Substance Abuse and Mental Health Services Administration (SAMHSA),

Center for Substance Abuse Prevention (CSAP)

National Outcome Measures (NOMs)

Reference Document

Strategic Prevention Framework

State Incentive Grant (SPF -- SIG) Cohort 3

**ADAPTED BY CSAP'S WESTERN CAPT**

***Purpose: Reference Material for Community Level Data Collection***

***Regional Cross-State Sharing Teleconference***

**August 29, 2007**

NOMs Overview

The National Outcome Measures (NOMs) are a set of domains and measures
that SAMHSA uses to measure whether the agency's vision is being
achieved. In addition, completion of the NOMs satisfy SAMHSA's Federal
reporting requirements including reducing burden and redundancy for
grantees.

SAMHSA's vision is a "Life in the Community for Everyone: Building
Resilience and Facilitating Recovery." This vision has three goals for
all agency initiatives: accountability, capacity, and effectiveness. The
NOMs address SAMHSA's goal of accountability with a
performance-monitoring approach. Given the differing components of
SAMHSA, the actual measures are slightly different across its three
Centers---CSAP, the Center for Mental Health Services (CMHS), and the
Center for Substance Abuse Treatment (CSAT).

The NOMs, which were finalized in 2006, were developed to meet SAMHSA
federal reporting requirements under the Government Performance and
Results Act (GPRA) of 1993, and Performance Assessment Rating Tool
(PART) requirements established in 2002.

GPRA, a public law passed by the U.S. Congress in 1993, was enacted to
improve stewardship in the Federal government and to link resources and
management decisions with program performance. GPRA requires that all
Federal departments do the following:

-   Develop a strategic plan specifying what they will accomplish over a
    3- to 5-year period.

-   Annually set performance targets related to their strategic plan.

-   Annually report the degree to which the targets set in the previous
    year were met.

-   Regularly conduct evaluations of their programs and use the results
    to explain their successes and failures on the basis of the
    performance-monitoring data.

The PART requirements were developed by the Office of Management and
Budget to rate each Federal program according to a set of criteria. The
most important of these criteria is: ***outcomes***, which accounts for
50 percent of the total score. All activities are monitored in each
Center, and SAMHSA's performance is rated.

A.  SAMHSA Overview of NOMs

With NOMs, SAMHSA is using data to manage and measure performance. In
collaboration with the States and jurisdictions, SAMHSA has defined ten
domains in which the NOMs are grouped (see Table 1, p. 6). Associated
with the domains are relevant outcomes for people who are striving to
attain and sustain recovery; build resilience; and work, learn, live,
and participate fully in their communities.

The SAMHSA website
([www.nationaloutcomemeasures.samhsa.gov](http://www.nationaloutcomemeasures.samhsa.gov/))
presents a matrix (see Table 1) defines the NOMs domains, outcomes, and
specific measures for mental health, prevention, and treatment. This
NOMs Reference Document addresses the substance abuse prevention NOMs.

Key Concepts

**State-, Community-, and Program-Level NOMs for SPF-SIG Cohort 3**

NOMs data must be collected and reported for all CSAP-funded programs.
The specific NOMs required will vary depending on the CSAP Program. For
the SPF-SIG Cohort 3 the following NOMs data are required:

-   State-level NOMs are required for each CSAP program that receives
    State-level funding. Prepopulated State-level NOMs will be finalized
    in the State SAPT Block Grant Application. For the SPF-SIG Cohort 3,
    grantees are only required to report the following State-level NOMs:
    number of people served, number of evidence-based programs and cost
    band information.

-   Community-level NOMs will be required from all SPF-SIG subrecipient
    communities, however the community is defined.

-   Program-level NOMs are required to be reported for the SPF-SIG
    Cohort 3.

***SPF-SIG Cohort 3 NOMs Reporting for Territories and Tribes***

The NOMs reporting requirements for the territories and tribes will
differ from the State requirements. For the SPF-SIG each territory and
tribe may have unique designations for State, community, and program
levels. Each territory and tribe will work with its CSAP Project Officer
to clarify the designations for NOMs reporting purposes.

For the SPF-SIG Cohort 3 territories and tribes are NOT required to
submit State-level NOMs that are being prepopulated in the SAPT Block
Grant Application unless estimates have been developed for them.
However, if relevant data are available to the territory or tribe, they
are encouraged to provide the data to CSAP. The territories and tribes
will need to report State-level NOMs for the SPF-SIG results for the
following NOMs: number of people served, number of evidence-based
programs and strategies and cost bands.

Territories and tribes that are SPF SIG Cohort 3 grantees are
responsible for community-level NOMs. Territories and tribes that are
SPF SIG Cohort 3 grantees are responsible for program-level NOMs.
Technical assistance will be available to the territories and tribes to
assist in the NOMs Reporting. The TA will be provided by the
organization (SPFAS and CAPTs) as established per contract for the Block
Grant and SPF-SIG grant programs.

NOMs Data Collection for SPF-SIG Cohort 3

#  {#section .DCCC-Heading-1}

NOMs data must be collected from all grantees that have been awarded and
received grant funds from CSAP. The data must be collected from grantees
and any subrecipients funded by the grantees. Table 2 identifies the
CSAP Grant Programs that are required to reports NOMs data. In order to
minimize the potential burden for the grantees, the collection of NOMs
data is being integrated into existing data collection efforts. For
example, NOMs reporting for the SAPT Block Grant will be included in the
annual Block Grant application process currently entered onto the SAPT
Block Grant Application and SPF-SIG NOMs reporting is included in the
cross-site evaluation data collection processes.

