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OMB No. 0920-xxxx
Expiration Date: XX/XX/XXXX
Injection Drug Use Surveillance Project
Attachment # 11
Screenshots of IDU Survey Questions in REDCap
Privacy Act Statement:
This information is collected under the authority of the Public Health Service Act, Section
301, "Research and Investigation," (42 U.S.C. 241); and Sections 304, 306 and 308(d) which
discuss authority to maintain data and provide assurances of confidentiality for health
research and related activities (42 U.S.C. 242 b, k, and m(d)). This information is also
being collected in conjunction with the provisions of the Government Paperwork Elimination
Act and the Paperwork Reduction Act (PRA). This information will only be used by the Centers
for Disease Control and Prevention (CDC) and staff at the University of Washington to develop
a surveillance system to monitor drug use risk and prevention behaviors and the infectious
disease consequences of high-risk drug use in syringe services programs (SSPs) in rural and
urban areas the US.
Public reporting burden of this collection of information is estimated to average 30 minutes
per survey. 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. Send
comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance
Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)
Confidential
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READ: "Thank you for answering the questions. I'm going to start by asking you about the person who gave you this
coupon. Please remember that your answers will be kept private."
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HIDDEN, AUTOMATIC: Start time where respondent starts
answering questions
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__________________________________
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[GIVE RESPONDENT FLASHCARD C.]
NS1. Which of the following describes how you know
the person who gave you this coupon? You can choose
more than one answer.
[READ choices. CHECK ALL that apply.]
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A relative or family member
A person you have sex with
A person you use drugs with or buy drugs from
A friend
An acquaintance, that is, a person you know but do
not consider a friend
A stranger, you don't know the person or just met
them
Refuse to Answer
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READ: "Now, I'm going to ask you about people you know. Specifically, I'm going to ask you how many people you
know who inject or use drugs and whom you have seen in the past 30 days. I will not ask you questions about any
specific person."
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NS2. Please tell me how many people you know who
inject and whom you have seen in the past 30 days.
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__________________________________
(IF DON'T KNOW OR REFUSED, LEAVE BLANK)
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NS3. Please tell me how many people you know who
use drugs but do not inject and whom you have seen
in the past 30 days.
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__________________________________
(IF DON'T KNOW OR REFUSED, LEAVE BLANK)
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READ: "Next, I'd like to ask you some questions about where you live. Please remember your answers will be kept
private."
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DM1. In the past 6 months, have you been homeless? By
homeless, I mean you were living on the street, in a
shelter, or in a car.
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No
Yes
Don't Know
Refuse to Answer
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DM2. Which zip code do you usually live in?
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__________________________________
(IF DON'T KNOW OR REFUSED, LEAVE BLANK)
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READ: "The next questions are about health insurance. By health insurance, we mean health plans people get
through employment or purchase directly, as well as government programs like Medicare and Medicaid that provide
medical care or help pay medical bills."
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DM3. Do you currently have health insurance or health
care coverage?
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No
Yes
Don't Know
Refuse to Answer
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[GIVE RESPONDENT FLASHCARD D.]
DM4. What kind of health insurance or coverage do you
currently have?
[READ choices. CHECK ALL that apply.]
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A private health plan - through an employer or
purchased directly
A government plan, such as Medicaid or Medicare
Some other health insurance
Don't Know
Refuse to Answer
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DM4spec. INTERVIEWER: Specify other health
insurance or coverage:
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__________________________________
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DM5. In the past 6 months, have you seen a doctor,
nurse, or other healthcare provider?
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No
Yes
Don't Know
Refuse to Answer
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DM6. In the past 6 months, how many times have you
gone to an emergency room for medical care?
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__________________________________
(IF DON'T KNOW OR REFUSED, LEAVE BLANK)
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DM7. In the past 6 months, have you felt that
healthcare staff treated you poorly because you use
drugs?
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No
Yes
Don't Know
Refuse to Answer
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DM8. In the past 6 months, have you avoided seeking
healthcare because you were worried about being
treated poorly by healthcare staff because of your
drug use?
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No
Yes
Don't Know
Refuse to Answer
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DM9. What is the highest level of education you
completed?
[DO NOT READ choices.]
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Never attended school
Grades 1 through 8
Grades 9 through 11
Grade 12 or GED
Some college, Associate's Degree, or Technical
Degree
Bachelor's Degree
Any post graduate studies
Don't Know
Refuse to Answer
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DM10. During the last 6 months, what was the main
source of income you lived on? Your main source of
income could be formal or informal. Remember all
information you provide will be kept private.
[DO NOT READ choices.]
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Full-time job/employed with a regular salary
Temporary work, including legal part-time and odd
jobs, off-books, etc.
