SAI

Instructions
Some problems are barriers to employment
and the quicker they are identified the faster
staff can help you work them through. The
goal is to help you get a decent job and
succeed in your career.

Section 1
The following statements should be
answered true or false. If a statement is true
put an X under T for True on your answer
sheet. If a statement is false put an X under
F for False.
1. There are times when I worry about
what people think or say about me.
2. Sometimes I drink too much.
3. When I wake up I usually look
forward to each day.

The Self-Assessment Index (SAI) screens

barriers to employment such as negative
attitudes,
alcohol
and
other
drug
involvement or difficulties handling stress.
Your help in providing honest answers to
many personal questions is needed if we
are to help you attain your vocational goals.

4. Many of my friends use drugs.

Towards that end, the SAI has a

Truthfulness Scale built-in to measure how
open, honest and cooperative you are. Your
records may also be reviewed to verify the
information you provide. It is in your best
interest to be honest and cooperative while
completing the SAI. It is important that you
answer items truthfully and do not attempt
to minimize or deny problems. As noted
earlier, the goal is to help you get a decent
job and succeed in your career.

8. I have used drugs like pot, crack,

cocaine or heroin.

Read each item slowly to avoid mistakes.

There are no trick questions. Mark your
answer with an X on your answer sheet.
When you understand these instructions you
may begin.

5. I get upset when people criticize me.

6. I am concerned about my drinking.
7. People say I let too many little things
bother me.

9. There are times when I am really

down, depressed and discouraged.
10. I am a recovering alcoholic. I had
an alcohol problem but do not drink
anymore.
11. I am not happy with my life.
12. When offered drugs I may or may not
use them. It depends on how I feel at
the time.
13. It bothers me when my friends
overlook or ignore me.
14. A close family member told me to get
help for my drinking problem.

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15. People close to me say I

demanding and even controlling.

am

16. I have had a drug abuse problem in the

past.
17. There are times when I get really
frustrated and angry.
18. I have lied to people about my use of
drugs.
19. I have wished I could win the lottery
and pay off my debts.
20. Drinking has been a problem for me.
21. A lot of people irritate me and make
me angry.
22. I have done some things when angry
or mad that I later regretted.
23. I have attended Alcoholics Anonymous
(AA) meetings for help with my
drinking.
24. Many of my friends and relatives get
unemployment or welfare checks.
25. A family member has said that I
should get help for my drug use.
26. I do not always tell the whole truth
when asked about my money
problems.

31. I have admitted to a family member

that I have a drinking problem.
32. I dont keep jobs very long.
33. I only smoke pot (marijuana) socially.
34. There have been times when I have
been jealous or resentful of others.
35. When I drink I often seem like a
different person.
36. I have been told I have a negative
attitude.
37. I have been treated for a drug problem.
38. There are times when I really worry
about my life and what will happen to
me.
39. In the last year, using drugs has been a
problem for me.
40. I have been embarrassed and worried
about mistakes I have made.
41. My family and friends do
encourage me to improve myself.

not

42. There are times when

discouraged and unhappy.

am

43. Drinking has interfered with my

happiness and success in life.

27. I have been told I have a drinking

problem.

44. There have been times when I have

lied to members of my family.

28. It is not fair that some people have so

much more than others.

45. When annoyed or frustrated I tend to

fly off the handle and lash out at
others.
46. There are times when I am concerned
that others may not approve of me.

29. My use of drugs has threatened my

happiness and success in life.
30. I was not caught for some of the things
I have done that were wrong.

47. I have a drug problem.

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48. Sometimes I worry about myself and

my future.
49. My drinking is more than just a little
or minor problem.
50. In the past I couldnt make enough
money to make working worthwhile.
51. I am in treatment for a drug problem.

Section 2
Rate yourself by selecting the answer (1,2,3
or 4) that is accurate for you.
1. Rare or Never
2. Sometimes

3. Often
4. Very Often or Always

Put an X on your answer sheet under the

number (1, 2, 3 or 4) that is accurate for you.

52. At times I get angry and upset at

myself.

62. Positive Attitude / Outlook

53. I have asked for help with my

drinking.

64. Satisfied with Self / Like Self

54. I lose my temper quickly.

63. Dissatisfied with Life

65. Good Sense of Humor / Laugh
66. Difficulty with Others / Conflict

55. There have been times when I have

felt guilty about using drugs.

