Age: _________ Gender: ( ) Female ( ) Male Year level: ___________

Part I. Instructions: This is a 7-point likert scale which ranges from very wrong to very true
based on how you deal with certain situations in life. Please put a checkmark () on the
column of your answer based on the legend below: (only one checkmark per item.)
1 = very wrong 5 = slightly true
2 = moderately wrong 6 = moderately true
3 = slightly wrong 7 = very true
4 = neutral
STATEMENTS 1 2 3 4 5 6 7
1. I feel like I am free to decide for myself how to live my life.
2. I really like the people I interact with.
3. Often, I do not feel very competent.
4. I feel pressured in my life.
5. People I know tell me I am good ate what I do.
6. I get along with people I come into contact with.
7. I pretty much keep to myself and dont have a lot of social
contacts.
8. I generally feel free to express my ideas and opinions.
9. I consider the people I regularly interact with to be my friends.
10. I have been able to learn interesting new skills recently.
11. In my daily life, I frequently have to do what I am told.
12. People in my life care about me.
13. Most days I feel a sense of accomplishment from what I do.
14. People I interact with on daily basis tend to take my feeling
into consideration.
15. In my life, I do not get much of a chance to show how
capable I am.
16. There are not many people that I am close to.
17. I feel like I can pretty much be myself in my daily situations.
18. The people I interact with regularly do not seem to like me
much.
19. I often do not feel very capable.
20. There is not much opportunity for me to decide for myself
how to do things in my daily life.
21. People are generally pretty friendly towards me.
Part II. Instructions: This is a 5-point likert scale which ranges from not at all to extremely
responses for the following statements assessing your self-evaluation. Please put a checkmark
() on the column of your answer based on the legend below: (only one checkmark per item.)
1 = not at all 4 = very much
2 = a little bit 5 = extremely
3 = somewhat

STATEMENTS 1 2 3 4 5
1. I feel confident about my abilities.
2. I am worried about whether I am regarded as a success or a
failure.
STATEMENTS 1 2 3 4 5
3. I feel satisfied with the way my body looks right now.
4. I feel frustrated or rattled about my performance.
5. I feel that I am having trouble understanding things that I read.
6. I feel that others respect and admire me.
7. I feel dissatisfied with my weight.
8. I feel self-conscious.
9. I feel as smart as others.
10. I feel displeased with myself.

Part III. Instructions: These questions are about your experiences upon drinking beverages with
alcoholic content. Please put a checkmark () for yes if you agree with the statements or
no if otherwise. (Only one checkmark per item.)

STATEMENTS YES NO
1. Do you enjoy drinking now and then?
2. Do you feel you are a normal drinker? (normal- drink as
much or less than most other people)
3. Have you ever awakened the morning after some drinking the night before
and fount that you could not remember a part of the evening?
4. Does your mother, father, or other relative ever worry or complain about
your drinking?
5. Can you stop drinking without a struggle after one or two drinks?
6. Do you ever feel guilty about your drinking?
7. Do friends or relative think you are a normal drinker?
8. Are you able to stop drinking when you want to?
9. Have you ever attended a meeting of Alcoholics Anonymous?
10. Have you gotten into physical fights when drinking?
11. Has your parent (or other family member) ever gone to anyone (e.g.
therapist) for help about your drinking?
12. Has your drinking ever created a problems between you and your mother,
father or other relative?
13. Have you ever lost friend/s because of your drinking?
14. Have you ever gotten into trouble at school because of drinking?
15. Have you failed at school because of drinking?
16. Have you ever neglected your obligations, your family or your studies for
two or more days in a row because you were drinking?
17. Do you drink before noon fairly often?
18. Have you ever been told you have liver trouble? (e.g. cirrhosis)
19. After drinking, have you ever experienced severe sweating, severe shaking
or heard voices or seen things that are really not there?
20. Have you ever gone to anyone for help about your drinking?
21. Have you ever been in a hospital because of drinking?
22. Have you ever been a patient in a psychiatric hospital or on a psychiatric
ward of a general hospital where drinking was part of the problem that
resulted in hospitalization?
23. Have you ever been seen at a psychiatric or mental health clinic or gone to
any doctor, social worker, or clergyman for help with any emotional
problem, where drinking was part of the problem?
24. Have you ever been arrested for drunk driving, driving while intoxicated,
or driving under the influence of alcoholic beverages? (If YES, How many
times? ___ )
25. Have you ever been arrested, or taken into custody even for a few hours,
because of other drunk behavior? (If YES, How many times? ___)

