NC State AlcoholEdu for Sanction

1. Please answer all of the questions on this survey! Some of the questions may seem redundant to you, but each one serves a purpose!

Demographic Information

Please answer all of the questions on this survey! Some of the questions may seem redundant to you, but each one serves a purpose! Demographic Information Name:
Student ID:
Local Address (Campus Address, for example):
City:
Zip Code:
Email Address:
Phone Number:

2. Sex

Sex Female

Male

3. Age

Age 17

18

19

20

21+

4. How much do you weigh?

How much do you weigh?

5. Are you currently taking prescription medications?

Are you currently taking prescription medications? No

Yes

6. How many years have you been at NC State?

How many years have you been at NC State? first year

second year

third year

fourth (or more) years

7. Who is requiring you to complete AlcoholEdu for Sanctions?

Who is requiring you to complete AlcoholEdu for Sanctions? Housing (Residence Director, Resident Advisor, etc.)

Office of Student Conduct (Paul Cousins, Turi Plish, Tony Shurer)

Other (please specify - Lawyer, City/County Law Enforcement, etc.)

8. Where did your violation occur? (If you have a question about what may be considered on or off campus, please review both lists below before marking an answer).

	On Main Campus (mark best choice)	Off Campus (mark best choice)
Violation occurred:	Where did your violation occur? (If you have a question about what may be considered on or off campus, please review both lists below before marking an answer). Violation occurred: On Main Campus (mark best choice)	Off Campus (mark best choice)

9. Briefly explain what happened that resulted in you receiving this alcohol violation

Briefly explain what happened that resulted in you receiving this alcohol violation

10. Was the issue of alcohol poisoning a factor in your violation?

Was the issue of alcohol poisoning a factor in your violation? No

Yes - there was a concern that I was experiencing alcohol poisoning and medical help was offered

Yes - there was a concern that someone I was with was experiencing alcohol poisoning and medical help was offered

Yes - Someone I was with was transported to a medical facility

Yes - I was transported to a medical facility

11. In the PAST MONTH, please describe a TYPICAL DRINKING WEEK. For each day, fill in the number of STANDARD DRINKS of each type of alcohol you consumed on that day and the TYPICAL NUMBER OF HOURS you drank on that day. (One STANDARD DRINK equals: 1 shot or mixed drink, 5 oz. wine, 1 cooler, 12 oz. beer).

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
BEER?	In the PAST MONTH, please describe a TYPICAL DRINKING WEEK. For each day, fill in the number of STANDARD DRINKS of each type of alcohol you consumed on that day and the TYPICAL NUMBER OF HOURS you drank on that day. (One STANDARD DRINK equals: 1 shot or mixed drink, 5 oz. wine, 1 cooler, 12 oz. beer). BEER? Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
WINE?	WINE? Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
LIQUOR?	LIQUOR? Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
HOURS?	HOURS? Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday

12. Think of the one occassion during the PAST MONTH when you drank the most. How many drinks did you have? Fill in the number of STANDARD DRINKS of each type consumed and the TYPICAL NUMBER OF HOURS you drank on that day. (One STANDARD DRINK equals: 1 shot or mixed drink, 5 oz. wine, 1 cooler, 12 oz. beer).


BEER?	Think of the one occassion during the PAST MONTH when you drank the most. How many drinks did you have? Fill in the number of STANDARD DRINKS of each type consumed and the TYPICAL NUMBER OF HOURS you drank on that day. (One STANDARD DRINK equals: 1 shot or mixed drink, 5 oz. wine, 1 cooler, 12 oz. beer). BEER?
WINE?	WINE?
LIQUOR?	LIQUOR?
HOURS?	HOURS?

