Pre-testing of Evaluation Surveys: An Examination of the Intersection of Domestic Human Trafficking with Child Welfare and Runaway and Homeless Youth Programs

Appendix A. Survey Instrument and Example Screenshots

Life Experiences Survey
Are you under the age of 18? Y N

CONSENT FORM—appropriate to age (under/over 18)

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to examine the intersection
of domestic human trafficking with child welfare and runaway and homeless youth programs. Information will be kept private to
the extent permitted by law. Public reporting burden for this collection of information is estimated to average 17 minutes per
response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of
information. 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 number for this information collection is [NUMBER] and the
expiration date is [DATE]. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to Meredith Dank; mdank@urban.org.

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Section A: About You
1. How old are you? (Now we are asking your specific age, not just whether you are an
adult or a minor.)
a. Enter Age in years _______________
b. I chose to skip this question
2. How do you identify your gender?
a. Female
b. Male
c. Genderqueer
d. Intersex
e. Transgender Female
f. Transgender Male
g. Transgender
h. I choose to skip this question
i. Other [specify_______]
3. What is your sexual orientation?
a. Heterosexual/straight
b. Gay
c. Lesbian
d. Bisexual
e. Queer/questioning
f. Asexual
g. I choose to skip this question
h. Other [specify_______]
4. Are you Hispanic, Latino/a, or of Spanish origin?
a. Yes
b. No
c. I choose to skip this question
5.

What is your race? You may select one or more.
a. American Indian or Alaska Native
b. Asian
c. Black or African American
d. Native Hawaiian or Other Pacific Islander
e. White
f. I choose to skip this question
g. Other (Specify_________)

6. Do you have any children of your own, or are you or your partner currently pregnant?
a. Yes
b. No
c. I choose to skip this question

Section B: School
7. Are you currently in school?
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a. Yes
b. No
c. I choose to skip this question
8. What is the highest level of education you finished?
a. 4th grade
b. 5th grade
c. 6th grade
d. 7th grade
e. 8th grade
f. 9th grade
g. 10th grade
h. 11th grade
i. Attended 12th grade but did not graduate
j. High school diploma
k. GED
l. Attended some college
m. 2-year, vocational, or technical degree
n. Bachelor’s degree or higher
o. I choose to skip this question
p. Other
9. Are you currently in a GED program?
a. Yes
b. No
c. I choose to skip this question
10. How many times did you skip school in the past 12 months?
a. Never
b. Once
c. 2-3 times
d. 4-10 times
e. More than 10 times
f. I have not been in school in the last 12 months
g. I choose to skip this question

Section C: Birthplace
11. Where did you grow up? If you were raised in more than one place, please list the place
where you spent the most time.
a. [State__________] (answer only if raised in the United States)
b. [Country________]
c. I choose to skip this question
12. Were you born in the United States?
a. Yes [SKIP to SECTION E]
b. No [CONTINUE to C13]
c. I choose to skip this question [CONTINUE to C13]

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13. [If C12=No or Skipped] Are you a U.S. citizen or lawful permanent resident (with a green
card)?
a. Yes
b. No
c. I choose to skip this question

Section D: Immigration
Only administer if individual was born outside the United States (IF C12=NO or Skipped).
Before starting this question, a reminder: anything you report about your immigration
experience or immigration status will be completely confidential and will in no way be
linked to your name.
14. How did you first come to the United States?
a. On my own
b. With a family member
c. With friends
d. I choose to skip this question
e. Other_______
15. Did anyone help or force you to come to the United States?
a. Yes - somebody helped me [CONTINUE to D16]
b. Yes - somebody forced me [CONTINUE to D16]
c. No [SKIP to SECTION E]
d. I choose to skip this question [CONTINUE to D16]
16. [If D15=Yes (a or b) or Skipped] Who was this?
a. Your parent(s)
b. A family member other than a parent
c. A friend of yours
d. A friend of your family
e. An employer or potential employer
f. A spouse/ or partner
g. I choose to skip this question
h. Someone else [specify: _____]
17. [If D15=Yes (a or b) or Skipped] Did you and/or your family borrow from or owe any
money to the person (or people) who helped or forced you to come to the US?
a. Yes
b. No
c. I choose to skip this question
18. [If D15= Yes (a or b) or Skipped] How did/do you pay the person or people who helped
or forced you into the U.S.?
a. Paid promptly (either at the beginning or after the service was provided)
b. I work(ed) for the person who helped/forced me to come to the U.S. to pay off my
debt.
c. Pay (or paid) little by little, over time, but I never worked for this person
d. I did not have to pay them back.
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e. I choose to skip this question
f. Other (please specify)________________
19. [If D15=Yes (a or b) or Skipped] Do you still owe the person or people who helped or
forced you into the U.S. money?
a. Yes
b. No
c. I choose to skip this question
20. [If D15=Yes (a or b) or Skipped] Did they ever hold your ID card, driver’s license,
passport, social security card, birth certificate or other ID without your permission?
a. Yes
b. No
c. I choose to skip this question
21. [If D15=Yes (a or b) or Skipped] Did the person or people who brought you into the U.S.
ever physically harm you (punched, slapped, hit, kicked, burned, etc.)?
a. Yes
b. No
c. I choose to skip this question
22. [If D15= Yes (a or b) or Skipped] Did the person or people who helped or forced you into
the U.S. ever sexually harm you (rape, sexual harassment, unwanted sexual contact or
experience, unwanted sexual photos or videos)?
a. Yes
b. No
c. I choose to skip this question

