Form 1 Alcohol Use

ID NUMBER:

FORM CODE: ALE VERSION: A 6/07/07

Contact Occasion

SEQ #

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 02 minutes 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). Do not return the completed form to this address.

H

OMB#: 0925-XXXX

Exp. XX/XXXX

CHS/SOL Alcohol Use Questionnaire

ID NUMBER:

FORM CODE: ALE VERSION: A 6/07/07

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date: // 0b. Staff ID:

Month Day Year

Instructions: Mark the appropriate box for the response. Unless instructed, mark ONLY one response.

Serving sizes for alcohol use in “standard drink” units are as follows: Beer = 12oz. glass or 355ml bottle; Wine = 3.5oz glass, 1 bottle =750ml= 8 glasses; Hard spirits = 1.5oz. or 1 shot.

1. Do you presently drink alcoholic beverages?

No 0  GO TO QUESTION 7

Yes 1

2. How many glasses of red wine do you usually have per week?

(if less than 1 per week enter “00”)

3. How many glasses of white wine do you usually have per week?

(if less than 1 per week enter “00”)

4. How many cans, bottles, or glasses of beer do you usually have per week? Beer includes more traditional beverages such as pulque and chicha.

(if less than 1 per week enter “00”)

5. How many drinks of liquor, spirits, or mixed drinks do you usually have per week? Spirits includes liquor such as whiskey, vodka, tequila, rum, and mixed drinks such as martinis, as well as more traditional beverages such as aguardiente and cañita. (1 serving = 1.5 oz or 1 shot)

(if less than 1 per week enter “00”)

6. How often did you have 4 or more drinks [for females] and 5 or more drinks [for males] containing any kind of alcohol within a two-hour period? (Mark only one)

Every day 1

5 to 6 days a week 2

3 to 4 days a week 3

2 days a week 4

1 day a week 5

2 to 3 days a month 6

1 day a month 7

Less than once a month 8

Never 9

END OF QUESTIONNAIRE

7. Did you ever drink alcohol? No 0  END OF QUESTIONNAIRE

Yes 1

8. About how long ago did you stop drinking alcohol? (Mark only one)

Less than 1 year ago 1

1 - 2 years ago 2

More than 2 years ago 3

9. Did you stop drinking alcohol for health reasons?

No 0

Yes 1

10. Did you stop drinking alcohol on the advice of a doctor (or health worker)?

No 0

Yes 1

Alcohol Use Form (ALE) Page 2 of 2