Form approved:

KNAP SURVEY QUESTIONNAIRE
August, 2003

INTERVIEWER'S CODE NUMBER:

DATE AND TIME INTERVIEW BEGAN:

DATE: (MM:DD:YY)
____ | ____ | ___
TIME: (HH:MM)
____ | ____
AM=1 / PM=2: ____

[INTRODUCTION TO PERSON FIRST ANSWERING AND THE PERSON SELECTED
TO BE INTERVIEWED.]
Hello, my name is ______________________, and I am calling from the Survey Research
Center at the University of Kentucky .
We are conducting a voluntary survey for adults on health issues, including the use of alcohol
and drugs. The State needs the results to plan for health services for its citizens. The interview
will take an average of about 15 minutes.
We need your help to make this study as accurate as possible. Your telephone number was
chosen randomly, and your participation is important for the study's validity. We do not have
your name or address, and your responses will not be linked to your phone number. All
information you give us will be kept strictly anonymous and no individual data will be reported.
May I proceed?
INSTRUCTIONS TO INTERVIEWER

Throughout the interview, response categories for don't know and refused have been
inserted where appropriate. Whenever one of these choices applies to a question, follow
the “GO TO” directions for the "NO" response unless otherwise instructed.
Never read the "DON'T KNOW" and "REFUSED" response categories or any
capitalized and bolded text to the respondent. Do not leave response categories blank;
use zero if appropriate.
SCREENING QUESTIONS
Have I reached a household, or is this a group quarters, such as a dormitory, shelter, nursing home, or institution? 1 Household
(GO TO S2)
Quarters
(GO TO J1a)
DON’T KNOW
REFUSED
S2. How many people live in your household, including yourself? ____ # PEOPLE
DON’T KNOW
REFUSED
How many of the people who live here are adults? Adult includes everyone age
18 and older. (IF NO ADULTS LIVE IN THE HOUSEHOLD, GO TO J1a)
____ # ADULTS
77
DON’T KNOW
REFUSED

S3. How many different telephone numbers do you have in this household? Do not count any
numbers that are used only for FAX machines, computers, business numbers, or
extensions that use the same number. Also do not count cell phones.
______# OF TELEPHONES
(IF MORE THAN 3, CONFIRM THAT IT IS A
RESIDENCE. IF IT IS NOT, GO TO J1a)
DON’T KNOW
8 REFUSED
Can you tell me, of the adults who now live in your household — including yourself —
who had the most recent birthday? Who would that be? (EXPLAIN AFTER
RESPONSE): We interview whoever had their birthday most recently to make our
choice totally random.
(PERSON WITH MOST RECENT BIRTHDAY OF THOSE 18 OR OLDER):
1
RESPONDENT
Then you’re the one I want to talk to
(GO TO S8)
SOMEONE ELSE
(GO TO S6)
ONLY KNOWS OWN BIRTHDAY
Then you’re the one I want to talk to
(GO TO S8)
DOESN’T KNOW ALL BIRTHDAYS
(GO TO S5)
(GO TO J1a)
(IF PERSON DOESN’T KNOW ALL BIRTHDAYS) — Of those 18 or older whose
birthdays you do know, who has had the most recent birthday?
1
RESPONDENT
Then you’re the one I want to talk to (GO TO S7)
SOMEONE ELSE (GO TO S6)
(IF SOMEONE ELSE) May I speak to that person?
1
TRANSFERRED TO NEW PERSON
(GO TO S7)
PERSON NOT AVAILABLE
(GO TO S9)
(READ INTRODUCTION TO NEW PERSON.) Am I speaking to a member of the
household who is at least 18 years old?
1
YES, PERSON AGREES TO INTERVIEW
(GO TO S8)
QUALIFIES, BUT REFUSED TO INTERVIEW
(GO TO J1a)
DOES NOT QUALIFY (ASK FOR ANOTHER PERSON) (GO TO S5)
DON’T KNOW
REFUSED
YES (GO TO SECTION A)
2 NO (GO TO S9)
7
DON’T KNOW
REFUSED

[IF PERSON NOT AVAILABLE TO BE INTERVIEWED NOW, RESCHEDULE.]
S9.
Could you suggest a convenient time for me to call back to reach.