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Section E: Family
CHECK: Is interview taking place with youth in a group home?
Yes [SKIP to E26]
No
23. Have you ever been in foster care? [skip pattern for those being surveyed in a foster
care setting]
a. Yes [CONTINUE to E24]
b. No [SKIP to E34]
c. I choose to skip this question [CONTINUE TO E24]
24. Are you currently in foster care? [skip pattern for those being surveyed in a foster care
setting or those who skipped the foster care question]
a. Yes [CONTINUE to E25]
b. No [SKIP to E26]
c. I choose to skip this question [CONTINUE to E25]
25. [If E23=Yes or Skipped] Which of the following best describes your current foster care
placement?
a. With my foster parent(s) who are unrelated to me
b. With relatives who are also my foster parents
c. In a group home or residential facility
d. I choose to skip this question
e. Other (specify) ______________________
26. [If E23=Yes or Skipped, or if interview is taking place with youth in group home/foster
care setting] How much total time have you spent in foster care, adding together all
foster care placements over the course of your life?
a. Enter Time in years _______________
b. I choose to skip this question
27. How many different foster care placements have you had in your life?
a. 1
b. 2-3
c. 4-6
d. More than 6
e. I choose to skip this question
28. How old were you when you were first placed in foster care?
a. Enter Age in years _______________ (enter 0 if you were less than one year
old)
b. I choose to skip this question
29. How long have you been in your current or most recent foster care placement?
a. Less than 6 months
b. 6 months to 1 year
c. 1 to 5 years
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d. More than 5 years
e. My whole life
f. I choose to skip this question
30. [If E25 = a or Skipped] What is your relationship like with your current foster family?
a. Very good
b. Good
c. Okay
d. Bad
e. Very bad
f. I choose to skip this question
31. [If E25 = b or Skipped] What is your relationship like with the adult relatives you live
with?
a. Very good
b. Good
c. Okay
d. Bad
e. Very bad
f. I choose to skip this question
32. [If E25 = c or Skipped] What is your relationship like with the adults in your group home?
a. Very good
b. Good
c. Okay
d. Bad
e. Very bad
f. I choose to skip this question
33. [If E25 = d or Skipped] What is your relationship like with the adults where you live?
a. Very good
b. Good
c. Okay
d. Bad
e. Very bad
f. I choose to skip this question
34. Do you have contact with your birth family?
a. Yes [CONTINUE to E35]
b. No [SKIP TO F36]
c. I choose to skip this question [CONTINUE to E35]
35. [If answer to E34=Yes or Skipped] What is your relationship like with your birth family?
People often have better or worse relationships with some family members than others.
Thinking of all of your relationships with members of your birth family, how would you
describe your relationship with them overall?
a. Very good
b. Good
c. Okay
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d.
e.
f.
g.