Unemployment benefits
Other public assistance such as welfare,
disability, or food stamps
Spouse, partner, friend, or relative's income
Sex for money
Selling drugs
Panhandling
Other (specify)
Don't Know
Refuse to Answer
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DM10spec. INTERVIEWER: Specify other main source of
income
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__________________________________
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READ: "The next questions are about your overall health."
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DM11. Are you deaf or do you have serious difficulty
hearing?
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No
Yes
Don't Know
Refuse to Answer
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DM12. Are you blind or do you have serious difficulty
seeing, even when wearing glasses?
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No
Yes
Don't Know
Refuse to Answer
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DM13. Because of a physical, mental, or emotional
condition, do you have serious difficulty
concentrating, remembering, or making decisions?
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No
Yes
Don't Know
Refuse to Answer
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DM14. Do you have serious difficulty walking or
climbing stairs?
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No
Yes
Don't Know
Refuse to Answer
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DM15. Do you have difficulty dressing or bathing?
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No
Yes
Don't Know
Refuse to Answer
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DM16. Because of a physical, mental, or emotional
condition, do you have difficulty doing errands
alone, such as visiting a doctor's office or shopping?
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No
Yes
Don't Know
Refuse to Answer
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HIDDEN, AUTOMATIC: End time of questions before
ACASI.
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ACASI
READ: "The next few sections will have some sensitive questions about your sex life and drug use. You have the
option to complete these sections on your own or with me. If you choose to do them on your own, I will still be
available to answer any questions you may have. First, I will show you the different types of questions and answers."
INTERVIEWER: The participant should be observed for this section to assess capacity for ACASI. Give the tablet to the
participant.
AC1. Some questions you answer by clicking either
"Yes" or "No." Please click on "Yes."
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No
Yes
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AC2. For other questions, you choose the best or
correct answer. For example, what is the day after
WEDNESDAY?
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Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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AC3. For some questions, you can choose more than
one answer. Select all the options which are
examples of food. You can select more than one option.
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Apples
Cereal
Radio
Green beans
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AC4. Lastly, there are questions you answer by
entering a number. Let's try entering the number "18."
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Please return the device to the interviewer.
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AC5. [INTERVIEWER: Enter code to continue.]
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AC6. We have finished the tutorial. Would you like
to complete the next set of questions on your own or
with me?
Participant will complete
Interviewer will complete
[INTERVIEWER ENTER RESPONSE]
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HIDDEN, AUTOMATIC: Start time of ACASI questions
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The next questions are about having sex. "Having sex" means vaginal or anal sex. Vaginal sex means penis in the
vagina; and anal sex means penis in the anus or butt.
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SX1. Have you ever had vaginal sex or anal sex?
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No
Yes
Don't Know
Refuse to Answer
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SX2. In the past 6 months, with how many different
people have you had vaginal or anal sex? Please
give your best estimate. If you do not know, you
may leave the response blank.
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__________________________________
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SX3. In the past 6 months, with whom have you had
vaginal or anal sex? You can select more than one.
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Men
Women
People with other gender identities
Don't Know
Refuse to Answer
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SX4. In the past 6 months, did you receive money,
drugs, or any other type of payment for having
vaginal or anal sex?
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No
Yes
Don't Know
Refuse to Answer
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SX5. In the past 6 months, did you give money, drugs,
or any other type of payment for having vaginal or
anal sex?
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No
Yes
Don't Know
Refuse to Answer
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SX6. In the past 6 months, did you have vaginal or
anal sex without using a condom?
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No
Yes
Don't Know
Refuse to Answer
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SX7. In the past 6 months, with whom did you have sex
without using a condom? You can select more than one
option.
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Main sex partner, such as your spouse,
boy/girlfriend
Casual sex partner
Someone you got drugs or money for sex
Someone else
Don't Know
Refuse to Answer
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The next questions are about injection drug use. Please remember your answers will be kept private.
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ID1. Think back to the very first time you injected
any drugs. How old were you when you first injected
any drug? Please give your best estimate. If you do
not know, you may leave the response blank.
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ID2. Which drug did you inject that very first time?
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Speedball
Goofball
Fentanyl, by itself or mixed with other drugs
Heroin
Methamphetamine, by itself
Powder cocaine, by itself
Crack cocaine, by itself
Painkillers, such as Oxycontin, Dilaudid, or
Percocet
Benzodiazepines or other downers
Methadone
Buprenorphine, also known as Suboxone or Subutex
Something else
Don't Know
Refuse to Answer
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The next questions are about drugs you injected in the past 6 months.
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ID3. In the past 6 months, when you were injecting,
about how often did you inject any drug?
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More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
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ID4. On a day when you inject any drug, on average,
how many times a day do you inject? Please give your
best estimate. If you do not know, you may leave
the response blank.
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The next questions are about the types of drugs you mentioned you had injected in the past 6 months.
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ID5. In the past 6 months, how often did you inject
speedball?
