0 - National Criminal Justice Reference Service

DRUG SCREEN
PLEASE COMPLETE ALL INFORMATION BELOW:
INSTITUTION (CIRCLE ONE):
TYPE OF PROGRAM (CIRCLE ONE):
1 = CRESSON 1= EDUCATION
2 = GRATERFORD 4 = "TINGDON 2 = OUTPATENT TREATMENT
3 = HOUTZDALE 5 = WAYMART 3 = THERAPEUTIC COMMUNITY
LAST NAME:
INMATE #:
FIRST NAME:
TODAY'S DATE:
MO DAY YEAR
L
HOW MANY CONSECUTIVE MONTHS HAVE YOU BEEN IN THIS PROGRAM? (CIRCLE ONE):
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 2j+
0
2. Did you tw to cut down on drugs and were unable to do it? ...................
3. Did you spend a lot of time getting drugs, using them,
or recovering fiom their use?
.................................................................
O=No
O=No
1 =Yes
1 =Yes
4. Did you often get SO hish or sick fiom drugs that it --
a. kept YOU from doing work, going to school,
or caring for children? .....................................................................
O=No
1 =Yes
b. caused an accident or became a danger to you or others? ..................
O=No
1 =Yes
5. Did you often spend less time at work. school, or with friends
so that you could use drugs? .................................................................
O=No
1 =Yes
6. In the last 6 months before prison, did your drug use often cause --
a. emotional or psychological problems? ..............................................
b. problems with family. friends. work, or police? ................................
c. phvsical health or medical problems? ................................................
O=No
O=No
O=No
1 =Yes
1 =Yes
1 =Yes
CONTINUE TO OTHER SIDE
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This document is a research report submitted to the U.S. Department of Justice. This report has not
been published by the Department. Opinions or points of view expressed are those of the author(s)
and do not necessarily reflect the official position or policies of the U.S. Department of Justice.