57 EtOH (Alcohol) Questionaire

Attachment 57
EtOH Questionnaire

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
EtOH Questionnaire - Adults
Estimated time burden: 2 minutes
[00-EtOH Adult]
On the next screens, we will ask you questions about alcohol use. Read each question carefully and
1
answer as well as you can.
After you make your choice, the computer will automatically go on to the next question. If you want to
change your answer, click on the GO BACK button to return to the previous question and then choose a
different answer.
Click on the CONTINUE button when you are ready to begin.
[01-EtOH Adult]
During the last 12 months, how often did you usually have any kind of drink containing alcohol? By a
drink we mean half an ounce of absolute alcohol (e.g., a 12-ounce can or glass of beer or cooler, a 5ounce glass of wine, or a drink containing 1 shot of liquor).
Every day
5 to 6 times a week
3 to 4 times a week
twice a week
once a week
2 to 3 times a month
once a month
3 to 11 times in the past year
1 or 2 times in the past year
I did not drink any alcohol in the past year, but I did drink in the past
I never drank any alcohol in my life

Public reporting burden for this collection of information is estimated to average 2 1/2 hours per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD
20892-7974, ATTN: PRA (0925-xxxx*) EXP: (xx/xxxx). Do not return the completed form to this address.

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[02- EtOH Adult]
During the last 12 months, how many alcoholic drinks did you have on a typical day when you drank
alcohol?
25 or more drinks
19 to 24 drinks
16 to 18 drinks
12 to 15 drinks
9 to 11 drinks
7 to 8 drinks
5 to 6 drinks
3 to 4 drinks
2 drinks
1 drink
I did not drink any alcohol in the past year, but I did drink in the past
I never drank any alcohol in my life
[03- EtOH Adult]
During the last 12 months, how often did you have 5 or more (if male) or 4 or more (if female) drinks
containing any kind of alcohol in within a two-hour period?
Every day
5 to 6 days a week
3 to 4 days a week
2 days a week
1 day a week
2 to 3 days a month
1 day a month
3 to 11 days in the past year
1 or 2 days in the past year
During the last 12 months, I never drank 5 or more drinks (if a male) or 4 or more drinks (if a
female)

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX

[04- EtOH Adult]
During your lifetime, what is the maximum number of drinks containing alcohol that you drank within a
24-hour period?
36 drinks or more
24 to 35 drinks
18 to 23 drinks
12 to 17 drinks
8 to 11 drinks
5 to 7 drinks
4 drinks
3 drinks
2 drinks
1 drink
I never drank any alcohol in my life

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
EtOH Questionnaire - Adolescents
Estimated time burden: 2 minutes
[00-EtOH Adolescents] Adolescents – 13-17
On the next screens, we will ask you questions about alcohol use. Read each question carefully and
answer as well as you can.
After you make your choice, the computer will automatically go on to the next question. If you want to
change your answer, click on the GO BACK button to return to the previous question and then choose a
different answer.
Click on the CONTINUE button when you are ready to begin.

[01- EtOH Adolescent]
During the past 30 days, how many times have you had a drink containing alcohol? By a drink we mean
half an ounce of absolute alcohol (e.g., a 12-ounce can or glass of beer or cooler, a 5-ounce glass of
wine, or a drink containing 1 shot of liquor).
Every day
5 to 6 times a week
3 to 4 times a week
twice a week
once a week
2 to 3 times a month
once a month
I never drank any alcohol in my life

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX

[02- EtOH Adolescent]
During the past 30 days, on days when you drank alcohol, how many drinks containing alcohol did you
usually have?
25 or more drinks
19 to 24 drinks
16 to 18 drinks
12 to 15 drinks
9 to 11 drinks
7 to 8 drinks
5 to 6 drinks
3 to 4 drinks
2 drinks
1 drink
I never drank any alcohol in my life

[03- EtOH Adolescent]
During the past 30 days, if you are a boy, how often did you have 5 or more drinks containing alcohol? If
you are a girl, how often did you have 4 or more drinks containing alcohol?
Every day
5 to 6 days a week
3 to 4 days a week
2 days a week
1 day a week
2 to 3 days a month
1 day a month
During the past 30 days I never drank 5 or more drinks (if a boy) or 4 or more drinks (if a girl)

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[04- EtOH Adolescent]
During your entire life, what is the most drinks containing alcohol that you have had in one day (within
a 24-hour period)?
36 drinks or more
24 to 35 drinks
18 to 23 drinks
12 to 17 drinks
8 to 11 drinks
5 to 7 drinks
4 drinks
3 drinks
2 drinks
1 drink
I never drank any alcohol in my life