67. Anxious / Worried / Fearful

56. I worry about getting a good job and

keeping it.

69. Tension / Stress / Nervous

57. I have a drinking problem.

70. Insomnia / Trouble Sleeping

58. Two or more of the following apply to

me (answer true or false on your
answer sheet):
a. Indifferent or unmotivated
b. Unreliable or untrustworthy
c. Careless or unthinking
d. Impulsive or reckless
e. Poor work or employment history

71. Careless / Thoughtless / Hasty

59. I have gone to Narcotics Anonymous

(NA) or Cocaine Anonymous (CA)
meetings because of my use of drugs.
60. My family responsibilities make it
hard for me to keep a job.
61. There are times when I really worry
about
my
responsibilities
and
happiness.

68. Depressed / Discouraged

72. Motivated / Self-Starter / Energized

73. Feelings Easily Hurt / Sensitive
74. Financially Stable / Responsible
75. Complaining / Fault Finding
76. Enthusiastic / Involved with Life
77. Fatigued / Tired / Sluggish
78. Exciting / Stimulating / Fun
79. Directly Deal with Problems
80. Emotionally Upset / Crying
81. Positive / Worthy / Hopeful
82. Angry / Hostile with Others
83. Lonely / Unhappy

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99. How would you describe your drug

use?
1. A serious problem
2. A moderate problem
3. A little or minor problem
4. Not a problem

Section 2, continued
84. Able to Handle Lifes Problems
85. Nervous / Unable to Relax
86. Patient / Tolerant / Understanding
87. Cant Make Decisions / Indecisive

100. How would you describe your present

home situation? I have serious:
1. Family problems
2. Marital or relationship problems
3. Both 1 and 2
4. None of the above

88. Work / Job Satisfaction

89. Admit my Errors / Mistakes
90. Bored / Indifferent / Uninterested
91. Accept Constructive Criticism
92. Trust my Own Judgment

101. During the last six months I have been:

1. Suicidal (dangerous to myself)
2. Homicidal (dangerous to others)
3. Both 1 and 2
4. None of the above

93. Careful / Watchful / Cautious

94. Adaptable / Adjustable
95. Marital / Family Problems
96. Self-Reliant / Independent

Section 3
Put an X on your answer sheet under the
number (1,2,3 or 4) that is accurate for you.
97. How would you describe
drinking problem?
1. A serious problem
2. A moderate problem
3. A little or minor problem
4. Not a problem

your

102. How many treatment programs for

drug problems have you been in?
1. One
2. Two
3. Three or more
4. None
103. How many alcohol treatment programs
have you been in?
1. One
2. Two
3. Three or more
4. None
Check to be sure you answered all items.

98. Recovering means you had a

problem in the past, but you do not
drink or take drugs now. I am a
recovering:
1. Alcoholic
2. Drug Abuser
3. Both 1 and 2
4. None of the above

Turn in your answer sheet and booklet.

Thank you for your cooperation.

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071900

SAI
Name: ______________________________
Age:________________ Sex:____________

Education (Highest Grade):__________________

Marital Status: ____________________________

Ethnicity (Race): ______________________

Date of Birth:_____________________________

In the following Number means total number within the last ten years.
1. Number of alcohol-related arrests within the last ten years: . . . . . . . . . . . . . . _________
2. Number of alcohol treatment programs you have attended in the last ten years:. . . . _________
3. Number of drug-related arrests within the last ten years:. . . . . . . . . . . . . . . . _________
4. Number of drug treatment programs you have attended in the last ten years: . . . . . _________
The information provided on this SAI answer sheet is true, correct and complete. I hereby agree to
answer all statements truthfully.
____________________________________________________
______________________
Client Signature

Date

Section 1
Put an X under T for True or under F for False.
F
T
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5.
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21.
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41.
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Section 2
Select the number (1, 2, 3 or 4) that describes you best.
1
2
3
4

62.

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79.

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63.

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80.

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64.

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81.

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65.

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82.

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66.

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83.

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67.

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84.

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68.

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85.

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69.

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86.

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70.

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87.

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71.

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88.

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72.

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89.

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73.

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90.

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74.

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91.

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75.

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92.

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76.

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93.

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77.

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94.

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78.

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95.

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96.

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Section 3
Put an X under the number that is accurate for you.
1

97.

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100.

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98.

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101.

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99.

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102.

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103.

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SAI Copyright 1998. ALL RIGHTS RESERVED.

071900