#  {#section-1 .DCCC-Heading-1}

For the SPF-SIG Cohort 3 grantees:

#  {#section-2 .DCCC-Heading-1}

-   The States are required to report only the following State-level
    NOMs: number of people served, number of evidence-based programs and
    strategies, and cost band information.

-   Community-level NOMs will be required from all SPF-SIG subrecipient
    communities, however the community is defined.

-   Program-level NOMs are required to be reported for the SPF-SIG
    Cohort 3.

NOMs Measures Required for SPF-SIG Cohort 3 Grantees

The table below provides a description of NOMs measures that are
required for SPF-SIG Cohort 3 grantees, community-level subrecipients,
and program providers. The table also describes the sources of data for
each of the NOMs measures.

+------------------------------+-------------+-------------+----------+
| **State-Level,               |             |             |          |
| Community-Level, and         |             |             |          |
| Program-Level Data**         |             |             |          |
+==============================+=============+=============+==========+
| **NOMs Measures**            | **          | *           | **       |
|                              | State-Level | *Community- | Program- |
|                              | Data        | Level Data  | Level    |
|                              | Source\***  | Source**    | Data     |
|                              |             |             | Source** |
+------------------------------+-------------+-------------+----------+
| **Abstinence From Drug       |             |             |          |
| Use/Alcohol Abuse**          |             |             |          |
+------------------------------+-------------+-------------+----------+
| -   30-day Substance Use     | Pre         | Community   | NOMs     |
|     (nonuse/reduction in     | populated\* | Survey      | Quest    |
|     use)                     |             |             | ionnaire |
+------------------------------+-------------+-------------+----------+
| -   Age of First Substance   | Pre         | Community   | NOMs     |
|     Use                      | populated\* | Survey      | Quest    |
|                              |             |             | ionnaire |
+------------------------------+-------------+-------------+----------+
| -   Perception of            | Pre         | Community   | NOMs     |
|     Disapproval/Attitude     | populated\* | Survey      | Quest    |
|                              |             |             | ionnaire |
+------------------------------+-------------+-------------+----------+
| -   Perceived Risk/Harm of   | Pre         | Community   | NOMs     |
|     Use                      | populated\* | Survey      | Quest    |
|                              |             |             | ionnaire |
+------------------------------+-------------+-------------+----------+
| **Increased/Retained         |             |             |          |
| Employment or Return to/Stay |             |             |          |
| in School**                  |             |             |          |
+------------------------------+-------------+-------------+----------+
| -   Perception of Workplace  | Pre         | Community   | NOMs     |
|     Policy                   | populated\* | Survey      | Quest    |
|                              |             |             | ionnaire |
+------------------------------+-------------+-------------+----------+
| -   Substance Abuse-Related  | Not         |             |          |
|     Suspensions and          | required    |             |          |
|     Expulsions               | yet -- in   |             |          |
|                              | development |             |          |
+------------------------------+-------------+-------------+----------+
| -   School Attendance and    | Pre         | Local       | Not      |
|     Enrollment               | populated\* | School      | Required |
|                              |             | District(s) |          |
+------------------------------+-------------+-------------+----------+
| **Decreased Criminal Justice |             |             |          |
| Involvement**                |             |             |          |
+------------------------------+-------------+-------------+----------+
| -   Alcohol-Related Car      | Pre         | Law         | NOMs     |
|     Crashes and Injuries     | populated\* | E           | Quest    |
|                              |             | nforcement/ | ionnaire |
|                              |             |             |          |
|                              |             | FAR         |          |
|                              |             | S/Community |          |
|                              |             | Survey      |          |
+------------------------------+-------------+-------------+----------+
| -   Alcohol and Drug-Related | Pre         | Law         | Not      |
|     Crime                    | populated\* | E           | Required |
|                              |             | nforcement/ |          |
|                              |             | UCR         |          |
+------------------------------+-------------+-------------+----------+
| **Increased Access to        |             |             |          |
| Services (Service            |             |             |          |
| Capacity)**                  |             |             |          |
+------------------------------+-------------+-------------+----------+
| -   Number of Persons Served | Aggregate   | Community   | NOMs     |
|     by Age, Gender, Race,    | of          | S           | Quest    |
|     and Ethnicity            | Community   | ubrecipient | ionnaire |
|                              | Data        |             |          |
+------------------------------+-------------+-------------+----------+
| **Increased Retention in     |             |             |          |
| Service Programs --          |             |             |          |
| Substance Abuse**            |             |             |          |
+------------------------------+-------------+-------------+----------+
| -   Total Number of          | Aggregate   | Community   | Program  |
|     Evidence-Based Programs  | of          | Grantee     | P        |
|     and Strategies Employed  | Community   |             | roviders |
|                              | Data        |             |          |
+------------------------------+-------------+-------------+----------+
| -   Percentage of Youth      | Pre         | Community   | NOMs     |
|     Seeing, Reading,         | populated\* | Survey      | Quest    |
|     Watching, or Listening   |             |             | ionnaire |
|     to a Prevention Message  |             |             |          |
+------------------------------+-------------+-------------+----------+
| **Increased Social           |             |             |          |
| Support/Social               |             |             |          |
| Connectedness**              |             |             |          |
+------------------------------+-------------+-------------+----------+
| -   Family Communication     | Pre         | Community   | NOMs     |
|     Around Drug Use          | populated\* | Survey      | Quest    |
|                              |             |             | ionnaire |
+------------------------------+-------------+-------------+----------+
| **Cost-Effectiveness of      |             |             |          |
| Services**                   |             |             |          |
+------------------------------+-------------+-------------+----------+
| -   Services Provided Within | Aggregate   | Community   | Program  |
|     Cost Bands -- Universal  | of          | S           | P        |
|     (D and I), Selective,    | Community   | ubrecipient | roviders |
|     and Indicated            | Data        |             |          |
+------------------------------+-------------+-------------+----------+
| **Use of Evidence-Based      |             |             |          |
| Practices**                  |             |             |          |
+------------------------------+-------------+-------------+----------+
| -   Total Number of          | Aggregate   | Community   | Program  |
|     Evidence-Based Programs  | of          | S           | P        |
|     and Strategies Employed  | Community   | ubrecipient | roviders |
|     (same as Increased       | Data        |             |          |
|     Retention, above)        |             |             |          |
+------------------------------+-------------+-------------+----------+
| \* Prepopulated source is    |             |             |          |
| the same as for the Block    |             |             |          |
| Grant                        |             |             |          |
+------------------------------+-------------+-------------+----------+

