOHOL=2 or 3] On how many days in the past 12 months did you drink an alcoholic beverage?

1 1 to 5 days

2 6 to 10 days

3 11 or more days

MARIJU This question is about marijuana or hashish. Marijuana is also called pot or grass. How long has it been since you last used marijuana or hashish?

1. I have never used marijuana or hashish

2. Within the past 30 days

3 More than 30 days ago but within the past 12 months

4 More than 12 months ago but with the past 5 years

5 More than 5 years ago

MJ_AMT [IF MARIJU=2 or 3] On how many days in the past 12 months did you use marijuana or hashish?

1 1 to 5 days

2 6 to 10 days

3 11 or more days

OTHERD This question is about certain types of illegal drugs. Have you ever used cocaine, heroin or methamphetamine?

1 Yes

2 No

LASTDRUG [IF OTHERD=1] How long has it been since you last used cocaine, heroin or methamphetamine?

1 Within the past 30 days

2 More than 30 days ago but within the past 12 months

3 More than 12 months ago but with the past 5 years

4 More than 5 years ago

RX_DRUG This question is about using prescription drugs in any way a doctor did not direct you to use them.

When you answer this question, please think only about your use of the drug in any way a doctor did not direct you to use it, including:

• Using it without a prescription of your own

• Using it in greater amounts, more often, or longer than you were told to take it

• Using it in any other way a doctor did not direct you to use it

Have you ever, even once, used any prescription drug in any way a doctor did not direct you to use it?

1 Yes

2 No

LAST_RX [IF RX_DRUG=1] How long has it been since you last used any prescription drug in any way a doctor did not direct you to use it?

1 Within the past 30 days

2 More than 30 days ago but within the past 12 months

3 More than 12 months ago but with the past 5 years

4 More than 5 years ago

SEX Are you male or female?

1 Male

2 Female

EDUC What is highest grade or year of school you have completed?

1 High school or less

2 High school diploma or GED

3 Some college, but no degree

4 Associate’s Degree (for example, A.A., A.S)

5 Bachelor’s Degree (B.A., B.S.)

6 Graduate Degree (for example, MA, MS, PhD, JD, MD, DDS)

HISP Are you of Hispanic, Latino, or Spanish origin?

1 Yes

2 No

RACE Which of these groups describes you? Check all that apply.

1 White

2 Black or African American

3 American Indian or Alaska Native

4 Native Hawaiian or Pacific Islander

5 Asian

6 Other

RACE2 [IF RACE=6] Please describe your other race.

______________________________________

LANG What is your primary language?

1 English

2 Spanish

3 Other

LANG2 [IF LANG=3] What is your primary language?

______________________________________

BLIND Are you blind or do you have serious difficulty seeing?

1 Yes

2 No

DEAF Are you deaf or do you have serious difficulty hearing?

1 Yes]

2 No

TERM [IF AGE=1 or 2] Thank you, but you are not eligible to participate in this study.

THANK Thank you! We will review your responses to see if you are eligible for this study. If you are eligible to participate in the study and we are still recruiting participants, we will contact you within 2 weeks to schedule an interview. The interview will last about 60 minutes and you will receive $40 in cash.

Please provide your contact information on the following screens. When we contact you, we will only say that we are contacting you about a health study for RTI International.

NAME Please provide your first name or a nickname.

NAME: _______________________________

EMAIL Please provide an email address where we can contact you about this study.

__________________________

PHONE Please provide a phone number where we can contact you about this study.

PHONE 1: _ _ _ - _ _ _ - _ _ _ _

PHONE 2: _ _ _ - _ _ _ - _ _ _ _

WHEN What is the best time to contact you?

____________________________________________________________

Eligibility Determination

Alcohol users: IF ALC_AMT = 2 or 3

Marijuana users: IF MJ_AMT = 2 or 3

Other drug users: IF (LASTDRUG = 1 or 2) OR (LASTRX = 1 or 2)

IF BLIND=1 OR DEAF=1, CONFIRM WHETHER THIS WILL BE A PROBLEM WITH THE RESPONDENT