Module 24: Substance Abuse History Form

A Module Used in The Measurement Group's Cross-Cutting Evaluation of the HRSA HIV/AIDS Bureau's Special Projects of National Significance on Innovative Models of HIV/AIDS Care

Purpose

• Standardized measure of lifetime and current substance abuse including both injection and non-injection routes of administration.

Content Domain - Ever used, use in last 6 months, use in last month of: alcohol, marijuana, cocaine, heroin, crack, speedballs, amphetamines, PCP, LSD, other hallucinogens, barbiturates, other drugs. Injection drug use. Drug use during and after sexual acts. Needle sharing/cleaning behaviors.

Operational Data Items - ID Letters/ID Numbers, Site, Sub-Provider, Date, Staff Code, Client Gender. Drug Use: Alcohol, Marijuana, Crack, Cocaine by itself, Heroin by itself, Heroin & Cocaine mixed together, Amphetamines, Other Drugs (ever used, age at first use, ever injected, used in the last 6 months, days used in last 30 days, days injected in last 30 days, times injected last in 30 days), Age First Injected Any Drug.

Citation - Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1997). Module 24: Brief Substance Abuse History Form. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group. Adapted from work used in the NIDA Risk Behavior Assessment (RBA).

Usage - Permission is granted for non-commercial use so long as form is not altered, the copyright is not removed, and a proper citation is made to the instrument. Non-commercial use is use by a not-for-profit organization in which the instrument is not sold. If you have questions about appropriate and proper uses, contact The Measurement Group.