(IF RESPONDENT) . you? What is your first name?
(IF OTHER PERSON)
. this person? What is the first name of this person?
[RECORD FIRST NAME AND DATE / TIME TO RETURN CALL. NEGOTIATE
ANOTHER TIME AS SOON AS CONVENIENT.]
FIRST NAME: ____________________

DATE: (MM:DD:YY)
____ | ____ | ____
TIME: (HH:MM)
____ | ____
AM=1 / PM=2: ____
A. CORE DEMOGRAPHICS
A1. Please tell me how old you are now. ____ YEARS OLD (RANGE 18-110. IF LESS THAN 18 GO TO J1b)
777
DON’T KNOW
REFUSED

[FROM THE SOUND OF THE RESPONDENT'S VOICE INFER SEX.]
A2. So you are a______-year old [male] [female], is that correct?
What language would you like to be interviewed in?
1 English (USE ENGLISH QUESTIONNAIRE)
2 Spanish (USE SPANISH QUESTIONNAIRE)
3
(USE ENGLISH QUESTIONNAIRE)
Are you of Hispanic or Latino(a) origin or background? (USE “(a)” FOR FEMALE)
1
YES (GO TO A4a)
DON’T KNOW
2 NO (GO TO A5)
REFUSED
A4a. Which of these groups best describes you? Mexican / Mexican American / Chicano(a) (USE “(a)” FOR FEMALE)
5 Other [DO NOT REQUEST, ONLY USE IF VOLUNTEERED.]
(SPECIFY)_______________________________________
DON’T KNOW
REFUSED
Which of these groups describes you? Select one or more groups. 1 White 2 Native Hawaiian or Other Pacific Islander [DO NOT REQUEST, ONLY USE IF VOLUNTEERED.]
(SPECIFY) ________________________________________________
DON’T KNOW
REFUSED
[ASK A5a IF MORE THAN ONE RACE WAS SELECTED IN A5.]
one of these groups, [READ GROUPS NAMED IN A5], best describes
Native Hawaiian or Other Pacific Islander 5 Asian
6 Other [DO NOT REQUEST, ONLY USE IF VOLUNTEERED.]
(SPECIFY) __________________________________
DON’T KNOW
REFUSED
Are you currently on active duty in the armed forces?
1
YES (GO TO J1c)
DON'T KNOW
(GO TO J1c)
NO (GO TO A7)
REFUSED (GO TO J1c)
B. TOBACCO PREVALENCE

Now I am going to ask you a series of questions about your use of cigarettes.
B1. Have you ever smoked part or all of a cigarette?
NO (GO TO B6)
DON’T KNOW
8 REFUSED

B2. How old were you the first time you smoked part or all of a cigarette?
________YEARS OLD (CODE 76 FOR 76 OR MORE)
77
DON’T KNOW
REFUSED
B2a. Have you smoked at least 100 cigarettes in your entire life? NO (GO TO B6)
DON’T KNOW
8 REFUSED
How long has it been since you last smoked part or all of a cigarette?
1
More than 30 days ago but within the past 12 months DON’T KNOW
REFUSED
(IF B3 = 1 ASK B4a. IF B3 = 2 OR 3, ASK B4b.)
B4a. During the past 30 days, on how many days did you smoke part or all of a
B4b. During the 30 days when you last smoked, on how many days did you

________# OF DAYS (RANGE 1 - 30)
77
DON’T KNOW
REFUSED

B5. (IF B3 = 1 ASK B5a. IF B3 = 2 OR 3, ASK B5b.)
B5a. During the past 30 days, how many cigarettes did you smoke per day, on B5b. During that same 30 days, how many cigarettes did you smoke per day, on DON’T KNOW
REFUSED
Now I am going to ask about your use of other tobacco products. B6. Please answer yes or no to each question. In the past 12 months, did you even once . 1 DON’T KNOW
REFUSED
ENTER CODES FOR QUESTION B6 OPTION B6.

