Alcohol and Substance Use Survey
We are gathering data on Hmong in the Fox Valley area's use of Alcohol and other Substances. This is a project we are working on in conjunction with WUCMAA and the Wisconsin Department of Tobacco and Alcohol. We are a small minority group here in Wisconsin and there is no data that measures Alcohol and substance use and how it affects the Hmong community here in Wisconsin. We would like your assistance in helping us collect this data.

Please help us with this project by filling out the survey below honestly. All surveys are anonymous.

Hmong American Partnership Fox Valley, Inc
1. Do you identify as Hmong? *
2. Do you reside in the Fox cities (Appleton, Neenah, Menasha, Grand Chute, Kaukauna, Hortonville and the surrounding cities)? *
3. Are you: *
4. How old are you as of September 1, 2017? (please specify age in years) *
Your answer
5. What is your marital status? *
6. In which country were you born? *
7. If you were born outside of the United States, in what year did you arrive in the United States?
Your answer
8. What is the highest level of education you have completed? *
9. During the last 12 months, have you had any alcoholic beverages to drink such as beer, wine, wine coolers, mixed drink and/or liquor? *
10. How old were you when you first drank an alcoholic beverage?
Your answer
11. During a typical day, about how many alcoholic drinks do you consume per day? By a drink, I mean a 12 oz. beer, a 5 oz. glass of wine, or 1.5 ounces of liquor. (Please specify number of drinks) *
Your answer
12. If you currently drink alcohol, do you consider yourself a heavy drinker, moderate drinker, or light drinker? *
13. During the last 12 months, have you tried to quit drinking alcohol?
14. During the last 12 months, have you used any of the following? [Check all that apply] *
15. If you have used any of the drugs above more than once, what is your reason to keep using the drug? [Check all that apply]
16. How easy or difficult was it for you to get the drug(s)?
17. During the last 12 months, have you tried to quit using any of the following? [Check all that apply]
18. Have you ever been diagnosed with any of the following health problems? [Check all that apply]
19. How much is your monthly personal income before taxes? *
20. Have you had any alcohol or drug related citation or conviction? *
Thank you for taking your time to help us with this survey. If you have comments or feedback regarding this survey, please respond below.
Your answer
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