Arizona Tea Questionnaire

DIRECTIONS
• Use a #2 pencil
• Make no stray marks
• Fill in the circles completely

Please shade bubbles like this:

and not like this: ✓ ✗

USE A NO. 2 PENCIL ONLY

Part 1: Demographics
Please print your Name, Today's Date, Phone
Number, Age, and Sex in the boxes provided.
1. Name:

Month Day Year

2. Today's Date: 2
3. Phone Number: ( ) – OFFICE USE ONLY
STUDY ID NUMBER STAGE
3/8" PERF

4. Age: years old

0 0 0 0 0 0 0 0 0 0 0 0
1 1 1 A A A 1 1 1 1 1 1 1 1 1 1
2 2 B B B 2 2 2 2 2 2 2 2 2 2
3 3 C C C 3 3 3 3 3 3 3 3 3 3
4 4 D D D 4 4 4 4 4 4 4 4 4 4
5 5 E E E 5 5 5 5 5 5 5 5 5 5
6 6 F F F 6 6 6 6 6 6 6 6 6 6
7 7 G G G 7 7 7 7 7 7 7 7 7 7
8 8 H H H 8 8 8 8 8 8 8 8 8 8
9 9 I I I 9 9 9 9 9 9 9 9 9 9
J J J

5. Sex: Male Female K K K

L L L

6a. Which of the following responses best describes M M M

N N N
your tea use or consumption in the past year O O O
(Include hot, iced, and herbal teas)? P P P

Frequent or regular tea drinker Q Q Q

Occasional tea drinker R R R

Herbal tea drinker only S S S

Never drink tea T T T

U U U

IF YOU CURRENTLY DO NOT DRINK TEA: V V V

W W W
6b. Did you used to drink tea? X X X

Yes - Go to Question 18 (Page 7) No - STOP Y Y Y

Z Z Z

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Mark Reflex® forms by Pearson NCS MM250021-1 654321 HC05 Printed in U.S.A.
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1
2 Part 2: For the following questions answer for your USUAL type of HOT tea
3
4 7a. Do you drink HOT tea?
5 Yes - Continue No - Go to Question 8a (Next Page)
6
7 IF YES:
8
9 7b. How much of the HOT tea you drink is decaffeinated?
10 None 25% 50% 75% All
11
12
13 7c. How do you usually drink your HOT tea?
14 Weak Medium Strong Very Strong
15
16
17 7d. At what temperature do you usually drink your HOT tea?
18 Room temperature Warm Hot Very Hot
19
20
21 7e. At what time of day do you usually drink your HOT tea?
22 Throughout the day With meals only Between meals only
23
24
25 7f. How do you usually prepare your HOT tea?
26 Recipe
27 Restaurant Bottled only Don't know - Go to Next Page
28
29 If RECIPE:
30

3/8" PERF
31 7g. When making HOT tea how 7h. How long do you brew your
32 much do you use? HOT tea?
33
34 bags per teaspoons minutes
35 cup per cup
36
37 0 0

38 0 0 OR 0 0 1 1

39 1 1 1 1 2 2

40 2 2 2 2 3 3

41 3 3 3 3 4 4

42 4 4 4 4 5 5

43 5 5 5 5 6 6

44 6 6 6 6 7 7

45 7 7 7 7 8 8

46 8 8 8 8 9 9

47 9 9 9 9

48
49
50 7i. Do you usually add anything to your tea?
51 Yes Sometimes
52 Never - Go to Next Page
53
54 If you add anything to your tea:
55
56 7j. What do you add to your HOT tea?
57 Citrus Herbs or herbal tea
58 Spices Milk
59 Sugars/sweeteners
60
61
62 Page 2 - Arizona Tea
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 Part 3: For the following questions answer for your USUAL type of ICED tea.

8a. Do you drink ICED tea?

Yes - Continue No - Go to Question 9 (Next Page)
IF YES:
8b. How much of the ICED tea you drink is decaffeinated?
None 25% 50% 75% All

8c. How do you usually drink your ICED tea?

Weak Medium Strong Very Strong

8d. Do you usually add ice to your ICED tea before drinking?
Yes Sometimes Never

8e. How much of your BLACK ICED tea is usually sun tea?
None 25% 50% 75% All

8f. How much of your GREEN ICED tea is usually sun tea?
days
None 25% 50% 75% All

8g. How long do you keep it refrigerated? 0 0

1 1
3/8" PERF

2 2
8h. At what time of day do you usually drink your ICED tea? 3 3

Throughout the day With meals only Between meals only 4 4

5 5
6 6
8i. How do you usually prepare your ICED tea? 7 7

Recipe 8 8

Restaurant Bottled only Don't know - Go to Next Page 9 9

IF RECIPE:
tea bags or teaspoons
8j. When making ICED tea how much do you use? per 1/2 gallon pot