**What community-level data are SPF-SIG Cohort 3 grantees required to
collect?**

Community subrecipients are required to report community-level data on
for those NOMs measures that are relevant to their targeted problem and
identified programs and strategies. Relevant NOMs are measures of the
objectives they are trying to accomplish with their selected strategies
and programs that target their prioritized problems. For example, if a
community is targeting drinking and driving, it would not be relevant
for the community to report on the NOM: School Attendance and Enrolment.
The community subrecipients will work with the coordinating State agency
to identify the specific community-level NOMs measures to be collected.

-   ***Survey Data***: Community-level surveys to collect the
    community-level NOMs data must use the OMB Approved NOMs measures.
    The NOMs measures may be added to an existing community survey. The
    survey must be a representative sample. The measures are included in
    this packet: NOMs Adult and Youth Community and Program Tools
    (Questionnaires).

-   ***Education and Arrest Archival Data***: The community subrecipient
    will need to collect the school and crime NOMs data from the local
    jurisdictions that collect and publish this data. The data will be
    collected for the jurisdictions representing the geographic area
    defined as the community. SPF-SIG Cohort 3 must collect the local
    data using the specific NOMs measures.

-   ***Program Provider Data***: The community subrecipient will collect
    NOMs measures including number of people serviced, number of
    evidence-based programs and strategies, and cost-band data from the
    providers contracted to provide the services.

    The SPF-SIG Cohort 3 will report NOMs measures using the CSAMS
    application. The collection of the SPF-SIG NOMs measures will be
    integrated into the Cross-Site Evaluation data collection
    activities.

    CSAP Data Collection Tools Available to States, Communities, and
    Program Providers

***1. CSAP NOMs Data Collection Instruments***

**Description**: CSAP has developed the following instruments that
include the required NOMs measures:

-   NOMs Youth and Adult Community and Program Tools (Questionnaires)
    (attached)

-   Cost Band Data Entry Form

***2. CSAP's Minimum DataSet (MDS)***

**Description**: CSAP's Minimum Data Set (MDS) enables States, substance
abuse agencies, community-based service providers, and others to collect
and report the numbers and types of primary substance abuse prevention
and early intervention services delivered across the United States and
its territories. MDS is a web-based evaluation tool that provides a
uniform method of collecting group-level process data. SAMHSA's
Prevention Platform (<http://www.preventionplatform.samhsa.gov/>)
provides a demonstration of the MDS application. Service providers enter
information into MDS on an ongoing basis about the services they are
performing in their communities. The MDS can be used by States to
collect the following NOMs:

-   Increased Access to Services (Service Capacity)

-   Number of Persons Served by Age, Gender, Race, and Ethnicity

-   Increased Retention in Service Programs -- Substance Abuse

-   Total Number of Evidence-Based Programs and Strategies Employed

-   Cost-Effectiveness of Services (Average Cost)

-   Services Provided Within Cost Bands (Universal, Selective, and
    Indicated)

-   Use of Evidence-Based Practices (same as Increased Access to
    Services, above)

-   Total Number of Evidence-Based Programs and Strategies Employed

The current release of MDS (version 4.4) will be modified in the future
to reflect NOMs reporting requirements. States using MDS will be
involved in the planning and transition to the updated MDS application.
Specific training will also be provided. The following modifications
will be made:

-   Change to the classification of Race/Ethnicity

-   Inclusion of a User-Defined Field to collect cost information

-   Modifications of the IOM Classification to include Universal Direct
    and Universal Indirect

-   Inclusion of a User-Defined Field to collect information on the
    implementation of Evidence-Based Programs and Strategies

-   Updates to key definitions related to NOMs (e.g., Cost Band,
    Universal-Direct, Universal-Indirect

-   Inclusion of reporting for Individual- and Population-based
    strategies

***3. CSAP's Database Builder (DbB)***

**Description:** The Database Builder (DbB) was developed under the
direction of CSAP to enable States, substance abuse agencies,
community-based service providers, and others to collect and report on
individual-level survey data. The DbB is a web-based evaluation tool
that provides a structure and a framework for collecting both prevention
process and prevention outcome data. SAMHSA's Prevention Platform
(<http://www.preventionplatform.samhsa.gov/>) provides a demonstration
of the DbB application. The DbB includes the tools to allow
questionnaires to be built interactively, the set of respondents to be
defined, and data to be collected.

The only change necessary for the DbB is to include the four NOMs
instruments in the Measurements and Instruments databases within DbB.
When the specific instruments are added, States and communities can
update their existing instruments (if necessary) with the appropriate
NOMs measures.

# .  {#section-3 .DCCC-Heading-1}

#  {#section-4 .DCCC-Heading-1}

B-1 Youth Community Survey Form

**Form Approved**

> **OMB No.: 09300230**

**     Expiration Date:  12/31/2008**

**Center for Substance Abuse Prevention**

**National Outcome Measures**

Youth Community Survey Form

(Youth ages 12--17)

Use this **Youth Community Survey Form** for surveys of communities in
which data may be collected at a single point in time or at multiple
time points, each time using different samples of individuals rather
than a matched pretest/posttest design.

