SAQ. Complete the information at the top of your answer sheet. Then, starting with question one, answer every question.

Transcription

1 SAQ Instructions The statements in this test are numbered. Do not skip any questions. Do not lie or give false information. This test measures truthfulness. In addition, your available records may be used to check the information you provide. Any dishonesty will likely be detected. In this test, Alcohol or Drinking refers to beer, wine or other liquors. Drugs refer to marijuana, cocaine, crack, ice, barbiturates, amphetamines and heroin. Complete the information at the top of your answer sheet. Then, starting with question one, answer every question. SAQ Copyright 1989, 1997, Section 1 The following statements can be answered True or False. If a statement is True put an X under T for True or a X under F for False. All statements must be answered. 1. My friends say I am quiet and peaceful. 2. I have used drugs (marijuana, cocaine, heroin, crack, etc.) excessively. 3. People tell me I am uncooperative. 4. In the past year, drinking has been a problem for me. 5. I do not always tell the whole truth when asked about my personal life. 6. I am easygoing and calm. 7. I have a drug-related problem. 8. I do not really see the need for this test or the 'help' people are giving me. 9. My drinking has not threatened my happiness or success in life. 10. Sometimes I worry about what others think or say about me. 11. I do not want anyone's advice about how to handle my life or problems. 12. People tell me I am overly aggressive. 13. My use of drugs has threatened my happiness and success in life. 14. I get into a lot of arguments or fights. 15. I have never had professional help, counseling or treatment for a drinking problem. 16. I can handle my own problems and do not want or need help. 17. I am nervous about taking this test. 18. My drinking is more than just a minor problem. 19. There have been times at work or school when I have not paid proper attention to what I was doing. 20. I have lied to people about my use of drugs-- either saying I use less than I really do, or hiding the fact that I do drugs at all. 21. I have a hard time taking advice when being told what to do. 22. I am concerned about my drinking. 23. I am outspoken and overly aggressive. 24. There are times when I am discouraged and very unhappy. 25. I smoke pot (marijuana) or use crack or cocaine at least once a month. 26. I have been convicted of assault, domestic violence or a violent crime. 27. Within the past year, I have had blackouts (memory loss), tremors (shakes), or been ill after drinking. 28. I do not like discussing my personal life and problems with others, even when they are trying to help. 29. Smoking marijuana or using cocaine helps me settle down and feel good. 30. There are times when I worry about my money, bills and debts. 31. Two or more of these qualities would apply to me: a) daring or fearless, b) outspoken or quick temper, c) disruptive or aggressive, d) hostile or combative. 32. I need help to overcome my drinking problem.

2 33. I do not know how to say it more clearly--i do not want anybody's help. 34. My use of drugs is out of control. 35. I would rather not discuss some of the things I have done. 36. I like excitement and activities that are risky and even dangerous. 37. I have gone to someone for help about my drug-related problems. 38. I wish people would leave me alone and let me deal with my own problems. 39. I do not have a drinking or alcohol-related problem. 40. There have been times when I have strongly disliked someone. 41. Within the past five years, I have caused one or more traffic accidents. 42. I never use illegal drugs. 43. I do not usually get along well with people in authority. 44. Within the past year, I have drunk alcohol to avoid or escape from worries and problems at work or home. 45. I have been embarrassed at work (or school) by mistakes I made. 46. I am a quiet, content and level-headed person. 47. Many of my close friends use drugs to handle the stress and boredom in their lives. 48. I do not like being told to change my attitude or the way I do things. 49. Within the past year, my family has shown concern about my drinking. 50. I have done things when I was angry, frustrated or mad that I later regretted. 51. Within the past year, I have not used drugs to relax or feel good. 52. I have a quick temper and need to learn how to control it better. 53. I am a recovering alcoholic. I have an alcoholrelated problem, but do not drink anymore. 54. I do not need help with my life or problems. 55. I do not get defensive or upset when others criticize me. 56. I can not stop using drugs. 57. I do not accept the fact that I have a problem I can not handle myself. 58. I have a lot of problems and conflicts with other people. 59. I am not concerned about my drinking. 60. It bothers me when I am overlooked or ignored by people I know. 61. I admit having problems I can not solve alone. 62. I have never been in treatment (inpatient, outpatient or counseling) for drug related problems. 63. There are times when I want to dominate and influence others. 64. Within the past year, there have been times I have enjoyed drinking alone. 65. There have been times when I have been very concerned about the disapproval of others. 66. I know I am overly aggressive. 67. I do not have a drug or drug-related problem. 68. I am tired of hearing everybody's advice about my life and problems. 69. There are times when I am really down, depressed and discouraged. 70. I have been told I am an alcoholic. 71. I really do not want help or advice from the staff. 72. I have lied to people about my drinking--either saying I drank less than I did or hiding the fact that I drink at all. 73. I am easily annoyed, disturbed or angered. 74. I have not always gotten along well with people at work or school. 75. There have been times when I have felt guilty about using drugs. 76. I lose my temper quickly. 77. I have asked for help with my drinking or alcohol-related problem. 78. People tell me that I am too defensive and sensitive. 79. I have tried to cut down or stop using drugs, but have failed.