8k. How long do you brew your ICED tea? minutes O hours 0 0

R 1 1
2 2
8l. Do you usually add anything to your tea? 0 0 0 0 3 3

Yes Sometimes 1 1 1 1 4 4

Never - Go to Next Page 2 2 2 2 5 5

3 3 3 3 6 6
If you add anything to your tea: 4 4 4 4 7 7

5 5 5 5 8 8
8m. What do you add to your ICED tea? 6 6 6 6 9 9

Citrus Herbs or herbal tea 7 7 7 7

Spices Milk 8 8 8 8

Sugars/sweeteners 9 9 9 9

Page 3 - Arizona Tea

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1 PLEASE DO NOT MARK IN THIS AREA

2 SERIAL #
3
4
5 Part 4: The next questions ask about your use of various types of tea during
6 the past year.
7
8 9. How often do you usually drink the following teas IN THE SUMMER?
9 Please fill in a
Less 1-3 1 2-3 4-6 1-2 3+
10
response for each than cups cup cups cups cups cups
11
12
type of tea. Never/ 1 cup/ per per per per per per
rarely month month week week week day day
13
14 HOT Black Tea
15
16 ICED Black Tea
17
18 HOT Green Tea
19
20 ICED Green Tea
21
22 HOT Herbal Tea
23
24 ICED Herbal Tea
25
26
27 10. How often do you usually drink the following teas IN THE WINTER?
28 Please fill in the
Less 1-3 1 2-3 4-6 1-2 3+
29
correct answer than cups cup cups cups cups cups
30

3/8" PERF
31
for each type of tea. Never/ 1 cup/ per per per per per per
rarely month month week week week day day
32
33 HOT Black Tea
34
35 ICED Black Tea
36
37 HOT Green Tea
38
39 ICED Green Tea
40
41 HOT Herbal Tea
42
43
ICED Herbal Tea
44
45
46
11. When you drink tea, how much do you usually drink?
47
Please fill in the correct answer Large Large
48 for each type of tea. Teacup Mug Mug Glass Glass
None (7 oz.) (9 oz.) (11 oz.) (12 oz.) (16 oz.)
49
50
HOT Black Tea
51
52
ICED Black Tea
53
54
HOT Green Tea
55
56
ICED Green Tea
57
58
HOT Herbal Tea
59
60
ICED Herbal Tea
61
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12. Of the tea you drink what percentage is from BAGS, LOOSE, INSTANT and
BOTTLED/CANNED? If 0%, leave the box blank.

HOT Black Tea ICED Black Tea

Bottled/ Bottled/
Bags Loose Instant Canned Bags Loose Instant Canned
% % % % % % % %

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

HOT Green Tea ICED Green Tea

Bottled/ Bottled/
Bags Loose Instant Canned Bags Loose Instant Canned
3/8" PERF

% % % % % % % %

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

HOT Herbal Tea ICED Herbal Tea

Bottled/ Bottled/
Bags Loose Instant Canned Bags Loose Instant Canned
% % % % % % % %

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

Page 5 - Arizona Tea

Part 5: The following questions are about your LIFETIME
CONSUMPTION of tea.

years
13. For how many years have you been drinking tea?
0 0
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9

years
14. How many years did you drink tea before you were age 25?
0 0
1 1
2 2
3 3
4 4
5 5
6 6
7 7

3/8" PERF
8 8
9 9

cups per
15. On average, how many cups of tea do you
month
usually drink per month?
0 0
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8

16. What brand do you usually use? 9 9

17. Is the pattern you have described for the past year similar
to this lifetime pattern?
Yes

No - Describe Changes:

THANK YOU FOR YOUR TIME. STOP HERE.

Page 6- Arizona Tea
 The following questions are for those who are currently non-tea drinkers.
years
18. How many years did you drink tea before stopping?
0 0
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9

19. How many years did you drink years

tea before you were age 25?
0 0
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
3/8" PERF

9 9

20. When you were drinking tea, how many cups of cups per
tea did you usually drink per month? month

0 0
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9

21. What type of tea were you usually drinking?

Black Green Herbal Mix

22. Why did you quit?

Health problems
Didn't like taste
Other (Specify: )

THANK YOU FOR YOUR TIME. STOP HERE.

Page 7- Arizona Tea
 OFFICE USE ONLY:
Interview Admin.
Method: by: Form Status: Collapsed:
Office visit Tech ____________ Admin. by_________ Y
Init.
Phone Self 0 0 N
Mail Guardian 1 1

Other Other 2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9

Form Status: QC:_____

Tech. ID MO DAY YEAR
QA:_____
Tech. ID MO DAY YEAR
Init. Init.

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4 4 4 4 4 4 4
5 5 5 5 5 5 5 5 5 5 5 5 5 5
6 6 6 6 6 6 6 6 6 6 6 6 6 6
7 7 7 7 7 7 7 7 7 7 7 7 7 7
8 8 8 8 8 8 8 8 8 8 8 8 8 8
9 9 9 9 9 9 9 9 9 9 9 9 9 9

3/8" PERF

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