Public Burden Statement: An agency may not conduct or sponsor, and a
person is not required to respond to a collection of information unless
it displays a currently valid OMB control number. The OMB control number
for this project is 0930-0230. Public reporting burden for this
collection of information is estimated to average 1 hour per client per
year, 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, 1 Choke Cherry Road, Room 7-1044, Rockville,
Maryland 20857.

**Center for Substance Abuse Prevention**

**National Outcome Measures**

Youth Community Survey Form

**This survey is voluntary. If you choose to take it, you may skip any
question you don't want to answer.**

This survey asks about your experience and opinion on a number of things
related to alcohol, tobacco, and drug use. Your answers to these
questions will be confidential. That means no one will connect your
answers with your name or any other information about you that can
identify who you are. To help us keep your answers secret, please do not
write your name on this survey form.

The information in this survey will be used to learn more about the
effectiveness of programs in preventing substance abuse and protecting
youth.

This is not a test, so there are no right or wrong answers. Some
questions may ask you to select all of the answers that are relevant,
and others ask you to select a single answer. If the question asks for a
single answer and you don't find an answer that exactly fits, choose one
that comes closest.

**Thank you for agreeing to participate in this survey.**

RECORD MANAGEMENT: Your survey administrator will tell you what to fill
in for these administrative questions. You may leave all but **Date
Completed** blank if you are not given any instructions.

Participant ID

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
                                                                        

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------

Contract/Grant ID

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
                                                                        

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------

Date Completed

  ----------------- -------- ----------------- -------- -----------------
                    /                          /        

  Month                      Day                        Year
  ----------------- -------- ----------------- -------- -----------------

  ------------------- ---------------------------------------------------
  **Program Name**    

  ------------------- ---------------------------------------------------

  ----------------------------------- -----------------------------------
  **Cohort Number**                   

  ----------------------------------- -----------------------------------

  -----------------------------------------------------------------------
  **These questions ask for general information about you. Please mark
  the response that best describes you.**

  -----------------------------------------------------------------------

1.  **What is your gender? (Check one)\
    ** Male Female

2.  **Are you Hispanic or Latino? (Check one)**\
    Yes No

3.  **What is your race? (Select one or more)\
    ** White\
    Black or African American\
    American Indian\
    Native Hawaiian or Other Pacific Islander\
    Asian\
    Alaska Native

4.  What is your date of birth?

  --------------------- ------- ---------------- ------- ------------------
                        /                        /       

  Month                         Day                      Year
  --------------------- ------- ---------------- ------- ------------------

  -----------------------------------------------------------------------
  **The next few questions ask about your use of and attitudes toward
  tobacco,\
  alcohol, and other substances.**

  -----------------------------------------------------------------------

**5. Think back over the past 30 days and report how many days, if any,
you used the following substances:**

+------------------------+-----+--------------------+---------+--------+
|                        |     |                    | Fill in | Check  |
|                        |     |                    | number  | if     |
|                        |     |                    | of      | don't  |
|                        |     |                    | days\   | know   |
|                        |     |                    | (0--30) | or     |
|                        |     |                    |         | can't  |
|                        |     |                    |         | say    |
+------------------------+-----+--------------------+---------+--------+
| **Cigarettes:**        | 5a. | During the past 30 |         |        |
| Include menthol and    |     | days, on how many  |         |        |
| regular cigarettes and |     | days did you smoke |         |        |
| loose tobacco rolled   |     | part or all of a   |         |        |
| into cigarettes        |     | cigarette?         |         |        |
+------------------------+-----+--------------------+---------+--------+
| **Other tobacco        | 5b. | During the past 30 |         |        |
| products:** Include    |     | days, on how many  |         |        |
| any tobacco product    |     | days did you use   |         |        |
| other than cigarettes  |     | other tobacco      |         |        |
| such as snuff, chewing |     | products?          |         |        |
| tobacco, and smoking   |     |                    |         |        |
| tobacco from a pipe    |     |                    |         |        |
+------------------------+-----+--------------------+---------+--------+
| **Alcoholic            | 5c. | During the past 30 |         |        |
| beverages:** Include   |     | days, on how many  |         |        |
| beer, wine, wine       |     | days did you drink |         |        |
| coolers, malt          |     | one or more drinks |         |        |
| beverages, and liquor  |     | of an alcoholic    |         |        |
|                        |     | beverage?          |         |        |
+------------------------+-----+--------------------+---------+--------+
| **Marijuana or         | 5d. | During the past 30 |         |        |
| hashish:** Also known  |     | days, on how many  |         |        |
| as grass, pot, hash,   |     | days did you use   |         |        |
| or hash oil            |     | marijuana or       |         |        |
|                        |     | hashish?           |         |        |
+------------------------+-----+--------------------+---------+--------+
| **Other illegal        | 5e. | During the past 30 |         |        |
| drugs:** Include       |     | days, on how many  |         |        |
| substances like:       |     | days did you use   |         |        |
|                        |     | any other illegal  |         |        |
| -   **Heroin, crack or |     | drug?              |         |        |
|     cocaine,           |     |                    |         |        |
|     methamphetamine**  |     |                    |         |        |
|                        |     |                    |         |        |
| -   **Hallucinogens**  |     |                    |         |        |
|     (drugs that cause  |     |                    |         |        |
|     people to see or   |     |                    |         |        |
|     experience things  |     |                    |         |        |
|     that are not real) |     |                    |         |        |
|     such as LSD        |     |                    |         |        |
|     (sometimes called  |     |                    |         |        |
|     acid), Ecstasy     |     |                    |         |        |
|     (sometimes called  |     |                    |         |        |
|     MDMA), PCP or      |     |                    |         |        |
|     peyote (sometimes  |     |                    |         |        |
|     called angel dust) |     |                    |         |        |
|                        |     |                    |         |        |
| -   **Inhalants or     |     |                    |         |        |
|     sniffed            |     |                    |         |        |
|     substances** such  |     |                    |         |        |
|     as glue, gasoline, |     |                    |         |        |
|     paint thinner,     |     |                    |         |        |
|     cleaning fluid, or |     |                    |         |        |
|     shoe polish (used  |     |                    |         |        |
|     to "feel good" or  |     |                    |         |        |
|     to get high)       |     |                    |         |        |
|                        |     |                    |         |        |
| -   **Prescription     |     |                    |         |        |
|     drugs without a    |     |                    |         |        |
|     doctor's orders,** |     |                    |         |        |
|     just to "feel      |     |                    |         |        |
|     good" or to get    |     |                    |         |        |
|     high               |     |                    |         |        |
+------------------------+-----+--------------------+---------+--------+