C. ALCOHOL PREVALENCE
I am going to ask you several questions about drinks of alcohol. Count as a drink — a can or bottle of beer, a glass of wine or a wine cooler, a shot of liquor or a mixed drink. Count a 40 oz. bottle of beer as 4 drinks. Please do not include times when you only had a sip or two from a drink. C1. Have ever, even once, had a drink of any type of alcoholic beverage?
YES (GO TO C1a)
DON'T KNOW
2 NO (GO TO SECTION D)
REFUSED
C1a. Have you ever had twelve or more drinks in the same year? (GO TO C2)
DON'T KNOW
REFUSED

C2. How old were you the first time you had a drink of an alcoholic beverage?
_______YEARS OLD
(CODE 76 FOR 76 OR MORE)
DON’T KNOW
REFUSED

C3. How long has it been since you last drank an alcoholic beverage?
More than 30 days ago but within the past 12 months DON’T KNOW
REFUSED
During the most recent times you were drinking, on how many days during an average
month did you have at least one drink?
______# OF DAYS
77 DON’T
KNOW
88 REFUSED
During this same time, about how many drinks a day have you usually had when you did
drink ?
______# OF DRINKS
(SKIP TO C6a, IF MALE AND >4 DRINKS A DAY,
OR FEMALE AND >3 DRINKS A DAY)
DON’T KNOW
88 REFUSED
[READ AS FOUR [4] DRINKS FOR FEMALES, AND FIVE [5] DRINKS FOR MALES
IN QUESTIONS C6, C6a, AND C6b.]
C6.
At any time in your life, did you ever have [4] [5] or more drinks on the same occasion?
(By occasion, we mean within several hours.)
1
YES (GO TO C6a)
DON'T KNOW
(GO TO C7)
REFUSED
C6a. How long has it been since you had [4] [5] or more drinks on the same occasion?
More than 30 days ago but within the past 12 DON’T KNOW
REFUSED
(IF C6a = 1 ASK C6b1. IF C6a = 2 OR 3 ASK C6b2.)

C6b1. In the past 30 days, on how many days did you have [4] [5] or more drinks

C6b2. In the 30 days when you last did that, on how many days did you have [4]
[5] or more drinks on the same occasion?
______# OF DAYS
77 DON’T
KNOW
88 REFUSED
At any time in your life, have you ever, even once, gone on a binge where you kept
drinking for a couple of days or more without sobering up?
1
DON'T KNOW
(GO TO C8)
REFUSED
C7a. When was the last time this happened? More than 30 days ago but within the past 12 DON’T KNOW
REFUSED
C8. At anytime in your life have you ever used alcohol in combination with any other drug? DON'T KNOW
REFUSED
C8a. When was the last time this happened? More than 30 days ago but within the past 12 DON’T KNOW
REFUSED
ever thought that you might have a problem with alcohol?
DON'T KNOW
REFUSED
D. PREVALENCE OF OTHER SUBSTANCES

I want to ask some questions now about your use of other drugs that were NOT PRESCRIBED
for you by your doctor or other health professional. You can just say yes or no as I read each
drug.
(FIRST, READ ALL DRUG NAMES DOWN COLUMN D1. THEN FOR EACH “YES”
DRUG IN D1, READ ACROSS EACH COLUMN IN TURN, FROM D2 TO D6. SKIP D4
AND/OR D5 TO COMPLY WITH INSTRUCTIONS FOR THESE QUESTIONS.)
D1. Have
ever, even once, used [DRUG]?
DON’T KNOW
REFUSED
How old were you the first time you used [DRUG]?
________YEARS OLD
(CODE 76 FOR 76 OR MORE)
DON’T KNOW
REFUSED
How long has it been since you last used [DRUG]?
1
More than 30 days ago but within the past 12 months DON’T KNOW
REFUSED
(IF D3 = 1 OR 2 ASK D4a. IF D3 = 3 ASK D4b OR SKIP TO D6.)