Bad
Very bad
No contact
I choose to skip this question

Section F: Housing
36. Over the last month, where did you sleep most nights?
a. In a house or apartment with my immediate family (parent or guardian) that we
rent or own
b. At another family member’s house or apartment
c. At the house or apartment of a foster parent
d. At a group home
e. At my own apartment (I pay rent)
f. Temporarily staying with friends or couch surfing
g. At my boyfriend/girlfriend/partner’s home
h. At a shelter
i. In a transitional housing program
j. A treatment facility or center (hospital, detox, etc.)
k. Inside a car, abandoned building, squat, etc.
l. Outside in the park, on the street, in a tent, etc.
m. At a transit station (subway or bus station or the airport)
n. A jail, prison, or detention facility
o. Hotel/motel
p. I choose to skip this question
q. Other (please specify): ______________________
37. How safe do you feel when you sleep there?
a. Very safe
b. Safe
c. Somewhat safe
d. Unsafe
e. Very unsafe
f. I choose to skip this question

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Section G: Running Away
38. Have you ever run away from your parent or guardian’s home?
a. Yes
b. No
c. I choose to skip this question
39. Have you ever been kicked out of your home by your parent or guardian?
a. Yes
b. No
c. I choose to skip this question
40. [If G38=Yes or Skipped] If you ran away from your parent or guardian’s home over the
past 6 months, where did you stay/sleep most often?
a. In a house or apartment with my immediate family (parent or guardian) that we
rent or own.
b. At the house or apartment of another family member
c. At the house or apartment of a foster parent
d. At my own apartment (I pay rent)
e. Temporarily staying with friends or couch surfing
f. At my boyfriend/girlfriend/partner’s home
g. At a shelter
h. In a transitional housing program
i. At a group home
j. A treatment facility or center (hospital, detox, etc.)
k. Inside a car, abandoned building, squat, etc.
l. Outside in the park, on the street, in a tent, etc.
m. At a transit station (subway or bus station or the airport)
n. A jail, prison, or detention facility
o. Hotel/motel
p. I have not run away in the last six months.
q. I choose to skip this question
r. Other (please specify): ______________________
41. [If G38=Yes or Skipped] How safe do you feel when you sleep there?
a. Very safe
b. Safe
c. Somewhat safe
d. Unsafe
e. Very unsafe
f. I choose to skip this question
42. [If G38=Yes or Skipped] How many times have you run away from your parent or
guardian’s home?
a. Once
b. Twice
c. Three or four times
d. Five or more times
e. I choose to skip this question

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43. [If G38=Yes or Skipped] How old were you the first time you ran away?
a. Enter Age in years ________
b. I choose to skip this question
44. [If G38=Yes or Skipped] Why did you run away? Please check all of the reasons that
apply.
a. Parents kicked/threw me out
b. Physical abuse
c. Emotional abuse
d. Sexual abuse
e. They had too many rules
f. My parent chose their boyfriend/girlfriend/husband/wife over me
g. They didn’t accept me for who I am
h. My parent was always drunk or on drugs
i. I didn’t get along with my parents/foster parents/guardians
j. I didn’t get along with the other kids I lived with
k. My parents could not afford to take care of me
l. I choose to skip this question
m. Other (please specify): _______________________
45. [If G39=Yes or Skipped] If you were kicked out by a parent/guardian over the past 6
months, where did you stay/sleep most often?
a. In a house or apartment with my immediate family (parent or guardian) that we
rent or own.
b. At the house or apartment of another family member
c. At the house or apartment of a foster parent
d. At my own apartment (I pay rent)
e. Temporarily staying with friends or couch surfing
f. At my boyfriend/girlfriend/partner’s home
g. At a shelter
h. In a transitional housing program
i. At a group home
j. A treatment facility or center (hospital, detox, etc.)
k. Inside a car, abandoned building, squat, etc.
l. Outside in the park, on the street, in a tent, etc.
m. At a transit station (subway or bus station or the airport)
n. A jail, prison, or detention facility
o. Hotel/motel
p. I have not been kicked out in the last six months.
q. I choose to skip this question
r. Other (please specify): ______________________
46. [If G39=Yes or Skipped] How safe do you feel when you sleep there?
a. Very safe
b. Safe
c. Somewhat safe
d. Unsafe
e. Very unsafe
f. I choose to skip this question
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47. [If G39=Yes or Skipped] How many times have your parent or guardian thrown you out
or kicked you out?
a. Once
b. Twice
c. Three or four times
d. Five or more times
e. I choose to skip this question
48. [If G39=Yes or Skipped] How old were you the first time you were kicked out of your
home by your parent/guardian?
a. Enter Age in years ________
b. I choose to skip this question
49. [If G39=Yes or Skipped] Why did your parent or guardian throw you out or kick you out?
Please check all of the reasons that apply.
a. I didn’t follow their rules
b. My parent chose their boyfriend/girlfriend/husband/wife over me
c. They didn’t accept me for who I am
d. My parents/guardian could not afford to take care of me
e. I don’t know
f. I choose to skip this question
g. Other (please specify): _______________________
CHECK: Is youth currently in foster care (E24= yes)
Yes [CONTINUE to G50]
No [SKIP to Section H]
I choose to skip this question [CONTINUE to G50]

