Attachment 4 - TCU Drug Screen 5 _6.30.25.pdf
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- Attached to
- T1464 - Substance Abuse Services
- Solicitation number
- 25DPP01102
- Issued by
- Cumberland County, New Jersey
About this file
The document is the TCU Drug Screen 5, a comprehensive substance abuse screening tool developed by the TCU Institute of Behavioral Research. This two-page assessment is designed to evaluate an individual's drug use patterns and potential substance abuse issues over the previous 12 months. The screening consists of 17 detailed questions that probe various aspects of drug use, including frequency of use, impact on daily functioning, attempts to control use, and the individual's perception of their drug-related problems.
The questionnaire covers a wide range of substances, including alcohol, marijuana, synthetic drugs, opioids, stimulants, prescription medications, and hallucinogens. It assesses key indicators of substance abuse such as tolerance, withdrawal symptoms, continued use despite negative consequences, and inability to control drug consumption. The form also inquires about previous drug treatment experiences and the individual's motivation for seeking treatment, providing a holistic view of the person's substance use history and potential intervention needs.
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Text version
Client ID# Today’s Date Facility ID# Zip Code Administration
TCU Drug Screen 5 (v.Aug17) 1 of 2 © Copyright 2017 TCU Institute of Behavioral Research, Fort Worth, Texas. All rights reserved.
TCU DRUG SCREEN 5
During the last 12 months (before being locked up, if applicable) – Yes No
1. Did you use larger amounts of drugs or use them for a longer time than you planned or intended?
2. Did you try to control or cut down on your drug use but were unable to do it?
3. Did you spend a lot of time getting drugs, using them, or recovering from their use?
4. Did you have a strong desire or urge to use drugs?
5. Did you get so high or sick from using drugs that it kept you from working, going to school, or caring for children?
6. Did you continue using drugs even when it led to social or interpersonal problems? ...
7. Did you spend less time at work, school, or with friends because of your drug use?
8. Did you use drugs that put you or others in physical danger?
9. Did you continue using drugs even when it was causing you physical or psychological problems?
10a. Did you need to increase the amount of a drug you were taking so that you could get the same effects as before?
10b. Did using the same amount of a drug lead to it having less of an effect as it did before?
11a. Did you get sick or have withdrawal symptoms when you quit or missed taking a drug?
11b. Did you ever keep taking a drug to relieve or avoid getting sick or having withdrawal symptoms?
12. Which drug caused the most serious problem during the last 12 months? [CHOOSE ONE]
None Stimulants – Methamphetamine (meth) Alcohol Synthetic Cathinones (Bath Salts) Cannaboids – Marijuana (weed) Club Drugs – MDMA/GHB/Rohypnol (Ecstasy) Cannaboids – Hashish (hash) Dissociative Drugs – Ketamine/PCP (Special K) Synthetic Marijuana (K2/Spice) Hallucinogens – LSD/Mushrooms (acid) Opioids – Heroin (smack) Inhalants – Solvents (paint thinner) Opioids – Opium (tar) Prescription Medications – Depressants Stimulants – Powder Cocaine (coke) Prescription Medications – Stimulants Stimulants – Crack Cocaine (rock) Prescription Medications – Opioid Pain Relievers Stimulants – Amphetamines (speed) Other (specify)
25DPP01102 T1464 Substance Abuse Services
ATTACHMENT 4 - TCU DRUG SCREEN 5
Client ID# Today’s Date Facility ID# Zip Code Administration
TCU Drug Screen 5 (v.Aug17) 2 of 2 © Copyright 2017 TCU Institute of Behavioral Research, Fort Worth, Texas. All rights reserved.
13. How often did you use each type of drug Only 1-3 1-5 during the last 12 months? a few times per times per Never times month week Daily
a. Alcohol
b. Cannaboids – Marijuana (weed)
c. Cannaboids – Hashish (hash)
d. Synthetic Marijuana (K2/Spice)
e. Opioids – Heroin (smack)
f. Opioids – Opium (tar)
g. Stimulants – Powder cocaine (coke)
h. Stimulants – Crack Cocaine (rock)
i. Stimulants – Amphetamines (speed)
j. Stimulants – Methamphetamine (meth)
k. Synthetic Cathinones (Bath Salts)
l. Club Drugs – MDMA/GHB/Rohypnol (Ecstasy)
m. Dissociative Drugs – Ketamine/PCP (Special K)
n. Hallucinogens – LSD/Mushrooms (acid)
o. Inhalants – Solvents (paint thinner)
p. Prescription Medications – Depressants
q. Prescription Medications – Stimulants
r. Prescription Medications – Opioid Pain Relievers
s. Other (specify)
14. How many times before now have you ever been in a drug treatment program?
[DO NOT INCLUDE AA/NA/CA MEETINGS]
Never 1 time 2 times 3 times 4 or more times
15. How serious do you think your drug problems are?
Not at all Slightly Moderately Considerably Extremely
16. During the last 12 months, how often did you inject drugs with a needle?
Never Only a few times 1-3 times/month 1-5 times per week Daily
17. How important is it for you to get drug treatment now?
Not at all Slightly Moderately Considerably Extremely
File details come from the government source that posted it. Updated .