D4a. During the past 12 months, on how many days did you have at least a little [DRUG]?
D4b. During the 12 months when you last used [DRUG], on how many days did you have at

______# OF DAYS
(CODE 76 FOR 76 OR MORE)
77 DON’T
KNOW
88 REFUSED
(IF D3 = 1 ASK D5a. IF D3 = 2 OR 3 ASK D5b.)
D5a. During the past 30 days, on how many days did you use [DRUG]?
D5b. During the 30 days when you last used [DRUG], on how many days did you

________ # OF DAYS
(RANGE 1-30)
DON’T KNOW
88 REFUSED]
ever thought that you might have a problem with [DRUG]?
1 YES
2 NO
7 DON’T
KNOW
8 REFUSED]
D1 through D6 - Drug Prevalence
READ EACH DRUG WHEN D1=YES, THEN READ ACROSS
5 Non-over-the-counter Pain Relievers or Other Opiates, (ASK ALL RESPONDENTS)
D7.
Have you ever injected any drug in order to get high, even just once? 1 (GO TO SECTION E)
DON’T KNOW
REFUSED

D7a. How long has it been since you last injected a drug to get high?
More than 30 days ago but within the past 12 months DON’T KNOW
REFUSED
E. ALCOHOL AND DRUG PROBLEM INDEX
INTERVIEWER INSTRUCTIONS:

ALCOHOL SCREEN: Ask questions for Alcohol (Columns A & B) ONLY IF:
1. Alcohol was used once a week or more (in C4) in the past 12 months (in C3), AND
2. Response was “YES” to ANY ONE of the following:
Ever had a problem with alcohol, OR
C7a. Binged in the past 12 months, OR
IF FEMALE:C5.
Averaged 3 or more drinks per occasion, OR
C6a. Had 4 or more drinks at least once in the past 12 months.
Averaged 4 or more drinks per occasion, OR
C6a. Had 5 or more drinks at least once in the past 12 months.

Ask alcohol questions in Problem Index below? ALC_SCRN. 1

DRUG SCREEN: Ask questions for Drugs (Columns A & B) ONLY ONCE, and only if
ANY drug was used once a month or more (D4) in the past 12 months (D3=1 or2)
For positive screen results (First for Alcohol, then for all drugs combined):
Read questions E1 to E19 and record responses for Columns A and B.
Substitute “alcohol” or “the drugs you used” for [SUBST] below.
NOTE: The questions are to be asked only one time for “Drugs.” Before asking the
DRUG questions, read the following to the respondent:
“I am going to ask you one set of questions about things that might have happened as a
result of your using any of the drugs you have used in the past 12 months. I won’t be
asking which drug was responsible for any particular thing, but only if it happened.
Before I start, you reported, that you used (recite drugs reported within past 12
months in D3). Is that correct?” (If NO, clarify and correct.)