INFORMED CONSENT FOR ACTUAL STUDY

Title of Research: Psychological needs, Self-esteem and Alcohol Use among College Students
Investigators: Krishna Jem D. Asiain (0923 546 8949), Reine Chiara B. Concha (0932 264
4895), Ma. Angelica S. Cornista (0999 928 5327) and Gemvirle A. Tan (0942 466 8292), Third
Year Students, College of Nursing, Velez College
Purpose and Background: The purpose of this study is to determine the two relationships.
Firstly, the relationship between psychological needs and self-esteem. Secondly, the
relationship between self-esteem and alcohol use among college students. The study conducted
is an academic requirement for the Nursing Research 1 subject. All data collected through the
use of questionnaires will used as findings for the study.
Procedure: A stratified random sampling will be used for the study. This sampling method
will take a sample population from each college equal to their percentage based on the
total population of Velez College so that each college will be represented equally. A
total of 323 respondents will be needed in the study through the use of the Slovins
formula. The researchers will select class sections randomly based on their availability
and willingness to participate in the study.
If you agree to participate, the following things shall happen:
1. You will have to sign this consent form indicating that you agree to participate.
2. You will have to answer 3 questionnaires. The first questionnaire is a 21 item form
which will inquire regarding how well each psychological needs is generally satisfied
your daily life. It is answered through a 7-point Likert scale ranging from 1 for very
wrong to 7 for very true. It is then followed by a 10 item questionnaire that will ask
your subjective emotional evaluation of self. In answering this you will have to choose
if the questions apply to you in manner from Not at all to Extremely 5-point scale.
Lastly, the third questionnaire is a 24-item yes or no test which will revolve
around alcohol-related problems and practices. The data collection will only be at
taken at one point and it will only take about 15 min to accomplish.

Potential Risk: There may be risk that you may find some sensitive questions regarding self-
esteem and alcohol use in the questionnaires. If you are not comfortable with the questions,
you may inform the researchers and withdraw your participation from the study. However,
there are no obvious physical, psychological, social and economic risks identified so far.
Potential Benefit: The study will provide information with regards to the relationship of
psychological needs, self-esteem and alcohol use. It will give the readers necessary
insights on how the psychological concepts can affect an individuals alcohol use and
provide them rich information regarding the three different variables that may be of
help to their alcohol use practices.
Confidentiality: The questionnaires will not require the names of the respondents instead, a
control number will be assigned to each questionnaire. The questionnaires will be placed on a
locked cabinet and will be shredded after the duration of the research study. The data will be
stored in a password protected computer. All information obtained in this study will be
considered confidential and used only for research purposes. However, if you wish to know the
result of the study, you may contact the researchers through their mobile numbers provided
above.
Questions: KRISHNA JEM D. ASIAIN, REINE CHIARA B. CONCHA, MA. ANGELICA S.
CORNISTA AND GEMVIRLE A. TAN, the researchers, has discussed these necessary
information with you and offered to answer your questions. You can contact them through their
given mobile numbers.
Right to Refuse or Withdraw: Your participation in this study is entirely voluntary, and you
are free to refuse to take part of it or withdraw at any time without any consequences.
Consent: You agree to participate in this study. You have been given a copy of this form and
had the chance to read it.
This study has been approved by the Velez College Ethics Review Committee (VCERC). For
more information, you may contact:
Dr. Johnny J. Yao Jr.
79 F. Ramos St. Cebu City
Email: velezerc@gmail.com
Telephone Number: 253-7388

Signature of Participant: _________________________

Year and Section: __________ Gender:_____ Age:______ Date:____________

Asiain, Krishna Jem D. Concha, Reine Chiara B.

Researcher Researcher

Cornista, Ma. Angelica S. Tan, Gemvirle A.

Researcher Researcher