ALCOHOL CONSUMPTION INTERVIEW / INTERROGATION Page 1 of 5

INTERVIEW

MEDICAL

Have you been cleared as being physically fit to perform the duties of __________? YES NO
Did your background investigation include a physical assessment? YES NO
Did it show you have been medically cleared for the duties of _______? YES NO
Can you state there are NO physical limitations that would preclude you
from performing the duties? YES NO

Do you take any medications for any medical condition? YES NO
If yes: what ________________________________________
where ________________________________________
when ________________________________________
why ________________________________________
how much ________________________________________
how many ________________________________________

Have you taken any prescribed medications today? YES NO

If yes: what ________________________________________
where ________________________________________
when ________________________________________
why ________________________________________
how much ________________________________________
how many ________________________________________
If yes: Do you feel the effects of the medication at this time
what ______________________________________________
how ______________________________________________

Have you taken any type of medication or drugs today, over the counter or otherwise? YES NO
If yes: what ________________________________________
where ________________________________________
when ________________________________________
why ________________________________________
how much ________________________________________
how many ________________________________________
If yes: Do you feel the effects of the medication at this time
what ______________________________________________
how ______________________________________________

Can you state that you are NOT under the influence of any drugs or medication at this time? YES NO
ALCOHOL CONSUMPTION INTERVIEW / INTERROGATION Page 2 of 5

ALCOHOL
Do you drink alcoholic beverages? This is a YES OR NO question YES NO
If yes: with whom ________________________________________
what ________________________________________
where ________________________________________
when ________________________________________
why ________________________________________
how much ________________________________________
how many ________________________________________

Do you have any alcoholic beverages in your private residence? YES NO
If yes: what ________________________________________
where ________________________________________
when ________________________________________
why ________________________________________
how much ________________________________________
how many ________________________________________

Do you consume any alcoholic beverages in your private residence? YES NO
If yes: what ________________________________________
where ________________________________________
when ________________________________________
why ________________________________________
how much ________________________________________
how many ________________________________________

Do you have any alcoholic beverages at your workplace? YES NO

If yes: what ________________________________________
where ________________________________________
when ________________________________________
why
how much ________________________________________
how many ________________________________________

Do you consume any alcoholic beverages at your workplace? YES NO

If yes: with who ________________________________________
what ________________________________________
where ________________________________________
when ________________________________________
why ________________________________________
how much ________________________________________
how many ________________________________________
ALCOHOL CONSUMPTION INTERVIEW / INTERROGATION Page 3 of 5

Do you consume any alcoholic beverages during the day YES NO
If yes: with who _________________________________________
what _________________________________________
where _________________________________________
when  morning  brunch  lunch time
 mixers  cocktail hours  after hours
why _________________________________________
how much _________________________________________
how many _________________________________________

Do you consume any alcoholic beverages during the evening? YES NO
If yes: with who _________________________________________
what _________________________________________
where _________________________________________
when _________________________________________
why _________________________________________
how much _________________________________________
how many _________________________________________

Do you consume any alcoholic beverages at night? YES NO

If yes: with who _________________________________________
what _________________________________________
where _________________________________________
when _________________________________________
why _________________________________________
how much _________________________________________
how many _________________________________________

Can you state that you are sober right now? YES NO
Do you feel the effects of alcohol at this time YES NO
If yes: what ________________________________________
how ________________________________________
ALCOHOL CONSUMPTION INTERVIEW / INTERROGATION Page 4 of 5

INTERROGATION
Have you consumed any alcoholic beverage today? YES NO
If yes, with who
what ________________________________________
where ________________________________________
when ________________________________________
why ________________________________________
how much ________________________________________
how many ________________________________________

When did you have your last drink?

when specifically at what time ______________________
with whom name(s) of participants ______________________
what specific drink ______________________
where specific location ______________________
why occasion: ______________________
how much specific number ______________________
how many specific number ______________________

Have you abstained from consuming alcohol today? YES NO

If no,: Do you feel the effects of alcohol at this time YES NO
If yes: what ________________________________________
how ________________________________________

When is the last time you abstained from drinking alcoholic beverages
When ______________________________________________
For how long ______________________________________________

When did you last consume an alcoholic beverage

When ______________________________________________

How often do you drink

Number of times per day __________________________________
Number of times per week __________________________________
Number of times per month __________________________________

When is the last time you were sober for more than
one day ______________________________________________
three days ______________________________________________
a week ______________________________________________
a month ______________________________________________
a year ______________________________________________
ALCOHOL CONSUMPTION INTERVIEW / INTERROGATION Page 5 of 5

When is the last time you abstained from consuming alcohol for
one day _____________________________
two days _____________________________
three days _____________________________
a week _____________________________
a month _____________________________
a year _____________________________

Is that to say you have not been sober for more than
one day _____________________________
two days _____________________________
a week _____________________________
a month _____________________________
a year _____________________________

Why do you drink alcoholic beverages?

1.) _____________________________________
2.) _____________________________________
3.) _____________________________________
4.) _____________________________________
5.) _____________________________________

Is there any anything you would like to say or add regarding this interview?
1.) _____________________________________
2.) _____________________________________
3.) _____________________________________
4.) _____________________________________
5.) _____________________________________