Ask drug questions in Problem Index below? DRUG_SCRN. 1
DON’T KNOW
REFUSED
FOR EACH “YES” ASK: Did it happen in the past year?
(GO TO NEXT SYMPTOM)
9 NO
How long has it been since this last happened?
1
DON’T KNOW
REFUSED
Diagnostic Questions
A. Ever B.
A. Ever B.
Was there ever a time when.
Have you found that you have to use more [SUBST], (pause) than you used to , to
Do you find that you have to use other drugs in combination with [SUBST] in
order to get the high you used to get from [SUBST] alone?
Have you ever experienced symptoms like shaking, difficulty sleeping, nausea, agitation, seizure, or other problems when you attempted to stop using [SUBST] or
cut back significantly on the amount you were using?
Have you ever taken alcohol or other drugs to get over feeling shaky or sick after a period of heavy [SUBST] use?
5 Have you often found that you use more [SUBST] than you intend or that you use
[SUBST] for a longer time than you intend?
You wanted to stop using, (pause) or cut down on [SUBST] more than once, but
You spent a good deal of time thinking about [SUBST] or planning your next use
of [SUBST]?
You spent a great deal of time using [SUBST] or getting over its effects?
9 You have given up activities that you once found enjoyable because of your use of [SUBST]?
10 You have gotten into trouble at work because of your use of [SUBST] or because
of the after effects of your use of [SUBST]?
11 You sometimes neglected important obligations to your family or friends because you were using [SUBST]?
12 You continued to use [SUBST] when you had a medical problem that you thought
might be caused by your use of [SUBST] (like an ulcer or pneumonia or
numbness or tingling in your hands) or worsened by your use of [SUBST]?
13 You continued to use [SUBST] when you had an emotional problem (like
depression, anxiety, suicidal thoughts or difficulty concentrating or remembering)
which you thought might be caused by your use of [SUBST] or worsened by
your use of [SUBST]?
14 Your use of [SUBST] affected your performance on the job (or at school), like
causing you to be late or to leave early or to miss work (school) altogether or to have trouble focusing on your work? 15 You used [SUBST] when you were likely to do something that was made more
dangerous by your use like driving a car or boat or operating machinery? 16 You have been arrested on a charge related to the use of [SUBST] or while you
were under the influence of [SUBST]?
17 You often had arguments with family members about your use of [SUBST] or
Diagnostic Questions
A. Ever B.
A. Ever B.
Was there ever a time when.
while you were under the influence of [SUBST]?
18 You have gotten into physical fights while using [SUBST]?
19 You have been assaulted or robbed while under the influence of [SUBST]?
F. OTHER BEHAVIORS
F1. To F6. CODE THE NEXT QUESTIONS (F1 TO F11) IN THE BOX AS:
A.
DON’T KNOW
8 REFUSED
How many times did this happen?
______ # OF TIMES
77 DON’T KNOW
88 REFUSED]
(IF ALC_SCRN = “NO” SKIP TO D.)
C.
How many of these involved you drinking alcohol? ______ # OF TIMES (CODE 6 OR MORE AS 6)
7
DON’T KNOW
8 REFUSED
(IF DRUG_SCRN = “NO” SKIP TO NEXT QUESTION)
D.
______ # OF TIMES (CODE 6 OR MORE AS 6)
7 DON’T KNOW
8 REFUSED
In the past 12 months, . . .
Did you drive at all after drinking or using drugs? Were you arrested for driving under the influence of alcohol or drugs? F3. Were you arrested and booked for drunkenness or other drug or liquor law F4. Were you arrested or booked for possession or sale of drugs? F5. Were you on probation or parole at any time? F6. Did you do anything else that could be considered risky after you used G. TREATMENT HISTORY

(IF BOTH C1 AND D1 ARE ANSWERED “NO” GO TO G11)
The next questions are about counseling or treatment for alcohol or drugs, but not cigarettes or
other tobacco. First I will ask about attendance at self-help group meetings. Do not include
educational classes in any of your answers.
G1. Have you ever attended even one meeting of a self help group such as Alcoholics
Anonymous or Narcotics Anonymous because you thought you might have a problem? DON’T KNOW
(GO TO G2)
REFUSED

G1a. About how many self-help meetings have you ever attended in your entire life?
DON’T KNOW
REFUSED
G1b. How long has it been since the last time you attended a self-help meeting? More than 30 days ago but within the past 12 months DON’T KNOW
REFUSED

Now I will ask you about professional help that you have received for alcohol or drug problems,
not including self-help groups such as AA or educational classes on drugs or DUI.
G2. Have you ever received treatment or counseling for your use of alcohol or any drug?
YES (GO TO G2a)
DON’T KNOW
NO (GO TO G8)
REFUSED
G2a. How many times in your life have you been in treatment or counseling for your use of ________# OF TIMES (RANGE 1 - 6 CODE MORE THAN 6 AS 6)
7
DON’T KNOW
REFUSED
G2b. Were you last in treatment or counseling . More than 30 days ago but within the past 12 months? DON’T KNOW
REFUSED
G3. What was the main place where you received treatment or counseling the last time?
Residential drug or alcohol rehabilitation facility prog. Outpatient drug or alcohol rehabilitation program DON’T KNOW
REFUSED
G4. The last time you received treatment or counseling, was it for. DON’T KNOW
REFUSED
G5. How did your treatment or counseling end? (GO TO G5b)
DON’T KNOW
REFUSED
What was the main reason for not completing? Did you leave because .
1
You couldn’t afford to continue treatment? Some other reason: (specify)_________________________________ DON’T KNOW
REFUSED
G5b. How long did you stay in treatment or counseling the last time? ______# OF DAYS/MONTHS/YEARS
(GO TO G6)
DON’T KNOW
(GO TO G6)
REFUSED
G5c. How long have you been in treatment or counseling this time? ______# OF DAYS/MONTHS/YEARS
77
DON’T KNOW
REFUSED