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More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
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ID6. In the past 6 months, how often did you inject
goofball?
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More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
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ID7. In the past 6 months, how often did you inject
heroin, by itself?
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More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
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ID8. In the past 6 months, how often did you inject
methamphetamine, by itself?
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More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
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ID9. In the past 6 months, how often did you powder
cocaine, by itself?
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More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
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ID10. In the past 6 months, how often did you inject
crack cocaine, by itself?
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More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
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ID11. In the past 6 months, how often did you inject
painkillers, such as Oxycontin, Dilaudid, or Percocet?
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More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
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ID12. In the past 6 months, how often did you inject
benzodiazepines or other downers?
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More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
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ID13. In the past 6 months, how often did you inject
methadone?
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More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
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ID14. In the past 6 months, how often did you inject
buprenorphine, also known as Suboxone or Subutex?
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More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
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ID15. In the past 6 months, how often did you inject
fentanyl by itself or mixed with other drugs?
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More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
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ID16. When you injected fentanyl in the past 6
months, was it mixed with any other drug?
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No
Yes
Don't Know
Refuse to Answer
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ID17. What other drugs was fentanyl mixed with? You
can select more than one option.
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Speedball
Goofball
Heroin
Methamphetamine
Powder cocaine
Crack cocaine
Painkillers, such as Oxycontin, Dilaudid, or
Percocet
Benzodiazepines or other downers
Methadone
Buprenorphine, also known as Suboxone or Subutex
Something else
Don't know
Refuse to answer
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ID18. In the past 6 months, how often did you inject
in a public place, like an alley, public bathroom,
library, or outside?
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Never
Rarely
About half the time
Most of the time
Always
Don't Know
Refuse to Answer
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ID19. In the past 6 months, how often were you alone
when you injected?
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Never
Rarely
About half the time
Most of the time
Always
Don't Know
Refuse to Answer
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The next questions are about assisting someone who has never injected drugs with their first injection of any drug.
This means you gave them their first injection or you showed them how to inject and they injected themselves.
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ID20. In the past 6 months, have you injected drugs
in front of someone who had never injected drugs?
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No
Yes
Don't Know
Refuse to Answer
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ID21. In the past 6 months, have you assisted anyone
with their first time injecting any drug?
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No
Yes
Don't Know
Refuse to Answer
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Next, the questions will be about the needles you used in the past 6 months.
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ID22. In the past 6 months when you injected, how
often did you use a new, sterile needle? By a new,
sterile needle, I mean a needle never used before by
anyone, even you.
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Never
Rarely
About half the time
Most of the time
Always
Don't Know
Refuse to Answer
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ID23. In the past 6 months, after you injected, how
often did you put a used needle in a medical sharps
or other secure container and/or took it to a
syringe exchange program?
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Never
Rarely
About half the time
Most of the time
Always
Don't Know
Refuse to Answer
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ID24. In the past 6 months, how often did you reuse a
needle you already injected with?
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Never
Rarely
About half the time
Most of the time
Always
Don't Know
Refuse to Answer
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The next questions are about your injecting behaviors in the past 6 months.
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ID25. In the past 6 months, did you use needles that
someone else had already injected with?
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No
Yes
Don't Know
Refuse to Answer
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ID26. In the past 6 months, with how many different
people did you use a needle after they injected with
it? Please give your best estimate. If you do not
know, you may leave the response blank.
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ID27. In the past 6 months, did you give your needle
to someone else to use after you had already
injected with it?
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No
Yes
Don't Know
Refuse to Answer
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ID28. In the past 6 months, with how many different
people did you give your needle to use after you had
already injected with it? Please give your best
estimate. If you do not know, you may leave the
response blank.
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ID29. In the past 6 months, did you use cookers,
cottons, filters, or water that someone else had
already used?
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No
Yes
Don't Know
Refuse to Answer
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ID30. In the past 6 months, with how many different
people did you use the same cooker, cotton, or water
that they had already used? Please give your best
estimate. If you do not know, you may leave the
response blank.
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ID31. I the past 6 months, did you use drugs that had
been divided with a syringe that someone had already
injected with, also known as backloading or splitting?
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No
Yes
Don't Know
Refuse to Answer
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ID32. In the past 6 months, with how many different
people did you use drugs that had been divided with
a syringe that they had already used? Please give
your best estimate. If you do not know, you may
leave the response blank.
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Now, think about the last time you injected in the past 6 months.
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ID33. The last time you injected any drug, did you
inject in a public place, like an alley, public
bathroom, library, or outside?
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No
Yes
Don't Know
Refuse to Answer
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ID34. The last time after you injected, did you put
the used needle in a medical sharps or other secure
container and/or took it to a syringe exchange
program?
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No
Yes
Don't Know
Refuse to Answer
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ID35. The last time you injected any drug, did you
use a new, sterile needle?
