Driver Impairment Index

Instructions
Many statements in this booklet are
personal. Your answers are confidential.
Your court and/or driving records may be
used to check your answers.
Any
dishonesty will likely be detected. Read
each statement carefully and choose the
answer that is accurate for you.
Section 1. The statements in this section are
to be answered true or false. If a statement is
true, put an X under T for True, if a statement
is false, put an X under F for False
1. I have been offended and hurt by what
someone has said about me.
2. There are times when I feel guilty about my
drinking.
3. I use and sometimes abuse drugs.

16. I have been told I have a drug problem.

17. There are times when I am really down
depressed and discouraged.
18. I am concerned about my drinking.
19. A family member has said I should get help
for my drug use.
20. When offered marijuana, I may or may not
use it. It depends on how I feel at the time.
21. I have done things when angry that I later
regretted.
22. My drinking is more than just a little or minor
problem.
23. My use of drugs has caused family and social
problems for me.
24. I have used marijuana more than I should.
25. There are times I really worry about my
responsibilities.

4. I have been irritated, frustrated and angered

by other drivers.

26. I have a drinking problem.

5. Within the last year my family has shown

concern about my drinking.

27. Compared to others, I smoke a lot of

marijuana.

6. I smoke marijuana (pot, weed or cannabis) to

get high, relax and feel good.

28. I have done things that were wrong and I was

not caught.

7. I am concerned about my use of drugs.

29. I have had a drug abuse problem in the past.

8. Even though I was not caught, I have made

mistakes while driving that were my fault.

30. I have lied about my use of marijuana, either

minimizing how much I use, or hiding the fact
that I use marijuana at all.

9. I have been told I have a drinking problem.

10. There are times when I feel guilty about my
using drugs.

31. It bothers me when I am overlooked or

ignored by people I know.
32. My drinking is a serious problem.

11. Sometimes I worry about what others think or

say about me.
12. In the last year drinking has been a problem
for me.
13. I have used drugs excessively or more than I
should.

33. I have gone to someone for help with my drug

problem.
34. My marijuana smoking has greatly increased
in the last year.
35. There have been times while driving when I
have been angry and upset.

14. I use and sometimes abuse marijuana.

15. I have lied about my drinking, either
minimizing how much I drink or hiding the fact
that I drink at all.

36. I go to Alcoholics Anonymous (AA) meetings

for help with my drinking.
37. Within the last year I have had persistent
cravings and strong urges for drugs.

38. I have used marijuana in potentially

dangerous situations like before driving,
boating or drinking.
39. There have been times when I have gotten
very angry at another driver.
40. Drinking has interfered with my happiness
and success in life.
41. There are times at home when I get really
frustrated and angry.
42. I go to Narcotics Anonymous (NA) or Cocaine
Anonymous (CA) meetings for help with my
drug problem.
43. There are times when I am discouraged and
unhappy.
44. I need help to overcome my drinking problem.
45. My use of drugs has threatened my
happiness and success in life.
46. In the last year using drugs has been a
problem for me.
47. I have a marijuana problem.
48. I have been embarrassed and uneasy about
some of the things I have done while driving.
49. My drinking has caused family and social
problems for me.
50. I am concerned that others may think badly of
me.
51. I have a drug problem.
52. I often drink more (or for longer periods) than
I intended.
53. I have been diagnosed drug dependent.
54. I have asked for help with my drinking
problem.
55. There are times when I really worry about
myself and my happiness.
56. I was cited for Evading Law Enforcement
during my present DUI.
57. In my present arrest I was charged with
felony DUI.

Section 2.
The statements in this section
describe you or your situation. Put an X in the
box next to the number (1, 2, 3 or 4) that is
accurate for you.
58. How would you describe your marijuana
use?
1. Frequent and excessive
2. Daily or everyday
3. Occasionally or infrequently
4. Dont smoke marijuana
59. How would you describe your drug use?
1. A serious problem
2. A moderate problem
3. A mild problem
4. Not a problem
60. How would you describe your drinking?
1. A serious problem
2. A moderate problem
3. A mild problem
4. Not a problem
61. Recovering means having a substance
abuse problem, but not drinking or
abusing drugs anymore. I am a
recovering:
1. Alcoholic
2. Drug abuser
3. Both 1 and 2
4. None of the above
62. My present DUI was for Drugs, My
Chemical Test Results were:
1. Positive (drugs were found in my
system)
2. Negative (no drugs were found in my
system)
3. I refused to take a chemical test
4. This does not apply to me
63. When asked to submit to a chemical test, I:
1. Completed a Blood Test
2. Completed a Breath Test
3. Completed a Urine Test
4. Refused to complete a Preliminary
Alcohol Screen (PAS) or chemical test
64. At the time of my present DUI my drivers
license was:
1. Suspended
2. Revoked
3. Restricted
4. None of the above
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DII Answer Sheet