G6. Did any of the following sources pay even part of the cost of your last treatment? Answer
yes or no to each as I read them. [READ LIST OF SOURCES.]
DON’T KNOW
REFUSED
Payment sources

G7. (question removed)

G8. During the past 12 months, did you need treatment or counseling for your use of alcohol but
YES (GO TO G8a)
DON’T KNOW
NO (GO TO G9)
REFUSED
G8a. During the past 12 months, did you try to get treatment or counseling for your use of
DON’T KNOW
REFUSED
(IF D1 = “NO” THEN GO TO H1)

G9. During the past 12 months, did you need treatment or counseling for your use of drugs but
YES (GO TO G9a)
DON’T KNOW
NO (GO TO SECTION H)
REFUSED
G9a. During the past 12 months, did you try to get treatment or counseling for your use of
DON’T KNOW
REFUSED
G10. How important to you now is treatment of these drug problems? 0 NOT AT ALL
1 SLIGHTLY
2 MODERATELY
3 CONSIDERABLY
4 EXTREMELY
G11. In the past 12 months, how many times have you seen a health professional (such as a
doctor or nurse) for any physical health problems?
______# OF TIMES
77 DON’T KNOW
88 REFUSED
G11a. During the past 12 months, would you say your physical health has been excellent, very good, good, fair, or poor? 1 EXCELLENT
2 VERY
3 GOOD
4 FAIR
7 DON’T
KNOW
8 REFUSED

G12. Have you had a significant period in which you have…….? (Questions G12a - G12c concern a period that was not a direct result of drug or alcohol use) G12a. Experienced serious depression for at least two weeks? 1. Past 30 days: 1 YES 2. In your life: 1 YES
G12b. Experienced serious anxiety or tension for at least 2 weeks? 1. Past 30 days: 1 YES 2. In your life: 1 YES
G12c. Been prescribed any medication for any psychological/emotional problem? 1. Past 30 days: 1 YES 2. In your life: 1 YES

IF "NO" TO ALL OF G12a - G12c THEN SKIP TO G15

G13. How many days in the last 30 have you experienced these psychological/emotional
problems?
_______# OF DAYS
G13a. How many days have you experienced these psychological/emotional problems in _______ # OF DAYS
G14. How important to you now is treatment of these psychological problems? 0 NOT AT ALL
1 SLIGHTLY
2 MODERATELY
3 CONSIDERABLY
4 EXTREMELY

G15. In the past 12 months, how many times (sessions) have you seen a health professional
(such as a counselor or therapist) for any emotional or psychological problems?
______# OF TIMES
77
DON’T KNOW
88 REFUSED