50. Have you ever run away from foster care?
a. Yes [SKIP to G52]
b. No [CONTINUE to G51]
c. I choose to skip this question [CONTINUE TO G51]
51. Have you ever been thrown out or kicked out of your home by a foster parent?
a. Yes
b. No
c. I choose to skip this question
52. [If G50=Yes or Skipped] Over the past 6 months, where did you usually stay/sleep after
you ran away from your foster home? Select all that apply.
a. In a house or apartment with my immediate family (parent or guardian) that we
rent or own.
b. At the house or apartment of another family member
c. At my own apartment (I pay rent)
d. Temporarily staying with friends or couch surfing
e. At my boyfriend/girlfriend/partner’s home
f. At a shelter
g. In a transitional housing program
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h.
i.
j.
k.
l.
m.
n.
o.
p.
q.

At a group home
A treatment facility or center (hospital, detox, etc.)
Inside a car, abandoned building, squat, etc.
Outside in the park, on the street, in a tent, etc.
At a transit station (subway or bus station or the airport)
A jail, prison, or detention facility
Hotel/motel
I have not run away in the past 6 months.
I choose to skip this question
Other (please specify): ______________________

53. [If G50=Yes or Skipped] How safe do you feel when you sleep there?
a. Very safe
b. Safe
c. Somewhat safe
d. Unsafe
e. Very unsafe
f. I choose to skip this question
54. [If G50=Yes or Skipped] How many times have you run away from foster care?
a. Once
b. Twice
c. Three or four times
d. Five or more times
e. I choose to skip this question
55. [If G50=Yes or Skipped] How old were you the first time you ran away from your foster
home?
c. Enter Age in years ________
d. I choose to skip this question
56. [If G50=Yes or Skipped] Why did you run away from foster care? Please check all of the
reasons that apply.
a. Physical abuse
b. Emotional abuse
c. Sexual abuse
d. They had too many rules
e. I wanted to see my family or my friends
f. They didn’t accept me for who I am
g. I didn’t get along with my foster parents or group home staff
h. I didn’t get along with the other kids where I lived
i. I choose to skip this question
j. Other (please specify): _______________________
57. [If G51=Yes or Skipped] Over the past 6 months, where did you usually stay/sleep after
you were kicked out of your foster home? Select all that apply.
a. In a house or apartment with my immediate family (parent or guardian) that we
rent or own.
b. At the house or apartment of another family member
c. At my own apartment (I pay rent)
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d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.

Temporarily staying with friends or couch surfing
At my boyfriend/girlfriend/partner’s home
At a shelter
In a transitional housing program
At a group home
A treatment facility or center (hospital, detox, etc.)
Inside a car, abandoned building, squat, etc.
Outside in the park, on the street, in a tent, etc.
At a transit station (subway or bus station or the airport)
A jail, prison, or detention facility
Hotel/motel
I have not been kicked out in the past six months.
I choose to skip this question
Other (please specify): ______________________

58. [If G51=Yes or Skipped] How safe do you feel when you sleep there?
a. Very safe
b. Safe
c. Somewhat safe
d. Unsafe
e. Very unsafe
f. I choose to skip this question
59. [If G51=Yes or Skipped] How many times have you been kicked out of foster care?
a. Once
b. Twice
c. Three or four times
d. Five or more times
e. I choose to skip this question
60. [If G51=Yes or Skipped] How old were you the first time you were kicked out of your
foster home?
a. Enter Age in years ________
b. I choose to skip this question
61. [If G51=Yes or Skipped] Why did your foster parent kick you out? Please check all of the
reasons that apply.
a. I didn’t follow their rules
b. My foster parent chose their boyfriend/girlfriend/husband/wife over me
c. They didn’t accept me for who I am
d. I don’t know
e. I choose to skip this question
f. Other (please specify): _______________________

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Section H: Work
Have you ever done any kind of work/other activity for something in return from an employer,
relative, friend, or stranger? This could mean that you received money, food, housing, drugs, or
anything else.
•
•

“Work/other activity” can be something like being a server at a restaurant or working at a
store, or something like selling drugs or trading sex.
This could include doing it for someone even though you didn’t want to.