13. For each of the following, estimate how common these behaviors are:

	Percent
What percent of U.S. college students (same sex) drink more than you?	For each of the following, estimate how common these behaviors are: What percent of U.S. college students (same sex) drink more than you? Percent
What percent of U.S. college students do not drink at all in a typical week?	What percent of U.S. college students do not drink at all in a typical week? Percent
What percent of U.S. college students have two (2) drinks or fewer in a typical week?	What percent of U.S. college students have two (2) drinks or fewer in a typical week? Percent
What percent of U.S. college students smoke marijuana at least once a year?	What percent of U.S. college students smoke marijuana at least once a year? Percent

14. How much would you estimate you spend on alcohol beverages per week?

How much would you estimate you spend on alcohol beverages per week?

15. After school expenses, how much money do you have to spend in an average month?

After school expenses, how much money do you have to spend in an average month?

16. During the PAST MONTH, how many days were you a passenger in a vehicle when the driver had three or more drinks?

	Days
Riding in vehicle when driver had 3+ drinks	During the PAST MONTH, how many days were you a passenger in a vehicle when the driver had three or more drinks? Riding in vehicle when driver had 3+ drinks Days

17. During the PAST MONTH, how many days did you drive a vehicle shortly after having three (3) or more drinks?

	Days
Days driven shortly after having 3+ drinks	During the PAST MONTH, how many days did you drive a vehicle shortly after having three (3) or more drinks? Days driven shortly after having 3+ drinks Days

18. Think about the number of your BLOOD RELATIVES who are now, or have been in the past, problem drinkers, or alcoholics.

	NUMBER
Number of parents?	Think about the number of your BLOOD RELATIVES who are now, or have been in the past, problem drinkers, or alcoholics. Number of parents? NUMBER
Number of brothers or sisters?	Number of brothers or sisters? NUMBER
Number of grandparents?	Number of grandparents? NUMBER
Number of uncles or aunts?	Number of uncles or aunts? NUMBER
Number of first cousins?	Number of first cousins? NUMBER

19. Please check the answer that is correct for you:

	No	Yes, but not in the last year	Yes, during the last year
Have you or someone else been injured as a result of your drinking?	Please check the answer that is correct for you: Have you or someone else been injured as a result of your drinking? No	Yes, but not in the last year	Yes, during the last year
Has a relative, friend, doctor or other health worker been concerned about your drinking or suggested you cut down?	Has a relative, friend, doctor or other health worker been concerned about your drinking or suggested you cut down? No	Yes, but not in the last year	Yes, during the last year

20. Please check the answer that is correct for you:

	1 or 2	3 or 4	5 or 6	7 to 9	10 or more
How many drinks containing alcohol do you have on a typical day when you are drinking?	Please check the answer that is correct for you: How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2	3 or 4	5 or 6	7 to 9	10 or more

21. Please check the answer that is correct for you:

	Never	Monthly or less	2 to 4 times a month	2 to 3 times a week	4 or more times a week
How often do you have a drink containing alcohol?	Please check the answer that is correct for you: How often do you have a drink containing alcohol? Never	Monthly or less	2 to 4 times a month	2 to 3 times a week	4 or more times a week

22. Please check the answer that is correct for you:

	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
How often do you have six drinks or more on one occasion?	Please check the answer that is correct for you: How often do you have six drinks or more on one occasion? Never	Less than monthly	Monthly	Weekly	Daily or almost daily
How often during the last year have you found that you were not able to stop drinking once you had started?	How often during the last year have you found that you were not able to stop drinking once you had started? Never	Less than monthly	Monthly	Weekly	Daily or almost daily
How often during the last year have you failed to do what was normally expected from you because of drinking?	How often during the last year have you failed to do what was normally expected from you because of drinking? Never	Less than monthly	Monthly	Weekly	Daily or almost daily
How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?	How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never	Less than monthly	Monthly	Weekly	Daily or almost daily
How often during the last year have you had a feeling of guilt or remorse after drinking?	How often during the last year have you had a feeling of guilt or remorse after drinking? Never	Less than monthly	Monthly	Weekly	Daily or almost daily
How often during the last year have you been unable to remember what happened the night before because you had been drinking?	How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never	Less than monthly	Monthly	Weekly	Daily or almost daily

23. If a smoker, for how many years have you smoked regularly?

If a smoker, for how many years have you smoked regularly?

