(1) Heavy Alcohol Use: 

On about how many days did you have five or more drinks of beer, wine, or liquor on the same occasion during the past 30 days? (Again, by drink we mean a can of bottle or beer, a glass or wine or champagne, a shot glass of hard liquor, or a mixed drink, like a glass of gin and tonic. By "occasion" we mean at the same time or within a couple of hours or each other.)

(2) Current and Past Year Illicit Drug Use:

When was the most recent time that you used [name of drug]? (note: the questions that asked about prescription-type drugs such as analgesics, sedatives, and tranquilizers specified use for non-medical reasons and excluded over-the-counter drugs).

(3) Drug Testing: 

During the past 12 months, have you been required by your employer to take a drug test?

(4) Age: What is your date of birth?

(5) Marital Status: Which of the following best describes your current marital status?

Married,

Widowed,

Divorced or separated, or

Have you never married?

(6) Work Status: Which of the statements describes your present work situation:

Working Full-Time, 35 or more hours per week;

Working Part-Time, Less than 35 hours per week;

Have a job, but not at work because of extended illness, maternity leave, furlough, or strike;

Unemployed or laid off and looking for work;

Unemployed and not looking for work;

Full-Time homemaker;

In school only;

Retired;

Disabled, not able to work;

Or something else?

(7) Occupation: What is/was your occupation or job title?

(8) Occupation: What kind of work (are/were) you (last) doing; that is, what (are/were) your most important activities or duties in your job?

(9) Industry: In what type of business or industry (is/was) this; that is, what product (is/was) made or what service (is/was) offered?

(10) Number of jobs: How many different jobs have you had in the past five years?

(11) Missed work due to illness or injury:

During the last 30 days, how many days of work did you miss because you were sick or injured?

(12) Skipped work: During the last 30 days, how many days of work did you miss because you just didn't want to be there?