Request for Proposal #2626 Schedule G Interview and Questionnaire 2016 (Alcohol and Drug) These questions are for research purposes only. If you don’t want to answer a particular question, just leave it blank. This will only take a few minutes to complete. Me Have you been through a RoadWatch check stop in the past 12 months? Yes No ‘Are you aware that in Manitoba, a person can face an immediate 3, 15, 30, or 60-day licence suspension for driving with a blood alcohol concentration (BAC) over .057 Yes No What class of licence do you have? —_leamer Intermediate ___Class5 ___Class4 ___Class3 —Class2 ___Class 1 ___ Class 6 (Motorcycle) What is the maximum allowable level of alcohol for drivers who are in the Graduated Driver's Licence Program? 00 02 05 08 How many drinks does it take for you to reach an alcohol level of .057 (number of drinks) ___| don't know Are you the designated driver tonight? Yes No Please chack the statement that best describes your drinking tonight: ___! did not plan to drink tonight and did not drink ___! did not plan to drink tonight but I did drink | planned to drink tonight and drank about as much as | planned | planned to drink tonight but I drank less than { planned | planned to drink tonight but I drank more than | planned How easy is it for you to avoid drinking and driving? MB (Very easy) (Neutral) (Very hard)Schedule G Request for Proposal #2626 9. 10. 1. 12. 13, In your experience, what makes it hard for people to avoid drinking and driving? (check all that apply) ___ Taxis are not readily available The wait for a taxi is too long _— Taxis cost too much Public transit is poor or inconvenient ___ People don't think they are impaired _ People don’t want to leave their car somewhere _—— There is no public transit _ Staying overnight is inconvenient People don’t think they will be caught Other In the past 12 months, how often did you have a drink containing alcohol? __Never Monthly orless ___Weekly or less —23timesweek ___ 4+ times/week (if Never, please skip ahead to question #14) During the last 12 months, on days that you drank, how many drinks did you usually have? drinks How often in the past 12 months have you had five or more drinks on one occasion? Every day __5or6timesaweek __ 210 4 times a week —Onceaweek ___2to3timesamonth ___Once a month Less thanonceamonth _Never _Don’t know How often in the past 12 months have you had alcohol and taken a drug or medication on the same occasion? __ Every day ——Sor6timesaweek ___2to4 times a week _Onceaweek ___2to3timesamonth ___Once a month ——Lessthan once amonth _Never __Don't knowRequest for Proposal #2626 Schedule G 14. Please indicate with an X when you last used each of the following medications/drugs: Over Within | Within | Within Never |12months| past past | past | Today ago | 12 months | month | week Cough/cold medicines Energy drinks |(eg, Red Bull) GHB ‘Amphetamines (Ritalin, Aderall) Muscle Relaxants (Robaxacet, Robaxasal) Anti-Depressants (Prozac, Celexa, etc.) Marijuana / hashish Synthetic Cannabis/Stimulants (K2, Spice, Bath Salts, etc.) Cocaine (crack or coke) Ecstasy Sedatives (Valium, Zolpidem) Methamphetamine Heroin, methadone Prescription pain medicationsSchedule G Request for Proposal #2626 wD: Manitoba Roadside Interview 2016 | sy. Diverse ME Vetidetype: Gr Van Mian Ficup SW Motorele ‘capant Configuration: Seat vee use 1 Driver only ‘2, Family (with kids) Driver: Y oN UK 23. Apes if sex 4. 2pas. sme sex ‘5. Group, diff. sex 6. Group, same sex Pass Y oN UK Where are you coming tromt 1 Work 4 Restaurant 7. Sports/recrestion 2 Home ‘S. Bar/pub/nightclub & Other 2 eniratie 5 Mowe Where are you going? 1 Work 4. Rescue 2, ‘Sporejrecenson 2 Home ‘5. Bar/pub/nightclub 8. Other, 3. Friend/reiative ‘& Movie Inwhat ear were youbor? Doyouhaveaninemedaetiansa? YN How likely do you think itis for a person who fas had too much to drink to be stopped by police? {1 =enaremely unikety, 7= extremely likely) How likely do you think itis fora person who drives after using drugs to be stopped by police? {1-=earemely unikety, 7= extremely likely) Now for a question about alcohol: Have you had anything to drink in the last 12 hours? O=No | 1=Yes- How long ago did you Fish your last drink? hs. _min. Where did you do most of your drinking tonight? LBs 2 Restaurant/bar 3.Ownhome 4 Friend/relative's 5. Other. Refused: Interview BAC Saliva Questionnaire Language 2imahury 3. Notinterested Place matching ora fluid sticker here 4. Co rights 5. Fear of prosecution 6. Other,