GLOW Program- Adult Pre-Questionnaire
Administered by Kylie Paramore, Program Specialist. For more information e-mail

National Minority AIDS Initiative (MAI) & Substance Abuse/HIV Prevention Initiative Adult Questionnaire

Funding for data collection supported by the Center for Substance Abuse Prevention (CSAP),
Substance Abuse and Mental Health Services Administration (SAMHSA),
U.S. Department of Health and Human Services (HHS)

These questions are part of a data collection effort about how to prevent substance abuse and HIV infection. The questions are being asked of hundreds of other individuals throughout the United States. The data findings will be used to help prevention initiatives learn more about how to keep people from using drugs and getting infected with HIV. Completing this questionnaire is voluntary. If you do not want to answer any of the questions, you do not have to. If you decide not to participate in this survey, it will have no effect on your participation in direct service programs. However, your answers are very important to us. Please answer the questions honestly—based on what you really do, think, and feel. Your answers will not be told to anyone in your family or community.

Do not write your name anywhere on this questionnaire.

We would like you to work fairly quickly so that you can finish. Please work quietly by yourself. If you have any
questions or do not understand something, let the data collector know.

1. Answer each question by marking one of the answer circles. Some questions allow you to mark more than one
answer. If you don’t find an answer that fits exactly, choose the one that comes closest.
2. It is very important that you answer each question truthfully. Your responses will not be helpful unless you tell the truth.
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