**6.** **Think back over your entire lifetime and try to remember
whether you have EVER used any of the following substances. If so, what
was your age the FIRST TIME you used the substance:**

+-------------------------+---+-------------+-------+-------+--------+
|                         |   |             | Check | Fill  | Check  |
|                         |   |             | if    | in    | if     |
|                         |   |             | NEVER | your  | don't  |
|                         |   |             |       | age   | know   |
|                         |   |             |       | when  | or     |
|                         |   |             |       | you   | can't  |
|                         |   |             |       | first | say    |
|                         |   |             |       | used  |        |
|                         |   |             |       | (in   |        |
|                         |   |             |       | y     |        |
|                         |   |             |       | ears) |        |
+-------------------------+---+-------------+-------+-------+--------+
| **Cigarettes:** Include | 6 | Ever smoked |       |       |        |
| menthol and regular     | a | part or all |       |       |        |
| cigarettes and loose    | . | of a        |       |       |        |
| tobacco rolled into     |   | cigarette?  |       |       |        |
| cigarettes              |   |             |       |       |        |
+-------------------------+---+-------------+-------+-------+--------+
| **Other tobacco         | 6 | Ever used   |       |       |        |
| products:** Include any | b | any other   |       |       |        |
| tobacco product other   | . | tobacco     |       |       |        |
| than cigarettes such as |   | product?    |       |       |        |
| snuff, chewing tobacco, |   |             |       |       |        |
| and smoking tobacco     |   |             |       |       |        |
| from a pipe             |   |             |       |       |        |
+-------------------------+---+-------------+-------+-------+--------+
| **Alcoholic             | 6 | Ever had a  |       |       |        |
| beverages:** Include    | c | drink of an |       |       |        |
| beer, wine, wine        | . | alcoholic   |       |       |        |
| coolers, malt           |   | beverage?   |       |       |        |
| beverages, and liquor   |   | Do NOT      |       |       |        |
|                         |   | include any |       |       |        |
|                         |   | time when   |       |       |        |
|                         |   | you only    |       |       |        |
|                         |   | had a sip   |       |       |        |
|                         |   | or two from |       |       |        |
|                         |   | a drink.    |       |       |        |
+-------------------------+---+-------------+-------+-------+--------+
| **Marijuana or          | 6 | Ever used   |       |       |        |
| hashish:** Also known   | d | marijuana   |       |       |        |
| as grass, pot, hash, or | . | or hashish? |       |       |        |
| hash oil                |   |             |       |       |        |
+-------------------------+---+-------------+-------+-------+--------+
| **Other illegal         | 6 | Ever used   |       |       |        |
| drugs:** Include        | e | any other   |       |       |        |
| substances like:        | . | illegal     |       |       |        |
|                         |   | drug?       |       |       |        |
| -   **Heroin, crack or  |   |             |       |       |        |
|     cocaine,            |   |             |       |       |        |
|     methamphetamine**   |   |             |       |       |        |
|                         |   |             |       |       |        |
| -   **Hallucinogens**   |   |             |       |       |        |
|     (drugs that cause   |   |             |       |       |        |
|     people to see or    |   |             |       |       |        |
|     experience things   |   |             |       |       |        |
|     that are not real)  |   |             |       |       |        |
|     such as LSD         |   |             |       |       |        |
|     (sometimes called   |   |             |       |       |        |
|     acid), Ecstasy      |   |             |       |       |        |
|     (sometimes called   |   |             |       |       |        |
|     MDMA), PCP or       |   |             |       |       |        |
|     peyote (sometimes   |   |             |       |       |        |
|     called angel dust)  |   |             |       |       |        |
|                         |   |             |       |       |        |
| -   **Inhalants or      |   |             |       |       |        |
|     sniffed             |   |             |       |       |        |
|     substances** such   |   |             |       |       |        |
|     as glue, gasoline,  |   |             |       |       |        |
|     paint thinner,      |   |             |       |       |        |
|     cleaning fluid, or  |   |             |       |       |        |
|     shoe polish (used   |   |             |       |       |        |
|     to "feel good" or   |   |             |       |       |        |
|     to get high)        |   |             |       |       |        |
|                         |   |             |       |       |        |
| -   **Prescription      |   |             |       |       |        |
|     drugs without a     |   |             |       |       |        |
|     doctor's orders,**  |   |             |       |       |        |
|     just to "feel good" |   |             |       |       |        |
|     or to get high      |   |             |       |       |        |
+-------------------------+---+-------------+-------+-------+--------+

