KAP Keys Based on TIP 11

Simple Screening Instruments for 

Outreach for Alcohol and Other 

Drug Abuse and Infectious Diseases

CSAT’s 

Knowledge Application Program

KAP Keys

For Clinicians

Based on TIP 11 

Simple Screening 

Instruments for Outreach 

for Alcohol 

and Other 

Drug Abuse 

and Infectious 

Diseases

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

www.samhsa.gov
Introduction

These KAP Keys were developed to accompany the Treatment 

Improvement Protocol (TIP) Series published by the Center for 

Substance Abuse Treatment (CSAT), Substance Abuse and 

Mental Health Services Administration. These KAP Keys are 

based entirely on TIP 11 and are designed to meet the needs 

of the busy clinician for concise, easily accessed “how-to” 

information.

For more information on the topics in these KAP Keys, see 

TIP 11.

Other Treatment Improvement Protocols that 

are relevant to these KAP Keys:

TIP 6, Screening for Infectious Diseases Among Substance 

Abusers (1993, Reprinted 1995) BKD131

TIP 7, Screening and Assessment for Alcohol and Other Drug 

Abuse Among Adults in the Criminal Justice System (1993) 

BKD138

TIP 9, Assessment and Treatment of Patients With Coexisting 

Mental Illness and Alcohol and Other Drug Abuse (1994, 

Reprinted 1999) BKD134

TIP 16, Alcohol and Other Drug Screening of Hospitalized 

Trauma Patients (1995) BKD164

TIP 31, Screening and Assessing Adolescents for Substance 

Use Disorder (1999) BKD306

KAP Keys Based on TIP 11

Simple Screening Instruments for Outreach for Alcohol 

and Other Drug Abuse and Infectious Diseases
Simple Screening Instrument 

for Substance Abuse

1

KAP Keys Based on TIP 11

Simple Screening Instruments for Outreach for Alcohol 

and Other Drug Abuse and Infectious Diseases

(Administered by Interviewer)

Short version: Boldface questions only.

Long version: All questions.

Introductory Statement Made by Interviewer

I’m going to ask you a few questions about your use of alcohol and 

drugs during the last 6 months. Your answers will be kept private. 

Based on your answers to these questions, I may advise you to get 

a more complete assessment. This would be voluntary.

During the last 6 months

1. Have you used alcohol (such as wine, beer, or hard liquor) 

or drugs (such as pot, coke, heroin or other opioids, uppers, 

downers, hallucinogens, or inhalants)? 

_ Yes _ No 

If no, stop or skip to question 14.

2. Have you felt that you use too much alcohol or too many drugs? 

_ Yes _ No 

3. Have you tried to cut down on or quit drinking or using drugs? 

_ Yes _ No 

4. Have you gone to anyone (such as Alcoholics Anonymous, Narcotics 

Anonymous, Cocaine Anonymous, counselors, or a treatment 

program) for help because of your drinking or drug use? 

_ Yes _ No 

5. Have you had any of the following:

_ Blackouts or other periods of memory loss?

_ Injury to your head after drinking or using drugs?

_ Convulsions or delirium tremens (DTs)?

_ Hepatitis or other liver problems?

_ Feelings of being sick, shaky, or depressed when you 

stopped drinking or using drugs?

_ Feelings of “coke bugs,” or a crawling feeling under the 

skin, after you stopped using drugs?

_ Injury after drinking or using drugs?

_ The desire to use needles to shoot drugs?

Continued on next page
KAP Keys Based on TIP 11

Simple Screening Instruments for Outreach for Alcohol 

and Other Drug Abuse and Infectious Diseases

 6. Has drinking or drug use caused problems between you 

	 	 _ Yes _ No 

 7. Has your drinking or drug use caused problems at school 

_ Yes _ No 

 8. Have you been arrested or had other legal problems (such 

_ Yes _ No 

 9. Have you lost your temper or gotten into arguments or 

_ Yes _ No 

 10. Do you need to drink or use drugs more and more to get 

_ Yes _ No 

 11. Do you spend a lot of time thinking about or trying to get 

	 	 _ Yes _ No 

 12. When drinking or using drugs, are you more likely to do 

_ Yes _ No 

 13. Do you feel bad or guilty about your drinking or drug use?

 _ _ No 

Now I have some questions that are not limited to the 

last 6 months.

14. Have you ever had a drinking or drug problem?

_ Yes _ No

Continued on next page
Continued on next page

15. Have any of your family members ever had a drinking or 

drug problem?

_ Yes _ No

16. Do you feel that you have a drinking or drug problem now? 

_ Yes _ No

Thank you for answering these questions. Do you have any 

questions for me? Is there something I can do to help you?

Observation Checklist

The following signs and symptoms may indicate a substance 

abuse problem in the individual being screened:

_ Needle (track) marks

_ Skin abscesses, cigarette burns, or nicotine stains

_ Tremors (shaking and twitching of hands and eyelids)

_ Unclear speech: slurred, incoherent, or too rapid

_ Unsteady gait: staggering or off balance

_ Dilated (enlarged) or constricted (pinpoint) pupils

_ Scratching

_ Swollen hands or feet

_ Smell of alcohol or marijuana on breath

_ In possession of drug paraphernalia such as pipes, 

papers, needles, or roach clips

_ “Nodding out” (dozing or falling asleep)

_ Agitation

_ Inability to focus

_ Burns on the inside of the lips (from freebasing cocaine)

Simple Screening Instrument 

for Substance Abuse (continued)

1

KAP Keys Based on TIP 11

Simple Screening Instruments for Outreach for Alcohol 

and Other Drug Abuse and Infectious Diseases
KAP Keys Based on TIP 11

Simple Screening Instruments for Outreach for Alcohol 

and Other Drug Abuse and Infectious Diseases

Scoring

For short version (boldface questions), any yes answers by 

the respondent merit followup questioning.