G16. During the past 12 months, would you say your emotional or psychological health has been
excellent, very good, good, fair, or poor?
1 EXCELLENT
2
VERY GOOD
7 DON'T KNOW
REFUSED
G17. Which statement best describes your chance of getting HIV/AIDS? G18. Do you currently have health insurance coverage? DON’T KNOW
REFUSED
H. ADDITIONAL DEMOGRAPHICS
Now I am going to ask you a few more questions about your background and living situation before we complete the interview. H1. Are you now attending or enrolled in school? By school, I mean any public or private school, GED program, trade school, or a college or university. YES (GO TO H2)
DON’T KNOW
(GO TO H1a)
REFUSED
H1a. How old were you when you stopped attending school? ______YEARS OLD (CODE 76 FOR 76 OR MORE)
77 DON’T KNOW
88 REFUSED
0 None 1 First through 8th grade 2 Some high school, but no diploma 3 High school graduate or GED 4 Some college, but no degree 5 Associate 77 DON'T KNOW
88 REFUSED
Which one of the following best describes your current marital status. Are you . 4 Divorced or separated?
5 Widowed?
7 DON’T KNOW
8 REFUSED
YES ( GO TO H5)
DON’T KNOW
NO (GO TO H4a)
REFUSED
What country or U.S. territory were you born in? COUNTRY OR U.S. TERRITORY:___________________________
About how many years have you lived in the United States? _______ # OF YEARS (CODE 76 FOR 77 OR GREATER)
77 DON’T KNOW
78 REFUSED
Working full-time, 35 or more hours per week in one or more jobs (GO TO H6)
Working part-time (GO TO H6)
Not working at present (GO TO H5a)
DON’T KNOW
REFUSED
H5a. Are you not working because you are . 1 A seasonal worker? 2 A full-time homemaker? 3 In 4 Retired?
5 Disabled for work?
6 Other?
7 DON’T KNOW
8 REFUSED
H6. Think now about the last 12 months. Did you have any children under 18 living with you YES (GO TO H6a)
DON’T KNOW
NO (GO TO H7)
REFUSED
H6a. How many of these children did you have primary care responsibilities for? By primary care responsibilities, I mean that you fed and clothed them and took care of
them.
_______ # OF CHILDREN
77 DON’T KNOW
88 REFUSED

[ASK ONLY FEMALES AGE 50 OR LESS. FOR OTHERS GO TO H9.]
H7.
YES (GOTO TO H9)
DON’T KNOW
NO (GOTO TO H8)
REFUSED
Were you pregnant at any time in the last 12 months? DON’T KNOW
REFUSED

[ASK ALL RESPONDENTS]
Very often in health studies like this, information on the general area where people live is used
for health planning purposes. For this reason, we would like to know your county of
residence and five-digit zip code. (ENTER BOTH WITH LEADING ZEROS WHERE
NEEDED)
What county do you live in? ____ | ____ | ____ ( USE FIPS CODES)

H10. What is your 5-digit zip code? ____ | ____ | ____ | ____ | ____
H11. In studies like this, households are often grouped according to income. What was the total income of all persons in your household over the past year, including salaries or other earnings, interest, retirement, and so on, for all household members combined?
H12. What is your total household income per year?
1 $0.00 - $5,000
2 $5,001 - $7,500
3 $7,501 - $10,000
4 $10,001 - $12,500
5 $12,501 - $15,000
6 $15,001 - $20,000
7 $20,001 - $25,000
8 $25,001 - $30,000
9 $30,001 - $40,000
10 $40,001 - $50,000
11 $50,001 - $70,000
12 $70,001 - $90,000
13 $90,001 - $120,000
14 $120,001 and above
15 DON’T KNOW
16 REFUSED
That completes our survey. We appreciate your time and cooperation. Your answers, along with
those of others, will help us better provide for the residents of Kentucky. We want to reassure
you that your responses will be kept strictly confidential. Thank you so much. (GO TO J2)
J. CLOSING
J1a. Your household does not qualify for our survey. I appreciate your taking the time to speak with me. Thank you. (GO TO J2)
J1b. People who are younger than 18 years old are not eligible to be interviewed in this study. I appreciate your taking the time to speak with me. Thank you. (GO TO J2)
J1c. People who are on active duty in the armed forces are not eligible to be interviewed in this study. I appreciate your taking the time to speak with me. Thank you. (GO TO J2)
DATE AND TIME INTERVIEW ENDED:
DATE: (MM:DD:YY)
___ | ____ | ____
TIME: (HH:MM)
____ | ____
AM=1 / PM=2: ____