7.  **For each of the following five questions below check the box that
    shows how YOU think or feel.**

  ----- ------------------------- ------------ ------------ ------------ -------
                                  Neither      Somewhat     Strongly     Don't
                                  approve nor  disapprove   disapprove   know or
                                  disapprove                             can't
                                                                         say

  7a.   How do *you* feel about                                          
        someone your age smoking                                         
        one or more packs of                                             
        cigarettes a day?                                                

  7b.   How do you think *your                                           
        close friends* would feel                                        
        about YOU smoking one or                                         
        more packs of cigarettes                                         
        a day?                                                           

  7c.   How do *you* feel about                                          
        someone your age trying                                          
        marijuana or hashish once                                        
        or twice?                                                        

  7d.   How do *you* feel about                                          
        someone your age using                                           
        marijuana once a month or                                        
        more?                                                            

  7e.   How do *you* feel about                                          
        someone your age having                                          
        one or two drinks of an                                          
        alcoholic beverage nearly                                        
        every day?                                                       
  ----- ------------------------- ------------ ------------ ------------ -------

**8. For each of the three questions below check one box that shows HOW
MUCH you think people RISK HARMING themselves physically or in other
ways when they do the following things:**

  ----- ------------------------- ------ -------- ---------- ------- -----------
                                  No     Slight   Moderate   Great   Don't know
                                  risk   risk     risk       risk    or can't
                                                                     say

  8a.   When they smoke one or                                       
        more packs of CIGARETTES                                     
        per day?                                                     

  8b.   When they smoke MARIJUANA                                    
        once or twice a week?                                        

  8c.   When they have five or                                       
        more drinks of an                                            
        ALCOHOLIC BEVERAGE once                                      
        or twice a week?                                             
  ----- ------------------------- ------ -------- ---------- ------- -----------

+-----------------------------------+-----------------------------------+
| **This section asks just a few    |                                   |
| additional questions about your   |                                   |
| attitudes and experiences.**      |                                   |
+-----------------------------------+-----------------------------------+
| **9. Would you be more or less    | > More likely                     |
| likely to want to work for an     | >                                 |
| employer that tests its employees | > Less likely                     |
| for drug or alcohol use on a      | >                                 |
| random basis? Would you say more  | > Would make no difference        |
| likely, less likely, or would it  | >                                 |
| make no difference to you? (Check | > Don't know or can't say         |
| one)**                            |                                   |
+-----------------------------------+-----------------------------------+

+-----------------------------------+-----------------------------------+
| **10. Now think about the past 12 | > Yes                             |
| months through today. DURING THE  | >                                 |
| PAST 12 MONTHS, have you talked   | > No                              |
| with at least one of your parents | >                                 |
| about the dangers of tobacco,     | > Don't know or can't say         |
| alcohol, or drug use? By PARENTS, |                                   |
| we mean your biological parents,  |                                   |
| adoptive parents, stepparents, or |                                   |
| adult guardians---whether or not  |                                   |
| they live with you.**             |                                   |
+-----------------------------------+-----------------------------------+

+-----------------------------------+-----------------------------------+
| **11. During the past 12 months,  | > Yes                             |
| do you recall\                    | >                                 |
| hearing, reading, or watching an  | > No                              |
| advertisement about prevention of | >                                 |
| substance abuse?**                | > Don't know or can't say         |
+-----------------------------------+-----------------------------------+

B-3 Adult Community Survey Form

**Form Approved**

> **OMB No.: 09300230**

**     Expiration Date:  12/31/2008**

**Center for Substance Abuse Prevention**

**National Outcome Measures**

Adult Community Survey Form

(Adults ages 18 and older)

Use this **Adult Community Survey Form** for surveys of communities in
which data may be collected at a single point in time or at multiple
time points, each time using different samples of individuals rather
than a matched pretest/posttest design.

Public Burden Statement: An agency may not conduct or sponsor, and a
person is not required to respond to a collection of information unless
it displays a currently valid OMB control number. The OMB control number
for this project is 0930-0230. Public reporting burden for this
collection of information is estimated to average 1 hour per client per
year, 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, 1 Choke Cherry Road, Room 7-1044, Rockville,
Maryland 20857.

**Center for Substance Abuse Prevention\
National Outcome Measures**

Adult Community Survey Form

**This survey is voluntary. If you choose to take it, you may skip any
question you don't want to answer.**

This survey asks about your experience and opinion on a number of topics
related to alcohol, tobacco, and drug use. Your answers to these
questions will be confidential. That means no one will connect your
answers with your name or other identifying information. To help us keep
your answers confidential, please do not write your name on this survey
form.

The information in this survey will be used to learn more about the
effectiveness of programs in preventing substance abuse.

This is not a test, so there are no right or wrong answers. Some
questions may ask you to select all of the answers that are relevant,
and others ask you to select a single answer. If the question asks for a
single answer and you don't find an answer that exactly fits, choose one
that comes closest.

**Thank you for agreeing to participate in this survey.**

RECORD MANAGEMENT: Your survey administrator will tell you what to fill
in for these administrative questions. You may leave all but **Date
Completed** blank if you are not given any instructions.

