EXIT INTERVIEW

JACKSON-BIBBY AWARENESS GROUP

DRINKING DRIVING PROGRAM, SAN BERNARDINO COUNTY
EXIT INTERVIEW
Today's Date*

MonthDayYear
Date
Date of Last Drink*

MonthDayYear
Date
Number of DDP group meetings you have attended*
Read the statement and check the answer that best fits you.
1. Since Entering the DDP, my health has been*

BetterSameWorse
2 . Since Entering the DDP, my family life has been*

BetterSameWorse
3. Since Entering the DDP, my financial situation has been*

BetterSameWorse
Check the answer that best fits you.
4. I feel depressed or blue.*

Very OftenOftenSometimesRarelyNever
5. I have a sense of well being.*

Very OftenOftenSometimesRarelyNever
6. This program has helped me understand the effect of alcohol on my life.*

Strongly AgreeAgreeUncertainDisagreeStrongly Disagree
7. This program is a waste of time.*

Strongly AgreeAgreeUncertainDisagreeStrongly Disagree
8. The staff have treated me fairly.*

Strongly AgreeAgreeUncertainDisagreeStrongly Disagree
9. I have a drinking problem.*

Strongly AgreeAgreeUncertainDisagreeStrongly Disagree
10. As a result of participation in this program, my drinking has been*

Reduced to zeroReducedUnchangedIncreased
11. As a result of participation in this program, my drinking & driving has been…*

Reduced to zeroReducedUnchangedIncreased
Thank you for your help. Any comments?*
Location*
Name*

First NameLast Name
Email*
example@example.com
On submitting the form, the form(s) will be emailed directly to Jackson-Bibby.
Should be Empty:

JACKSON-BIBBY AWARENESS GROUP