COMPLETE REMAINING QUESTIONS AFTER ENDING PHONE CALL.
J2.
How would you (the interviewer) rate the quality of the information obtained in this interview? (GO TO THE END)
3 Good (a few problems but overall comprehension good) 2 Fair (a number of problems, but overall acceptable) 1 Poor (many problems, overall quality open to question) 0 Inadequate (interview was terminated by interviewer, or quality judged too poor to be (IF NOT EXCELLENT) What were the reasons that the quality of information was less
than excellent? (CHECK ALL THAT APPLY.)
1. Interview not in respondent's native language 2. Hearing (hearing loss or background noise) ____ 3. Interruptions or distractions 8. Respondent did not take interview seriously ____ 9. Respondent did not understand 10. Respondent was offended by interview 11. Respondent may not have been truthful 12. Other (SPECIFY:_______________________________)
*****************END OF SURVEY******************
Drug Categories for the STNAP Survey
The following list of drugs for each of the STNAP Survey categories are examples and are by no means all inclusive. The drugs are grouped into categories according to their legal usage and the conditions they are meant to treat. Benzodiazepines, therefore, fall into two categories. For example, the tranquilizer category includes Xanax and Klonopin and the sedative category includes Restoril. States may want to include questions on drugs such as GHB, Rohypnol, Ecstacy, Ketamine or Special K separately for their own use.
MARIJUANA - including Hashish and Hash oil. Also called “pot”, “grass”, “reefer”, and many

POWDER COCAINE - including freebase or coca paste
CRACK COCAINE - in rock or chunk form
HEROIN
PAIN RELIEVERS OR OTHER OPIATES, SUCH AS CODEINE OR PERCOCET
(use examples above of Oxycontin or Vicodin instead??? The pharmacist consultant said there is
no such thing as codeine by itself. It is an ingredient in other products.) We are not interested in use of “over-the-counter” pain relievers such as aspirin, Tylenol, or Advil that can be bought in drug stores or grocery stores without a doctor’s prescription. We are interested in use of any form of prescription pain relievers that were not prescribed for the respondent or that he took only for the experience or feeling they caused. Products containing codeine such as: Morphine (Demerol)
METHAMPHETAMINE - also called “crank”, “crystal” or “ice”
OTHER STIMULANTS, SUCH AS SPEED
Use of drugs such as amphetamines that are known as “uppers”, or “speed”. People sometimes
take these drugs to lose weight, to stay awake, or for attention deficit disorders. We are not interested in the use of “over-the-counter” stimulants, such as Dexatrim or No-Doz that can be bought in drug stores or grocery stores without a doctor’s prescription.
HALLUCINOGENS, SUCH AS PCP OR LSD
These drugs often cause people to see or experience things that are not real.
LSD, also called “acid”
PCP, also called “angel dust” or phencyclidine
Peyote
Mescaline
Psilocybin
TRANQUILIZERS, SUCH AS VALIUM
Tranquilizers are usually prescribed to relax people, to calm people down, to relieve anxiety, or
to relax muscle spasms. Sometimes called “nerve pills”. Tranquilizers or muscle relaxers (Consultant preferred muscle relaxers in title.) SEDATIVES, OR SLEEPING PILLS
Sedatives or barbiturates are also called “downers” or “sleeping pills”. People take these drugs to
help them relax or to help them sleep. Not interested in the use of “over-the-counter” sedatives such as Sominex, Unisom, Nytol. or Benadryl that can be bought in drug stores or grocery stores without a doctor’s prescription.
INHALANTS - breathable chemicals that produce mind altering vapors. Inhalants are ingested
by “sniffing”, “snorting” (through the nose), “bagging” (inhaling fumes from a plastic bag), or “huffing” (stuffing an inhalant soaked rag into the mouth). Slang terms include: laughing gas, rush, whippets, poppers, snappers. There are about 1400 products potentially usable as inhalants and they are grouped into four classes. Volatile solvents: gasoline, paint thinners, glue, cleaning solutions, etc. Aerosols: spray paints, etc. Anesthetic agents: chloroform, ether, oil and grease dissolvers Amyl, butyl, and isobutyl nitrates: such as room fresheners

Source: http://cdar.uky.edu/knap/04adultreport/04AdultReportPdfs/04%20Adult%20Report%20Appendix.pdf