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No
Yes
Don't Know
Refuse to Answer
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ID36. The last time you injected, how many other
people did you inject with? Please give your best
estimate. If you do not know, you may leave the
response blank.
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__________________________________
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ID37. The last time you injected, did you use a
needle after anyone else had already injected with it?
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No
Yes
Don't Know
Refuse to Answer
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ID38. The last time you injected, did you give your
needle to someone else to use after you had already
injected with it?
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No
Yes
Don't Know
Refuse to Answer
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ID39. The last time you injected, did you use a
cooker, cotton, or water that anyone else had
already used?
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No
Yes
Don't Know
Refuse to Answer
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ID40. The last time you injected, did you use drugs
that had been divided with a syringe that anyone
else had already injected with?
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No
Yes
Don't Know
Refuse to Answer
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The next questions are about the last person that you injected with. If you injected with more than one person,
please think of the one that you have injected with the most often. The next questions are about that person.
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ID41. What is this person's gender?
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Man
Woman
Gender not listed
Don't Know
Refuse to Answer
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ID42. How old is this person? Please estimate to the
best of your ability. If you do not know, you may
leave the response blank.
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__________________________________
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ID43. Which of the following best describes your
relationship to this person? Would you say this
person was a:
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Sex partner, such as your spouse,
boyfriend/girlfriend, or other person you have sex
with
Relative
Friend or acquaintance
Needle or drug dealer
Stranger or someone you did not know well
Someone else
Don't Know
Refuse to Answer
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The next questions are about times when you may have used drugs but did NOT inject them. This includes times that
you may have smoked, snorted, inhaled, or ingested drugs such as methamphetamine, cocaine, or crack. The next
questions are about the types of drugs you mentioned you had used but did not inject in the past 6 months.
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ND1. In the past 6 months, how often did you use
methamphetamine that you did not inject?
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More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
projectredcap.org
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Page 70
ND2. In the past 6 months, how often did you use
crack cocaine that you did not inject?
04/22/2020 3:33pm
More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 71
ND3. In the past 6 months, how often did you use
powder cocaine that you did not inject?
04/22/2020 3:33pm
More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 72
ND4. In the past 6 months, how often did you use
benzodiazepines or other downers that you did not
inject?
04/22/2020 3:33pm
More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 73
ND5. In the past 6 months, how often did you use
painkillers, such as Oxycontin, Dilaudid, or
Percocet that you did not inject?
04/22/2020 3:33pm
More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 74
ND6. In the past 6 months, how often did you use X or
ecstasy (MDMA) that you did not inject?
04/22/2020 3:33pm
More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 75
ND7. In the past 6 months, how often did you use
heroin that you did not inject?
04/22/2020 3:33pm
More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 76
ND8. In the past 6 months, how often did you use
Adderall, Ritalin, or other commonly prescribed
stimulants that you did not inject?
04/22/2020 3:33pm
More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 77
ND9. In the past 6 months, how often did you use
methadone that was not prescribed or not taken as
prescribed that you did not inject?
04/22/2020 3:33pm
More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 78
ND10. In the past 6 months, how often did you use
buprenorphine, also known as Suboxone or Subutex,
that was not prescribed or not taken as prescribed
that you did not inject?
04/22/2020 3:33pm
More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 79
ND11. In the past 6 months, how often did you use
fentanyl that you did not inject, by itself or mixed
with other drugs?
04/22/2020 3:33pm
More than once a day
Once a day
More than once a week
Once a week or less
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 80
ND12. When you used fentanyl, that you did not
inject, in the past 6 months, was it mixed with any
other drug?
04/22/2020 3:33pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 81
ND13. What other drugs was fentanyl mixed with? You
can select more than one option.
04/22/2020 3:33pm
Marijuana
Methamphetamine
Crack cocaine
Powder cocaine
Benzodiazepines or other downers
Painkillers, such as Oxycontin, Dilaudid, or
Percocet
X or ecstasy (MDMA)
Heroin
Adderall, Ritalin, or other commonly prescribed
stimulants
Methadone
Buprenorphine, also known as Suboxone or Subutex
Something else
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 82
ND14. In the past 6 months, has anyone injected drugs
in front of you?
04/22/2020 3:33pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 83
ND15. If you want to start injecting drugs, do you
know someone who would show you how?
04/22/2020 3:33pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 84
The next questions are about overdose from injection or use of opioids such as heroin, fentanyl, or painkillers such as
Oxycontin. By overdose, I mean if someone passed out, turned blue, or stopped breathing from using drugs.
04/22/2020 3:33pm
projectredcap.org
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Page 85
HIDDEN: Respondent used opioids
04/22/2020 3:33pm
__________________________________
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Page 86
DO1. In the past 6 months, how many times have you
overdosed on opioids? Please give your best
estimate. If you do not know, you may leave the
response blank.