Participant ID

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
                                                                        

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------

Contract/Grant ID

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------
                                                                        

  ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------

Date Completed

  ----------------- -------- ----------------- -------- -----------------
                    /                          /        

  Month                      Day                        Year
  ----------------- -------- ----------------- -------- -----------------

Program Name

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

Cohort Number

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------
  **These questions ask for general information about you. Please mark
  the response that best describes you.**

  -----------------------------------------------------------------------

1.  **What is your gender? (Check one)\
    ** Male Female

2.  **Are you Hispanic or Latino? (Check one)**\
    Yes No

3.  **What is your race? (Select one or more)\
    ** White\
    Black or African American\
    American Indian\
    Native Hawaiian or Other Pacific Islander\
    Asian\
    Alaska Native

4.  What is your date of birth?

  --------------------- ------- ---------------- ------- ------------------
                        /                        /       

  Month                         Day                      Year
  --------------------- ------- ---------------- ------- ------------------

  -----------------------------------------------------------------------
  **The next few questions ask about your use of and attitudes toward
  tobacco,\
  alcohol, and other substances.**

  -----------------------------------------------------------------------

**5. Think back over the past 30 days and report how many days, if any,
you used the\
following substances:**

+-------------------------+----+-------------------+---------+-------+
|                         |    |                   | Fill in | Check |
|                         |    |                   | number  | if    |
|                         |    |                   | of      | don't |
|                         |    |                   | days\   | know  |
|                         |    |                   | (0--30) | or    |
|                         |    |                   |         | can't |
|                         |    |                   |         | say   |
+-------------------------+----+-------------------+---------+-------+
| **Cigarettes:** Include | 5  | During the past   |         |       |
| menthol and regular     | a. | 30 days, on how   |         |       |
| cigarettes and loose    |    | many days did you |         |       |
| tobacco rolled into     |    | smoke part or all |         |       |
| cigarettes              |    | of a cigarette?   |         |       |
+-------------------------+----+-------------------+---------+-------+
| **Other tobacco         | 5  | During the past   |         |       |
| products:** Include any | b. | 30 days, on how   |         |       |
| tobacco product other   |    | many days did you |         |       |
| than cigarettes such as |    | use other tobacco |         |       |
| snuff, chewing tobacco, |    | products?         |         |       |
| and smoking tobacco     |    |                   |         |       |
| from a pipe             |    |                   |         |       |
+-------------------------+----+-------------------+---------+-------+
| **Alcoholic             | 5  | During the past   |         |       |
| beverages:** Include    | c. | 30 days, on how   |         |       |
| beer, wine, wine        |    | many days did you |         |       |
| coolers, malt           |    | drink one or more |         |       |
| beverages, and liquor   |    | drinks of an      |         |       |
|                         |    | alcoholic         |         |       |
|                         |    | beverage?         |         |       |
+-------------------------+----+-------------------+---------+-------+
| **Marijuana or          | 5  | During the past   |         |       |
| hashish:** Also known   | d. | 30 days, on how   |         |       |
| as grass, pot, hash, or |    | many days did you |         |       |
| hash oil                |    | use marijuana or  |         |       |
|                         |    | hashish?          |         |       |
+-------------------------+----+-------------------+---------+-------+
| **Other illegal         | 5  | During the past   |         |       |
| drugs:** Include        | e. | 30 days, on how   |         |       |
| substances like:        |    | many days did you |         |       |
|                         |    | use any other     |         |       |
| -   **Heroin, crack or  |    | illegal drug?     |         |       |
|     cocaine,            |    |                   |         |       |
|     methamphetamine**   |    |                   |         |       |
|                         |    |                   |         |       |
| -   **Hallucinogens**   |    |                   |         |       |
|     (drugs that cause   |    |                   |         |       |
|     people to see or    |    |                   |         |       |
|     experience things   |    |                   |         |       |
|     that are not real)  |    |                   |         |       |
|     such as LSD         |    |                   |         |       |
|     (sometimes called   |    |                   |         |       |
|     acid), Ecstasy      |    |                   |         |       |
|     (sometimes called   |    |                   |         |       |
|     MDMA), PCP or       |    |                   |         |       |
|     peyote (sometimes   |    |                   |         |       |
|     called angel dust)  |    |                   |         |       |
|                         |    |                   |         |       |
| -   **Inhalants or      |    |                   |         |       |
|     sniffed             |    |                   |         |       |
|     substances** such   |    |                   |         |       |
|     as glue, gasoline,  |    |                   |         |       |
|     paint thinner,      |    |                   |         |       |
|     cleaning fluid, or  |    |                   |         |       |
|     shoe polish (used   |    |                   |         |       |
|     to "feel good" or   |    |                   |         |       |
|     to get high)        |    |                   |         |       |
|                         |    |                   |         |       |
| -   **Prescription      |    |                   |         |       |
|     drugs without a     |    |                   |         |       |
|     doctor's orders,**  |    |                   |         |       |
|     just to "feel good" |    |                   |         |       |
|     or to get high      |    |                   |         |       |
+-------------------------+----+-------------------+---------+-------+

**6.** Think back over your entire lifetime and try to remember whether
you have EVER used any of the following substances. If so, what was your
age the FIRST TIME you used the substance:

+--------------------------+---+------------+-------+-------+--------+
|                          |   |            | Check | Fill  | Check  |
|                          |   |            | if    | in    | if     |
|                          |   |            | NEVER | your  | don't  |
|                          |   |            |       | age   | know   |
|                          |   |            |       | when  | or     |
|                          |   |            |       | you   | can't  |
|                          |   |            |       | first | say    |
|                          |   |            |       | used  |        |
|                          |   |            |       | (in   |        |
|                          |   |            |       | y     |        |
|                          |   |            |       | ears) |        |
+--------------------------+---+------------+-------+-------+--------+
| **Cigarettes:** Include  | 6 | Ever       |       |       |        |
| menthol and regular      | a | smoked     |       |       |        |
| cigarettes and loose     | . | part or    |       |       |        |
| tobacco rolled into      |   | all of a   |       |       |        |
| cigarettes               |   | cigarette? |       |       |        |
+--------------------------+---+------------+-------+-------+--------+
| **Other tobacco          | 6 | Ever used  |       |       |        |
| products:** Include any  | b | any other  |       |       |        |
| tobacco product other    | . | tobacco    |       |       |        |
| than cigarettes such as  |   | product?   |       |       |        |
| snuff, chewing tobacco,  |   |            |       |       |        |
| and smoking tobacco from |   |            |       |       |        |
| a pipe                   |   |            |       |       |        |
+--------------------------+---+------------+-------+-------+--------+
| **Alcoholic beverages:** | 6 | Ever had a |       |       |        |
| Include beer, wine, wine | c | drink of   |       |       |        |
| coolers, malt beverages, | . | an         |       |       |        |
| and liquor               |   | alcoholic  |       |       |        |
|                          |   | beverage?  |       |       |        |
|                          |   | Do NOT     |       |       |        |
|                          |   | include    |       |       |        |
|                          |   | any time   |       |       |        |
|                          |   | when you   |       |       |        |
|                          |   | only had a |       |       |        |
|                          |   | sip or two |       |       |        |
|                          |   | from a     |       |       |        |
|                          |   | drink.     |       |       |        |
+--------------------------+---+------------+-------+-------+--------+
| **Marijuana or           | 6 | Ever used  |       |       |        |
| hashish:** Also known as | d | marijuana  |       |       |        |
| grass, pot, hash, or     | . | or         |       |       |        |
| hash oil                 |   | hashish?   |       |       |        |
+--------------------------+---+------------+-------+-------+--------+
| **Other illegal drugs:** | 6 | Ever used  |       |       |        |
| Include substances like: | e | any other  |       |       |        |
|                          | . | illegal    |       |       |        |
| -   **Heroin, crack or   |   | drug?      |       |       |        |
|     cocaine,             |   |            |       |       |        |
|     methamphetamine**    |   |            |       |       |        |
|                          |   |            |       |       |        |
| -   **Hallucinogens**    |   |            |       |       |        |
|     (drugs that cause    |   |            |       |       |        |
|     people to see or     |   |            |       |       |        |
|     experience things    |   |            |       |       |        |
|     that are not real)   |   |            |       |       |        |
|     such as LSD          |   |            |       |       |        |
|     (sometimes called    |   |            |       |       |        |
|     acid), Ecstasy       |   |            |       |       |        |
|     (sometimes called    |   |            |       |       |        |
|     MDMA), PCP or peyote |   |            |       |       |        |
|     (sometimes called    |   |            |       |       |        |
|     angel dust)          |   |            |       |       |        |
|                          |   |            |       |       |        |
| -   **Inhalants or       |   |            |       |       |        |
|     sniffed substances** |   |            |       |       |        |
|     such as glue,        |   |            |       |       |        |
|     gasoline, paint      |   |            |       |       |        |
|     thinner, cleaning    |   |            |       |       |        |
|     fluid, or shoe       |   |            |       |       |        |
|     polish (used to      |   |            |       |       |        |
|     "feel good" or to    |   |            |       |       |        |
|     get high)            |   |            |       |       |        |
|                          |   |            |       |       |        |
| -   **Prescription drugs |   |            |       |       |        |
|     without a doctor's   |   |            |       |       |        |
|     orders,** just to    |   |            |       |       |        |
|     "feel good" or to    |   |            |       |       |        |
|     get high             |   |            |       |       |        |
+--------------------------+---+------------+-------+-------+--------+

**7. For each of the three questions below check one box that shows HOW
MUCH you think\
people RISK HARMING themselves physically or in other ways when they
engage in the**

**following behaviors:**

  ----- ------------------------- ------ -------- ---------- ------- ------------
                                  No     Slight   Moderate   Great   Don't know
                                  risk   risk     risk       risk    or can't say

  7a.   When they smoke one or                                       
        more packs of CIGARETTES                                     
        per day?                                                     

  7b.   When they smoke MARIJUANA                                    
        once or twice a week?                                        

  7c.   When they have five or                                       
        more drinks of an                                            
        ALCOHOLIC BEVERAGE once                                      
        or twice a week?                                             
  ----- ------------------------- ------ -------- ---------- ------- ------------

  -----------------------------------------------------------------------
  **This section asks just a few additional questions about your
  attitudes and experiences.**

  -----------------------------------------------------------------------

+-----------------------+-----------------------+-----------------------+
| 7.  **Would you be    | More likely           |                       |
|     more or less      |                       |                       |
|     likely to want to | Less likely           |                       |
|     work for an       |                       |                       |
|     employer that     | Would make no         |                       |
|     tests its         | difference            |                       |
|     employees for     |                       |                       |
|     drug or alcohol   | Don't know or can't   |                       |
|     use on a random   | say                   |                       |
|     basis? Would you  |                       |                       |
|     say more likely,  |                       |                       |
|     less likely, or   |                       |                       |
|     would it make no  |                       |                       |
|     difference to     |                       |                       |
|     you? (Check       |                       |                       |
|     one)**            |                       |                       |
+-----------------------+-----------------------+-----------------------+

+-----------------------------------+-----------------------------------+
| **9. Now think about the past 12  | Don't have any children           |
| months through today. DURING THE  |                                   |
| PAST 12 MONTHS, how many times    | 0 times                           |
| have you talked with your child   |                                   |
| about the dangers or problems     | 1 to 2 times                      |
| associated with the use of        |                                   |
| tobacco, alcohol, or drugs?**     | A few times                       |
|                                   |                                   |
|                                   | Many times                        |
|                                   |                                   |
|                                   | Don't know or can't say           |
+-----------------------------------+-----------------------------------+