Accurately Complete the Following Information
Name:_____________________________________________
Drivers License / ID#:_________________________________

Section 1
If a statement is True, put an X under T
for True. If a statement is False, put an X
under F for False.
T F
T F
T F
1. ___ ___ 20. ___ ___ 39. ___ ___

Date of Present DUI: ____ / ____ / ____

Age:__________

2. ___ ___ 21. ___ ___ 40. ___ ___

County of Arrest:_____________________

Sex:__________

3. ___ ___ 22. ___ ___ 41. ___ ___

Ethnicity (Race):__________

Date of Birth: ____ / ____ / ____

4. ___ ___ 23. ___ ___ 42. ___ ___

Marital Status:___________

Todays Date: ____ / ____ / ____

5. ___ ___ 24. ___ ___ 43. ___ ___

Education (Highest Grade Completed): ____________________

6. ___ ___ 25. ___ ___ 44. ___ ___

INSTRUCTIONS: Answer each statement truthfully and honestly. Your

court or driving records may be used to check your answers. If the
answer is none, put in a zero (0), if you dont know put in a DK. All items
must be answered. The symbol # can be used for the word Number. All
of the following items refer to either your Present Arrest or The Last 10
Years.

7. ___ ___ 26. ___ ___ 45. ___ ___

8. ___ ___ 27. ___ ___ 46. ___ ___
9. ___ ___ 28. ___ ___ 47. ___ ___

1. Blood Alcohol Content at Time of Present DUI: __.__ __

10. ___ ___ 29. ___ ___ 48. ___ ___

2. Number (#) of Prior DUI/DUID Convictions in the Last 10

Years (not including present DUI):.................................._____

11. ___ ___ 30. ___ ___ 49. ___ ___

3. # of Probation Revocations in Last 10 Years:.................._____

12. ___ ___ 31. ___ ___ 50. ___ ___

4. # of Alcohol (not DUI) Arrests in Last 10 Years: .............._____

13. ___ ___ 32. ___ ___ 51. ___ ___

5. # of Drug (not DUI) Arrests in Last 10 Years: .................._____

14. ___ ___ 33. ___ ___ 52. ___ ___

6. # of Marijuana (Not DUI) Arrests in Last 10 Years: ........._____

15. ___ ___ 34. ___ ___ 53. ___ ___

7. # of Victims with Bodily Injury in Present DUI:................._____

8. # of At-Fault Accidents (Collisions) in last 12 months: ...._____
9. # of Licensed Education/Counseling/Treatment DUI Programs
Completed: ....................................................................._____
10. Present DUI in Double Fine Zone: ................... Yes -- No
11. During Present DUI, Involved in Speed Contest:
................................................................................ Yes -- No
12. I Presently Have a Commercial Motor Vehicle License:
................................................................................ Yes -- No
13. I Have Had a Prior Felony DUI within the last 10 years:
.............................................................................. Yes -- No
14. Designated Habitual Traffic Offender at Time of Present
DUI: ................................................................ Yes -- No

16. ___ ___ 35. ___ ___ 54. ___ ___

17. ___ ___ 36. ___ ___ 55. ___ ___
18. ___ ___ 37. ___ ___ 56. ___ ___
19. ___ ___ 38. ___ ___ 57. ___ ___
Section 2
Put an X under the number (1, 2, 3 or 4)
that is accurate for you.
1
2
3
4
58. _____ _____ _____ _____
59. _____

_____

_____

_____

15. I was on DUI Probation at the Time of My Present DUI Arrest:

........................................................................ Yes -- No

60. _____

_____

_____

_____

16. Minor (under 14 years of age) was a Passenger in Vehicle

During Present DUI: ........................................ Yes -- No

61. _____

_____

_____

_____

62. _____

_____

_____

_____

63. _____

_____

_____

_____

64. _____

_____

_____

_____

17. Excessive Speed (Citation or Ticket) at Time of Present DUI:

........................................................................ Yes -- No
18. Reckless Driving Violation (Citation or Ticket) During Present
DUI: ................................................................. Yes -- No

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