04/22/2020 3:33pm
__________________________________
projectredcap.org
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Page 87
DO2. In the past 6 months, how many other people have
you seen overdose on opioids? Please give your best
estimate. If you do not know, you may leave the
response blank.
04/22/2020 3:33pm
__________________________________
projectredcap.org
Confidential
Page 88
DO3. The last time you saw someone overdose, did you
or someone around you try to get medical treatment
by calling 911 or taking them to the hospital?
04/22/2020 3:33pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 89
DO4. Have you ever heard of naloxone, also called
Narcan, a drug that can be used to reverse an
overdose due to use of opioids?
04/22/2020 3:33pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 90
DO5. In the past 6 months, have you bought or
otherwise gotten take-home naloxone or Narcan?
04/22/2020 3:33pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 91
DO6. In the past 6 months, have you used naloxone or
Narcan to help someone who was overdosing?
04/22/2020 3:33pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 92
DO7. In the past 6 months, have you been in a
situation when naloxone or Narcan was needed and it
was not available?
04/22/2020 3:33pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 93
Now I will ask you questions about consequences due to stimulant injection or use.
04/22/2020 3:33pm
projectredcap.org
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Page 94
DO8. In the past 6 months, did you need immediate
care or call 911 because you took too much
methamphetamine or were having a bad reaction to
methamphetamine?
04/22/2020 3:33pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 95
DO9. In the past 6 months, did you need immediate
care or call 911 because you took too much cocaine
or crack or were having a bad reaction to cocaine or
crack?
04/22/2020 3:33pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 96
The next questions are about experiences you may have had with the criminal justice system or law enforcement.
04/22/2020 3:33pm
projectredcap.org
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Page 97
JT1. During the past 6 months, have you been held in
a detention center, jail, or prison for more than 24
hours?
04/22/2020 3:33pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 98
JT2. The last time you were in detention, jail, or
prison, did you get treatment for drug use?
04/22/2020 3:33pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 99
JT3. The last time you were released from detention,
jail or prison, were you told where to get treatment
for drug use?
04/22/2020 3:33pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 100
JT4. In the past 6 months, have you been arrested on
drug possession charges?
04/22/2020 3:33pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 101
JT5. In the past 6 months, have you been arrested or
cited for possession of needles or other injection
equipment?
04/22/2020 3:33pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 102
JT6. In the past 6 months, have the police taken,
confiscated, or destroyed your needles or other
injection equipment without arresting or citing you?
04/22/2020 3:33pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 103
JT7. In the past 6 months, have the police taken,
confiscated, or destroyed your naloxone or Narcan
without arresting or citing you?
04/22/2020 3:33pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 104
Next are questions about some situations that may have happened to you.
04/22/2020 3:33pm
projectredcap.org
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Page 105
VI1. In the past 6 months, has anyone beaten,
stabbed, or shot you with a weapon or another object?
04/22/2020 3:33pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 106
VI2. In the past 6 months, has anyone slapped,
punched, shoved, kicked, shaken, or otherwise
physically hurt you? Do not consider times when a
weapon or object was used.
04/22/2020 3:33pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
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Page 107
VI3. In the past 6 months, has anyone forced or
pressured you to have vaginal, oral, or anal sex
when you did not want to?
04/22/2020 3:33pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 108
Thank you for answering these questions. You have completed the questions that you answer yourself. Please let the
interviewer know when you are ready to continue with the interview.
04/22/2020 3:33pm
projectredcap.org
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Page 109
HIDDEN, AUTOMATIC: End time for ACASI questions
04/22/2020 3:33pm
__________________________________
projectredcap.org
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Page 1
Post ACASI
HIDDEN, AUTOMATIC: Start time for post-ACASI
interview questions
04/22/2020 3:34pm
__________________________________
projectredcap.org
Confidential
Page 2
INTERVIEWER: The participant has answered difficult questions. Please check with the participant to make sure they
feel comfortable moving forward with the questionnaire and if they need any assistance. Mention there will be
referrals at the end of the questionnaire, if needed.
04/22/2020 3:34pm
projectredcap.org
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Page 3
READ: "Next, I'm going to ask you about your experiences in receiving treatment for drug use. By treatment, I mean
you participated in a program or took medicine to treat your drug use. This includes outpatient, inpatient, residential,
detox, or 12-step program. This does not include treatment for alcohol use."
04/22/2020 3:34pm
projectredcap.org
Confidential
Page 4
TX1. In the past 6 months, have you felt that you
needed treatment for your drug use?
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 5
TX2. In the past 6 months, have you received
treatment for your drug use?
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 6
READ: "Now, I am going to ask you about your experiences with taking medicines to treat drug use due to use of
opioids such as heroin, fentanyl, or painkillers such as Oxycontin. Medicines to treat drug use would include
methadone or buprenorphine. Please only think about these medicines given to you by a doctor or other healthcare
provider."