24. During the PAST MONTH, how many cigarettes did you smoke on a typical day?

During the PAST MONTH, how many cigarettes did you smoke on a typical day?

25. What other drugs have you used for recreational purposes or for purposes other than those prescribed by a physician? (Choose all that apply).

	have never used	have used 1-2 times lifetime	within last year	within last six months	within last 30 days	within last 2 weeks	within last week
Cigarettes	What other drugs have you used for recreational purposes or for purposes other than those prescribed by a physician? (Choose all that apply). Cigarettes have never used	have used 1-2 times lifetime	within last year	within last six months	within last 30 days	within last 2 weeks	within last week
Tobacco from a water pipe (hookah)	Tobacco from a water pipe (hookah) have never used	have used 1-2 times lifetime	within last year	within last six months	within last 30 days	within last 2 weeks	within last week
Cigars, little cigars, clove cigarettes	Cigars, little cigars, clove cigarettes have never used	have used 1-2 times lifetime	within last year	within last six months	within last 30 days	within last 2 weeks	within last week
Smokeless tobacco	Smokeless tobacco have never used	have used 1-2 times lifetime	within last year	within last six months	within last 30 days	within last 2 weeks	within last week
Marijuana	Marijuana have never used	have used 1-2 times lifetime	within last year	within last six months	within last 30 days	within last 2 weeks	within last week
Cocaine (crack, rock, freebase)	Cocaine (crack, rock, freebase) have never used	have used 1-2 times lifetime	within last year	within last six months	within last 30 days	within last 2 weeks	within last week
Methamphetamine (crystal, meth, ice, crank)	Methamphetamine (crystal, meth, ice, crank) have never used	have used 1-2 times lifetime	within last year	within last six months	within last 30 days	within last 2 weeks	within last week
Amphetamines (diet pills, bennies)	Amphetamines (diet pills, bennies) have never used	have used 1-2 times lifetime	within last year	within last six months	within last 30 days	within last 2 weeks	within last week
Sedatives (downers, ludes)	Sedatives (downers, ludes) have never used	have used 1-2 times lifetime	within last year	within last six months	within last 30 days	within last 2 weeks	within last week
Hallucinogens (LSD, PCP)	Hallucinogens (LSD, PCP) have never used	have used 1-2 times lifetime	within last year	within last six months	within last 30 days	within last 2 weeks	within last week
Anabolic steroids (Testosterone)	Anabolic steroids (Testosterone) have never used	have used 1-2 times lifetime	within last year	within last six months	within last 30 days	within last 2 weeks	within last week
Opiates (heroin, smack, morphine, oxycontin)	Opiates (heroin, smack, morphine, oxycontin) have never used	have used 1-2 times lifetime	within last year	within last six months	within last 30 days	within last 2 weeks	within last week
Inhalants (glue, solvents, gas)	Inhalants (glue, solvents, gas) have never used	have used 1-2 times lifetime	within last year	within last six months	within last 30 days	within last 2 weeks	within last week
MDMA (ecstasy)	MDMA (ecstasy) have never used	have used 1-2 times lifetime	within last year	within last six months	within last 30 days	within last 2 weeks	within last week
Club drugs (GHB,Ketamine, Rohypnol)	Club drugs (GHB,Ketamine, Rohypnol) have never used	have used 1-2 times lifetime	within last year	within last six months	within last 30 days	within last 2 weeks	within last week

26. How many drinks do you think the average NC State student consumes per an occassion?

How many drinks do you think the average NC State student consumes per an occassion? 0-2 drinks

3-4 drinks

5-6 drinks

7-8 drinks

9 or more drinks

1.

1. Please answer all of the questions on this survey! Some of the questions may seem redundant to you, but each one serves a purpose!Demographic Information