Items 1 and 15 are not scored. For the remaining questions, 

score 1 for yes and 0 for no.

_____ 2 

_____ 3 

_____ 4 

_____ 5 

_____ 6 

_____ 7 

_____ 8 

_____ 9 

_____ 10 

_____ 11 

_____ 12 

_____ 13 

_____ 14

_____ 16 

_____ Total score

Preliminary Interpretation of Results

Score Degree of Risk for Alcohol and Drug Abuse

0 or 1 None to low

2 or 3 Minimal

≥ 4 Moderate to high; possible need for further assessment

See TIP 11, pages 12 and 13.
2 Simple Screening Instrument 

for Infectious Diseases

KAP Keys Based on TIP 11

Simple Screening Instruments for Outreach for Alcohol 

and Other Drug Abuse and Infectious Diseases

(Administered by Interviewer)

Introductory Statement Made by Interviewer

I’m going to ask you a few questions about your health and 

lifestyle. I want you to know that my agency will not give this 

information to anyone without your permission. Based on your 

answers I may advise you to get a physical exam or further 

tests. This would be voluntary—it would be your choice whether 

to have the exam. If you do get an exam and are found to have 

certain diseases, they must be reported to the health 

department.

1. Have you seen a doctor or other healthcare provider in the 

last 3 months? (A; see Key) 

_ Yes _ No 

2. a. Do you live on the street or in a shelter? (C, F) 

_ Yes _ No

b. Have you ever been in jail? (C, F) 

_ Yes _ No

3. Have you ever been told you tested positive for HIV (the 

virus that causes AIDS)? (G) 

_ Yes _ No

4. Women: Have you missed your last two periods? (D, E, F) 

_ Yes _ No

5. Have you ever had a positive TB skin test? I mean a test 

where you got a shot in your forearm and a few days later 

a hard bump like a blister appeared. (C) 

vYes _ No

6. Have you ever been told you have TB? Has anybody you 

know or have lived with been diagnosed with TB in the last 

year? (C) 

_ Yes _ No

Continued on next page
KAP Keys Based on TIP 11

Simple Screening Instruments for Outreach for Alcohol 

and Other Drug Abuse and Infectious Diseases

 7. a. Within the last 30 days, have you had any of the following 

symptoms lasting for more than 2 weeks? (B, C, F)

_ Fever

_ Drenching night sweats that were so bad you had to 

change your clothes or the sheets on the bed

_ Attacks of coughing up blood

_ Shortness of breath

_ Lumps or swollen glands in the neck or armpits

_ Weight loss without trying

_ Diarrhea (“runs”) lasting more than a week.

 b. Do you live with someone who has any of the following 

_ Attacks of coughing up blood

_ Drenching night sweats.

 8. Do you use needles to shoot drugs? (F) 

_ Yes _ No

 9. Do you use coke or crack? (D, F) 

_ Yes _ No

 10. In the last 6 months, have you had VD (venereal diseases) or 

_ Yes _ No

 11. Have you, or anyone you’ve had sex with, had any of the 

_ Sore or ulcer on the penis/vagina (“down there”)?

_ Rash, spots, or other skin problems, especially on 

your palms or the soles of your feet?

_ Women: A vaginal discharge that is different from 

what you usually have?

_ Women: Pain when you have vaginal sex?

_ Men: Discharge from the penis?

Continued on next page
Simple Screening Instrument 

for Infectious Diseases (continued) 2

KAP Keys Based on TIP 11

Simple Screening Instruments for Outreach for Alcohol 

and Other Drug Abuse and Infectious Diseases

12. Have you had sex with more than two people—at different 

times—in the last 6 months? I mean any type of vaginal, 

rectal, or oral contact, such as you “went down” on your 

partner or he or she “went down” on you, with or without a 

condom? (D, F) 

__ Yes __ No

13. Have you used your rectum for sex? (Use regionally 

appropriate terminology to indicate anal penetration, as 

opposed to other types of sexual contact.) (F) 

_ Yes _ No

14. In the last 6 months, have you had sex with someone in 

return for anything like money, alcohol or drugs, a place to 

stay, or just to survive? (D, F) 

_ Yes __ No

15. Have you ever been forced to have sex against your will? (A) 

_ Yes _ No

Key

A = Needs supporting data

B = General medical evaluation

C = TB screening

D = STD assessment

E = Prenatal care

F = HIV/AIDS counseling, testing, referral, and partner 

notification (Assessment for hepatitis B and hepatitis C 

is also warranted.)

G = HIV/AIDS care/early intervention

See TIP 11, pages 23–26.
Ordering Information

TIP 11

Simple Screening Instruments for Outreach 

for Alcohol and Other Drug Abuse and 

Infectious Diseases

Easy Ways to Obtain Free Copies of 

All TIP Products

1. Call SAMHSA’s National Clearinghouse for Alcohol and 

Drug Information (NCADI) at 800–729–6686, 

TDD (hearing impaired) 800–487–4889

2. Visit CSAT’s Web site at www.csat.samhsa.gov

Do not reproduce or distribute this publication for a fee 

without specific, written authorization from the Office of 

Communications, Substance Abuse and Mental Health 

Services Administration, U.S. Department of Health and 

Human Services.

DHHS Publication No. (SMA) 01-3560 

Printed 2001

KAP Keys Based on TIP 11

Simple Screening Instruments for Outreach for Alcohol 

and Other Drug Abuse and Infectious Diseases