04/22/2020 3:34pm
projectredcap.org
Confidential
Page 7
TX3. In the past 6 months, have you taken medicines
that were provided by a doctor or other healthcare
provider to treat opioid use?
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 8
TX4. In the past 6 months, which medicines that were
provided by a doctor or other healthcare provider
did you take to treat opioid use?
[READ choices. CHECK ALL that apply.]
04/22/2020 3:34pm
Methadone
Buprenorphine, also known as Suboxone or Subutex
Naltrexone, also known as Vivitrol
Other medicine
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 9
TX4spec. INTERVIEWER: Specify other medication.
04/22/2020 3:34pm
__________________________________
projectredcap.org
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Page 10
TX5. In the past 6 months, when you took
buprenorphine (e.g., Suboxone) or methadone, did you
feel it relieved your symptoms?
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 11
TX6. In the past 6 months, did you try to get
medicines to treat opioid use but were unable to?
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 12
TX7. In the past 6 months, which medicines did you
try to get to treat drug use but were unable to?
[READ choices. CHECK ALL that apply.]
04/22/2020 3:34pm
Methadone
Buprenorphine, also known as Suboxone or Subutex
Naltrexone, also known as Vivitrol
Other medicine
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 13
TX7spec. INTERVIEWER: Specify other medicine.
04/22/2020 3:34pm
__________________________________
projectredcap.org
Confidential
Page 14
READ: "Now I'm going to ask you a few questions about getting tested for HIV."
04/22/2020 3:34pm
projectredcap.org
Confidential
Page 15
HT1. Have you ever had an HIV test?
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 16
HT2a. When did you have your most recent HIV test?
Please tell me the month and year.
[INTERVIEWER: FIRST ENTER MONTH OF HIV TEST.]
04/22/2020 3:34pm
January
February
March
April
May
June
July
August
September
October
November
December
Don't Know
Refuse to Answer
projectredcap.org
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Page 17
HT2b. [INTERVIEWER: ENTER YEAR OF MOST RECENT HIV
TEST]
04/22/2020 3:34pm
__________________________________
(IF DON'T KNOW OR REFUSED, LEAVE BLANK)
projectredcap.org
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Page 18
Hidden calculation: Interim calculation - number of
years between IDATE_Y and RCNTST_Y
__________________________________
Hidden calculation: Interim calculation - number of
months
__________________________________
Hidden calculation: Interim calculation - estimated
number of months between IDATE and HIV test date,
factoring in years and months
Hidden calculation: R was tested for HIV in the last
12 months
04/22/2020 3:34pm
__________________________________
__________________________________
projectredcap.org
Confidential
Page 19
HT2c. Was your most recent HIV test in the past 12
months?
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 20
HT3. The last time you were tested for HIV, where did
you get tested?
[DO NOT READ choices.]
04/22/2020 3:34pm
HIV/AIDS street outreach program or mobile unit
Drug treatment program
Syringe exchange program
Correctional facility (jail or prison)
Family planning or obstetrics clinic
Public health clinic or community health center
Private doctor's office (including HMO)
Emergency room
Hospital (inpatient)
At home
Other
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 21
HT4. What was the result of your most recent HIV
test?
[READ choices.]
04/22/2020 3:34pm
Negative, you do NOT have HIV
Positive, you DO have HIV
Did not get result
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 22
HT5. I'm going to read you a list of reasons why some
people have not been tested for HIV. Which of these
best describes the most important reason you have
not been tested for HIV in the past 12 months?
[READ choices.]
04/22/2020 3:34pm
You think you are at low risk for HIV
Your last test was HIV-negative
You were afraid of finding out that you might have
HIV
You didn't have time
No one offered you an HIV test
No HIV testing was available
You did not know where to get HIV testing
Some other reason
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 23
HT5spec. INTERVIEWER: Specify other reason not been
tested for HIV in the past 12 months.
04/22/2020 3:34pm
__________________________________
projectredcap.org
Confidential
Page 24
HT6. Have you ever been seen by a doctor, nurse, or
other healthcare provider for a medical evaluation
or care related to your HIV infection?
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 25
HT7. Was your last visit for HIV care in the past 6
months?
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 26
HT8. Are you currently taking antiretroviral
medicines to treat your HIV infection?
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 27
READ: "The next questions are about the use of pre-exposure prophylaxis, or PrEP, such as Truvada, a medicine
taken for months or years by a person who is HIV-negative to reduce the risk of getting HIV."
04/22/2020 3:34pm
projectredcap.org
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Page 28
HT9. Before today, have you ever heard of PrEP?
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 29
HT10. In the past 6 months, did you take PrEP?
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 30
HT11. In the past 6 months, did you try to get PrEP
but were unable to?