62. Thinking about all types of “work” above, have you ever done work for someone?
a. Yes
b. No
c. I choose to skip this question
If H62 = No, Skip to Section I

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SHORT VERSION TOOL
63. [If H62=Yes or Skipped] Have you ever been unable to leave a place you worked or talk
to people you wanted to talk to, even when you weren’t working, because the person
you worked for threatened or controlled you?
a. Yes
b. No
c. I choose to skip this question
64. [If H62=Yes or Skipped] Did someone you work for ever refuse to pay what they
promised and keep all or most of the money you made?
a. Yes
b. No
c. I choose to skip this question
65. [If H62=Yes or Skipped] Were you ever physically beaten, slapped, hit, kicked, punched,
burned or harmed in any way by someone you work for?
a. Yes
b. No
c. I choose to skip this question
66. [If H62=Yes or Skipped] Did you ever feel emotionally abused by someone you worked
for?
a. Yes
b. No
c. I choose to skip this question

67. [If H62=Yes or Skipped] Did someone you work for ever ask, pressure, or force you to
do something sexually that you did not feel comfortable doing?
a. Yes
b. No
c. I choose to skip this question

68. [If H62=Yes or Skipped] Were you ever forced to engage in sexual acts with family,
friends, clients, or business associates for money or favors, by someone you work for?
a. Yes
b. No
c. I choose to skip this question
69. [If H62=Yes or Skipped] Did you ever trade sexual acts for food, clothing, money,
shelter, favors, or other necessities for survival before you reached the age of 18?
a. Yes
b. No
c. I choose to skip this question

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LONG VERSION TOOL – Use this to validate short version above
70. [If H62=Yes or Skipped] Which of the following kinds of work have you ever done for
someone, keeping in mind that by “work” we mean anything you did to get money or
something of value—including food, clothes, a place to stay, protection, drugs, or gifts—
for yourself (or your family). Please check all that apply.
a. Serving food in a restaurant or café
b. Another type of job in a restaurant or café
c. In a retail store (clothing store, grocery store, convenience store, at the mall, etc.)
d. Doing construction work or other home repairs (painting, plumbing, electricity,
etc.)
e. Mowing lawns, shoveling sidewalks, or other yard work
f. Office work (answering phones, filing, etc.)
g. Selling items door-to-door
h. Selling items, dancing, or performing on the street or in the subways
i. Asking for change or donations on the street or in the subway
j. Trading sex for money, clothes, shelter, or other things
k. Participating in sexual videos or photos for money, clothes, shelter, or other
things
l. Stripping
m. Babysitting
n. Cleaning homes
o. Delivering newspapers, restaurant food, groceries or other things to other
people’s homes
p. Doing nails or braiding hair
q. I choose to skip this question
r. Other (please specify)_________________

[If H62=Yes or Skipped] Employers, and people who help employers (e.g. managers, drivers,
crew leaders, security, etc.), may use threats or lies to make you feel afraid to leave, complain,
or seek help for your situation.
71. Have any of the following incidents happened to you at the hands of your employer or
people working for your employer ever in your life, or in the past year?

Did someone you work for …
FORCE
a. Physically force you to do something you didn’t
feel comfortable doing
b. Lock you up, restrain you or prevent you from
leaving
c. Physically harm you in any way (beat, slap, hit,
kick, punch, burn)
FRAUD
d. Trick you into doing different work than was
promised
16 | P a g e

Ever in your life?

In the past year?

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

e. Make you sign a document without
understanding what it stated, like a work
contract
f. Refuse to pay you or pay less than they
promised
COERCION
g. Restrict or control where you went or who you
talked to
h. Deprive you of sleep, food, water, or medical
care
i. Not let you contact family or friends, even when
you weren’t working
j. Keep all or most of your money or pay
k. Keep your ID documents (e.g. ID card, license,
passport, social security card, birth certificate)
from you
l. Threaten to get you deported
m. Threaten to harm you or your family or pet