3 80. There are times when I get real discouraged. 81. My drinking is a serious problem. 82. Within the past 6 months I have used drugs (marijuana, cocaine, heroin, crack, etc.). 83. There are times when I am defiant, rebellious and stubborn. 84. I have been in inpatient (residential) or outpatient (counseling) treatment for alcoholrelated problems. 85. There are times when I really worry about myself and my happiness. Section 2 Rate yourself on the next series of statements. Put an X under the number (1, 2, 3 or 4) that applies to you now. Use the following rating scale. 1. Rare or Never 3. Often 2. Sometimes 4. Very Often 103. Exercise/Physical Activity 104. Self Control/Composed 105. Headaches/Migraines 106. Positive Attitude/Outlook 107. Dissatisfied with Life 108. Good Sense of Humor/Laugh 86. People tell me I get angry too quickly Anxious/Worried 110. Depressed/Discouraged 87. My drinking has never hurt my family, damaged my social life or affected my work. 88. To be honest, I do not have any problems I want to discuss with the staff. 89. I am dependent on drugs and may be addicted to them. 90. There have been times when I have had a job but did not want to go to work Alcohol/Drugs 112. Manage Time Effectively 113. Insomnia/Trouble Sleeping 114. Satisfied with Self/Like Self 115. Inadequacy/Inferiority 116. Bored/Restless 117. Financially Stable/Responsible 118. Enthusiastic/Involved in Life 91. I have not found a way to stop drinking Tension/Stress 120. Fatigued/Tired/Sluggish 92. I want and need help with my problems. 93. When my friends offer me drugs, I may or may not use them. It depends on how I feel at the time. 94. There are times when I am worried about my responsibilities and happiness. 95. I know I have problems, but I want to deal with them myself. 96. I have a drinking or alcohol-related problem. 97. I am very competitive, even when playing a game. 98. I have been treated in a chemical dependency program for drug-related problems. 99. There have been times when I have been jealous or resentful of others My problems are my own business. I wish others would stop invading my privacy To be honest, I am an aggressive and irresponsible person It has been hard for me to just answer 'true' or 'false' to some of these questions Directly Deal with Problems 122. Emotionally Upset/Crying 123. Share My Thoughts Comfortably 124. Angry/Hostile with Others 125. Lonely/Unhappy 126. Able to Handle Life's Problems 127. Nervous/Unable to Relax 128. Patient/Tolerant/Understanding 129. Indecisive/Can't Make Decisions 130. Work/Job Satisfaction 131. Admit My Errors/Mistakes 132. Sweating/Racing Heart 133. Accept Constructive Suggestions 134. Trust My Own Judgment 135. Express My Feelings Comfortably 136. Stomach Problems/Acidity 137. Difficulty with Others/Friction 138. Adaptable/Adjustable 139. Marital/Family Problems 140. Self-Reliant/Independent 141. Job or Work Problems/Concerns 142. Satisfied/Contented with Life

4 Section 3 Select the answer to each of the following statements that is accurate for you. Put an X under the number (1, 2, 3 or 4) that applies to you now How many times have you had treatment (inpatient, outpatient, counseling, etc.) for alcohol or other drugs? 1. None 2. Once 3. Twice 4. Three times or more 144. My favorite substance has been: 1. Alcohol (beer, wine or liquor) 2. Drugs (marijuana, cocaine, heroin, etc.) 3. Both 1 and 2 (alcohol and drugs) 4. None of the above apply to me During the past year, I have been: 1. Potentially dangerous to myself (suicidal) 2. Potentially dangerous to others (homicidal) 3. Both 1 and 2 (suicidal and homicidal) 4. None of the above apply to me Select the statement that applies to you. 1. On probation 2. On parole 3. On 'work release' 4. None of the above 147. Select the statement that best describes your drinking problem. 1. Severe problem 2. Moderate problem 3. Slight problem 4. No problem 148. Select the statement that best describes your drug problem. 1. Severe problem 2. Moderate problem 3. Slight problem 4. No problem 149. Select the statement that most accurately describes your physical and medical condition. 1. Excellent, no physical or medical problems 2. Good, a few minor physical or medical problems 3. Fair, but have some physical or medical problems 4. Poor, concerned about my physical and medical condition Select the statement that indicates your desire (motivation) for alcohol rehabilitation, treatment or help. 1. Highly motivated (want help) 2. Some motivation (undecided) 3. Little motivation (handle it myself) 4. No motivation (no need) 151. Select the statement that indicates your desire (motivation) for drug rehabilitation, treatment or help. 1. Highly motivated (want help) 2. Some motivation (undecided) 3. Little motivation (handle it myself) 4. No motivation (no need) 152. Recovering means having an alcohol or drug problem, but not using or abusing them anymore. I am a recovering: 1. Alcoholic (beer, wine or liquor) 2. Drug abuser (marijuana, cocaine, etc.) 3. Both 1 and 2 (alcohol and drugs) 4. None of the above apply to me Are any family members known alcoholics, such as: 1. Your parents (mother and/or father) 2. Either of your grandparents 3. Both 1 and 2 (parent and grandparent) 4. None of the above Check to be sure you have answered all the questions. Turn in your booklet and answer sheet to your supervisor. Thank you for your cooperation!

5 SAQ Answer Sheet First Name: Middle Initial: Last Name: Age: Sex: Last Four Digits of Your Social Security Number: Ethnicity (Race): Date of Birth: Education (highest grade completed): Today s Date: 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 T F

6 SECTION 2 Put an X under number (1, 2, 3, or 4) that describes you best. Rare or Never Sometimes Often Very Often Rare or Never Sometimes Often Very Often SECTION 3 Put an X under number (1, 2, 3, or 4) that is most accurate for you