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 31
READ: "Next, I'd like to ask you some questions about your health, in general. The first questions are about hepatitis
C. Hepatitis C is spread through infected blood. Injection drug use is one of the most common reasons people get
hepatitis C."
04/22/2020 3:34pm
projectredcap.org
Confidential
Page 32
HC1. Have you ever been tested for hepatitis C
infection?
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 33
HC2a. When did you have your most recent hepatitis C
test? Please tell me the month and year.
[INTERVIEWER: FIRST ENTER MONTH OF MOST RECENT HCV
TEST.]
04/22/2020 3:34pm
January
February
March
April
May
June
July
August
September
October
November
December
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 34
HC2b. [INTERVIEWER: ENTER YEAR OF MOST RECENT HCV
TEST.]
04/22/2020 3:34pm
__________________________________
(IF DON'T KNOW OR REFUSED, LEAVE BLANK)
projectredcap.org
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Page 35
HC3. The last time you were tested for hepatitis C,
where did you get tested?
[DO NOT READ choices.]
04/22/2020 3:34pm
HIV/AIDS street outreach program or mobile unit
Drug treatment program
Syringe exchange program
Correctional facility (jail or prison)
Family planning or obstetrics clinic
Public health clinic or community health center
Private doctor's office (including HMO)
Emergency room
Hospital (inpatient)
At home
Other
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 36
HC3spec. INTERVIEWER: Type in other location where
respondent got the last hepatitis C test.
04/22/2020 3:34pm
__________________________________
projectredcap.org
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Page 37
[GIVE RESPONDENT FLASHCARD E.]
HC4. Has a doctor, nurse, or other healthcare
provider ever told you that you had hepatitis C?
[READ choices.]
04/22/2020 3:34pm
No
Yes, I have been told I have hepatitis C and I
have it now
Yes, I have been told I have hepatitis C, but I do
not have it now
Yes, I have been told I have hepatitis C, but I do
not know if I have it now
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 38
[GIVE RESPONDENT FLASHCARD F.]
HC5. Approximately when were you last told you had
hepatitis C?
[READ choices.]
04/22/2020 3:34pm
Less than 1 year ago
1 year to 5 years ago
6 years to 10 years ago
More than 10 years ago
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 39
HC6. Have you ever taken medicine to treat your
hepatitis C infection?
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 40
[GIVE RESPONDENT FLASHCARD F.]
HC7. Approximately when did you last take medicine to
treat your hepatitis C infection?
[READ choices.]
04/22/2020 3:34pm
Less than 1 year ago
1 year to 5 years ago
6 years to 10 years ago
More than 10 years ago
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 41
[GIVE RESPONDENT FLASHCARD G.]
HC8. What was the outcome of your most recent
hepatitis C treatment?
[READ choices.]
04/22/2020 3:34pm
The medication worked, you are cured
You are still on medication
You stopped taking medication, the medication did
not work
You stopped taking medication, waiting on results
You stopped taking medication for other reasons
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 42
HC9. Have you ever tried to get medicines to treat
your hepatitis C infection but were unable to?
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 43
READ: "Now I will ask you about other health conditions."
04/22/2020 3:34pm
projectredcap.org
Confidential
Page 44
HC10. Has a doctor, nurse, or other healthcare
provider ever told you that you had an infection of
the heart valve, also known as endocarditis?
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 45
HC11. Has a doctor, nurse, or healthcare provider
ever told you that you had a bone infection, also
known as osteomyelitis?
04/22/2020 3:34pm
No
Yes
Don't know
Refuse to answer
projectredcap.org
Confidential
Page 46
HC12. In the past 6 months, have you had an abscess?
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 47
HC13. In the past 6 months, did a doctor or
healthcare provider help take care of an abscess?
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 48
READ: "Next I'd like to ask you about some prevention services you may have received in the past 6 months. We will
be asking you questions about getting needles, whether you may have used them yourself or not."
04/22/2020 3:34pm
projectredcap.org
Confidential
Page 49
PA1. In the past 6 months, have you gotten any new
sterile needles? By new sterile needle, I mean no
one - not even you - had ever used it before.
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 50
PA2. From which of the following places or people did
you get sterile needles in the past 6 months? You
may choose more than one option.
[READ choices. CHECK ALL that apply.]
04/22/2020 3:34pm
Syringe exchange program
Pharmacy or drug store
Doctor's office, clinic, or hospital
Bought off the street
Internet
Someone who got them from a syringe exchange
Some other place or person
Don't know
Refuse to answer
projectredcap.org
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Page 51
PA2spec. INTERVIEWER: Type in other sources for
sterile needles.
04/22/2020 3:34pm
__________________________________
projectredcap.org
Confidential
Page 52
PA3. What are the reasons you did not get needles or
syringes from a syringe exchange program?
[DO NOT READ choices. CHECK ALL that apply.]