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes
Yes

No
No

Skip
Skip

Yes
Yes

No
No

Skip
Skip

Yes
Yes

No
No

Skip
Skip

Yes
Yes

No
No

Skip
Skip

n. Physically harm or threaten a co-worker or friend
COMMERCIAL SEX
o. Force you to do something sexually that you
didn’t feel comfortable doing
p. Put your photo on the Internet to find clients to
trade sex with
q. Force you to engage in sexual acts with family,
friends, or business associates for money or
favors
r. Encourage or pressure you to do sexual acts or
have sex, including taking sexual photos or
videos
s. Force you to trade sex for money, shelter, food
or anything else through online websites, escort
services, street prostitution, informal
arrangements, brothels, fake massage
businesses or strip clubs

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

Yes

No

Skip

72. [If H71 includes any “Yes” or “Skip” response, answer this question; otherwise, SKIP to
H73] How old were you when you were first involved in any of these work situations?
a. Enter age in years _________________
b. I choose to skip this question
73. In your life, have you ever—on your own—traded sex for money, shelter, food or
anything else? Do not count times when you were working for someone else.
a. Yes [CONTINUE to H74]
17 | P a g e

b. No [SKIP to I77]
c. I choose to skip this question [CONTINUE to H74]
74. [If H73=Yes or Skipped] In the past year, did you—on your own—trade sex for money,
shelter, food or anything else? Do not count times when you were working for someone
else.
a. Yes
b. No
c. I choose to skip this question
75. [If H73=Yes or Skipped] How old were you when you first traded sex for money, shelter,
food or anything else on your own?
a. Enter age in years _________________
b. I choose to skip this question
76. [If H71 includes any “Yes” or “Skip” response and/or H74=Yes or Skipped, ANSWER this
question; otherwise, SKIP to I77] If H71 includes any “Yes” or skipped response and/or
H74=Yes or skipped, for these work experiences, tell us how you found out about this
work? Select all that apply.
a. Online ad
b. Newspaper/magazine
c. Friend
d. Family member
e. Partner
f. Service provider
g. I choose to skip this question
h. Other

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Section I: Other Life Experiences
77. Have you ever been arrested?
a. Yes [CONTINUE to I78]
b. No [SKIP to I81]
c. I choose to skip this question [CONTINUE to I78]
78. Have you been arrested as a child, an adult, or both?
a. Child
b. Adult
c. Both
d. I choose to skip this question
79. Have you been arrested 3 or more times in your life?
a. Yes
b. No
c. I choose to skip this question
80. What were you arrested for most recently? (Check all that apply)
a. Curfew violation
b. Skipping school
c. Running away
d. Shoplifting
e. Drugs
f. Prostitution or Prostitution related charge (for example, loitering, soliciting)
g. Disorderly Conduct
h. Assault
i. Stealing a car
j. Theft of services (for example,. jumping the turnstile)
k. Trespassing
l. I choose to skip this question
m. Other [specify_____]
81. In the past month, have you used drugs other than those prescribed by a doctor or those
available “over-the-counter” (for example, marijuana, ecstasy or molly, heroin, crack,
cocaine)?
a. Yes
b. No
c. I choose to skip this question
82. In the past month, have you abused prescription or over-the-counter drugs—that is,
used them more frequently or in larger doses than prescribed or directed?
a. Yes
b. No
c. I choose to skip this question
83. In the past month, how often have you had five or more drinks on one occasion?
a. Never
b. 1 time per month or less
c. 2 to 4 times per month
d. 2 to 3 times per week
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e. Daily or almost daily
f. I choose to skip this question

Section J: Help-Seeking
84. Have you ever tried to get help for the situations described in this survey?
a. Yes
b. No
c. I choose to skip this question
85. [If J84=Yes or Skipped] Who did you go to for help?
a. Parent
b. Sibling
c. Other family member
d. Friend
e. Foster parent
f. Guardian
g. Child welfare case worker
h. Police
i. School official (e.g. guidance counselor, teacher)
j. Health care professional (e.g. doctor, nurse, therapist)
k. I choose to skip this question
86. Would you like to talk to someone today about the things on this survey and find out
about services that may be available to help you? Please remember that if agree to
speak to someone and seek services available to you, your answers relating to
those services you request will no longer be anonymous. For example, if you
seek drug treatment services, you will be self-disclosing your drug use to that
person, but the rest of the survey will remain anonymous and confidential.
a. Yes
b. No
c. I choose to skip this question

Thank you for participating in our survey!
Please take the Survey Handout with resources that might help you or your
family and friends.

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