04/22/2020 3:34pm
Did not know about the syringe exchange
Got needles from other sources
Tried and did not want to use it again
Location was inconvenient
Location was too far away
Hours were not convenient
Did not trust that information would be kept
private
Did not want to be identified as someone who
injects drugs
Afraid of arrest or harassment by police
Something else
Don't Know
Refuse to Answer
projectredcap.org
Confidential
Page 53
PA3spec. INTERVIEWER: Type in other reasons.
04/22/2020 3:34pm
__________________________________
projectredcap.org
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Page 54
PA4. In the past 30 days, how many new sterile
needles did you have for your personal use?
04/22/2020 3:34pm
__________________________________
(IF DON'T KNOW OR REFUSED, LEAVE BLANK)
projectredcap.org
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Page 55
PA5. In the past 30 days, how many of the [sndl30]
sterile needles did you get from the syringe
exchange program?
04/22/2020 3:34pm
__________________________________
(IF DON'T KNOW OR REFUSED, LEAVE BLANK)
projectredcap.org
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Page 56
INTERVIEWER: Number of needles obtained at a syringe exchange program cannot be greater than the total number
of needles. Please check these numbers with the respondent and correct those data.
04/22/2020 3:34pm
projectredcap.org
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Page 57
PA6. In the past 6 months, not including yourself,
for how many different people did you get needles at
the syringe exchange program?
04/22/2020 3:34pm
__________________________________
(IF DON'T KNOW OR REFUSED, LEAVE BLANK)
projectredcap.org
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Page 58
PA7. In the past 6 months, other than syringes, have
you received services, counseling, information, or
other products from the syringe exchange program?
04/22/2020 3:34pm
No
Yes
Don't Know
Refuse to Answer
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PA8. In the past 6 months, other than syringes, what
services, counseling, information, or other products
have you received from the syringe exchange program?
[DO NOT READ choices. CHECK ALL that apply.]
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Naloxone/Narcan and/or overdose prevention
education
Injecting equipment such as cookers, cotton,
water, etc.
Sharps container
Food, showers, or medication locker
Information on or referrals to mental health
services
Information or counseling on sexual risk behaviors
Information or counseling about injection risk
behaviors
Recovery coaches
Peer support
Referrals to treatment for drug use
Medication-assisted treatment for drug use (e.g.,
buprenorphine)
Treatment for HIV or HCV
Testing for and/or information on HIV or HCV
Wound care
Reproductive healthcare, pregnancy test, or condoms
Vaccinations
Something else
Don't Know
Refuse to Answer
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PA8spec. INTERVIEWER: Specify other services,
counseling, information, or products received at
syringe exchange program.
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__________________________________
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PA9. Now I'd like to ask about what you think could
make the syringe exchange program better for
you. Please list up to three ways:
[DO NOT READ CHOICES. SELECT NO MORE THAN THREE.]
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Open more days or hours
More convenient location or more locations
Available or accessible staff
Offered more needles/had no limit on the number of
needles
Delivered to homes
Naloxone/Narcan and/or overdose prevention
education
Injecting equipment such as cookers, cotton,
water, etc.
Sharps container
Food, showers, or medication locker
Information on or referrals to mental health
services
Information or counseling about sexual risk
behaviors
Information or counseling about injection risk
behaviors
Recovery coaches
Peer support
Referrals to treatment for drug use
Medication-assisted treatment for drug use (e.g.,
buprenorphine)
Treatment for HIV or HCV
Testing for and/or information on HIV or HCV
Wound care
Reproductive healthcare, pregnancy test, or condoms
Vaccinations
Something else
No changes needed
Don't Know
Refuse to Answer
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PA9spec. INTERVIEWER: Type in other services to
improve at syringe exchange program.
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__________________________________
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HIDDEN, AUTOMATIC: End time of questionnaire
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__________________________________
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READ: "Thank you for answering these questions and for your participation so far."
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END1. INTERVIEWER: Please confirm. Did the person
complete the survey?
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Did NOT complete the survey
DID complete the survey
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END2. INTERVIEWER: Please enter the date this
interview was completed (MM/YY/DDDD)
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__________________________________
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END3. INTERVIEWER: Please enter the time the
interview ended (HH:MM) using a 24-hour clock. For
example: 1:30 p.m. should be entered as 13:30.
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__________________________________
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END4. INTERVIEWER: How confident are you of the
validity of the respondent's answers?
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Confident
Some doubts
Not confident at all
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END4spec. INTERVIEWER: Please explain why you are not
confident in the respondent's answers.
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__________________________________
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END5. INTERVIEWER: Do you have any comments to add?
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No
Yes
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END6. Enter interviewer comments.
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__________________________________
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| File Type | application/pdf |
| Author | Ptomey, Natasha (CDC/OID/NCHHSTP) (CTR) |
| File Modified | 2020-04-22 |
| File Created | 2020-04-22 |