VAI. Instructions Answer each statement truthfully. Your records may be reviewed to verify the information you provide.

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1 VAI Instructions Answer each statement truthfully. Your records may be reviewed to verify the information you provide. Read each statement carefully and choose the answer that is accurate for you. Do not skip any questions. All items must be answered on your answer sheet. SECTION 1 Select the answer that describes you best. Put an X on your answer sheet under the number (1, 2, 3 or 4) that you select for your answer. Use the following scale: 1. Rare or Never 3. Often 2. Sometimes 4. Often Answer each statement as it applies to you now. All statements must be answered on your answer sheet. 1. Exercise / Physical Activity 2. Positive Attitude / Outlook 3. Dissatisfied with Life 4. Good Sense of Humor / Laugh 5. Anxious / Worried / Fearful 6. Depressed / Discourage 7. Insomnia / Trouble Sleeping 8. Satisfied with Self / Like Self 9. Financially Stable / Responsible 10. Enthusiastic / Involved with Life 11. Tension / Stress 12. Fatigued / Tired / Sluggish 13. Directly Deal with Problems 14. Emotionally Upset / Crying 15. Angry / Hostile with Others 16. Lonely / Unhappy 17. Able to Handle Life s Problems 18. Nervous / Unable to Relax 19. Patient / Tolerant / Understanding 20. Can t Make Decisions / Indecisive 21. Work / Job satisfaction 22. Admit My Errors / Mistakes 23. Fearful / Anxious 24. Accept Constructive Suggestions 25. Trust My Own Judgment 26. Stomach Problems / Acidity 27. Difficulty with Others / Conflict 28. Adaptable / Adjustable 29. Marital / Family Problems 30. Self-Reliant / Independent SECTION 2 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 on your answer sheet. All statements must be answered. 31. There have been times when I have been careless about my driving. 32. Driving is everybody s right -- not just a privilege. 33. I do not speed, get tickets or have accidents. 34. There are times when I get real discouraged. 35. I often pawn items at pawn shops. Copyright Protected. All Rights Reserved.

2 36. I often do things suddenly or impulsively, without a lot of thought. 37. I always drive within posted speed limits. 38. I will manipulate or lie to get my way. 39. I often yell at other drivers. 40. Two or more of the following apply to me (answer true or false on your answer sheet): a. Unreliable and Untrustworthy b. Negative, Hostile or Defiant c. Persistent Lying or Thefts d. Substance (Alcohol or Drugs) Abuse e. Poor Work or Employment History 41. Sometimes I get angry or upset at other drivers. 42. My insurance has been increased within the last five years because of my poor driving record. 43. I would rather not discuss some of the things I have done. 44. Low speed limits often annoy or frustrate me. 45. I have gotten more traffic tickets than most people I know. 46. Two or more of the following apply to me (answer true or false on your answer sheet): a. Careless or Thoughtless b. Impulsive or Unthinking c. Hurried or Rushed d. Irritable, Resentful or Angry e. Impatient or Nervous 47. At times I worry about what people think or say about me. 48. I cannot say it more clearly. I do not want anybody s help. 50. I always use my turn signal lights before turning. 51. People tell me I have a bad attitude. 52. I would like to drive faster on the highways. 53. There have been times when I have strongly disliked someone. 54. There are only a few people I care about anymore. 55. I am often moody, irritable and demanding. 56. I have been arrested for a DUI (Driving Under the Influence). 57. I have wished I could go back in time and do some things over -- but differently. 58. Anything I do is OK, as long as I do not get caught. 59. I am a defensive driver. 60. I know I shouldn t but I have been jealous of other s success. 61. People tell me I am insensitive or thick skinned. 62. There have been times when I have driven a vehicle without insurance. 63. There are times when I really worry about myself. 64. Two or more of the following apply to me (answer true or false on your answer sheet): a. Impulsive or Aggressive b. Hostile or Angry c. Argumentative or Defiant d. Irresponsible or Undependable e. Quick Tempered 49. Other drivers often annoy or anger me. Copyright Protected. All Rights Reserved.

3 65. I think the speed limit (55 M.P.H.) is to low. 66. There have been times when I knew I should not drive but did. 67. I am very sensitive and my feelings are easily hurt. 68. When asked, I do not always tell the whole truth about my personal life. 69. I have little remorse, sorrow or regret for the things I have done. 70. I have a right to choose not to wear a safety belt because if I got hurt, the only one I am hurting is myself. 71. I have broken some traffic laws and was not caught or given a ticket. 72. I believe cops like to give out tickets. 73. To be honest there are times when I am not a good driver. 74. There are times when I am really down. 75. Police have a quota and must give out a minimum number of traffic tickets (moving violations) each shift. 76. I often drive fast. 77. I have done things when angry that I regret. 78. The real reason the State has this driving program is to make more money. 79. Even though I was not caught, I have made mistakes while driving. 81. When I get frustrated or annoyed I tend to yell or argue a lot. 82. Sometimes I get annoyed or upset at myself. 83. People tell me that I often lie or con others. 84. I have gotten two or more traffic (moving violation) tickets in the last two years. 85. I have been embarrassed or worried about mistakes I have made. 86. Two or more of the following apply to me (answer true or false on your answer sheet): a. Cold or Indifferent b. Manipulative, Conning or Lying c. Argumentative or Violent Temper d. Alcohol or Drug Abuse e. Non-Payment of Bills, Debts or Loans 87. There have been times when I have had to drive without a valid driver s license. 88. I have always gotten along well with people at work or school. 89. Outside of my family, I do not trust anybody anymore. 90. I speed a lot and get tickets. 91. It bothers me when I am over-looked or ignored by people I know. 92. To be honest, I have a negative or disagreeable attitude. 80. This driver improvement program is a waste of my time. Copyright Protected. All Rights Reserved.

4 SECTION 3 Each of the following items consists of a pair of opposite terms that you are to rate yourself on. Rate yourself on how you feel now, or how you felt in the last six months. For example, rate yourself on Careful and Careless. Can t Often Often Decide Often Often Careful Careless In this example, 1 means you are Often Careful and 2 means you are Often Careful. A self-rating of 3 means you can t decide if you are careful or careless. Similarly, 4 means you are Often Careless and 5 means you are Often Careless. If you are usually careful, you would put an X under 1 for Often on the left side of the scale. If you are usually careless you would put an X under 5 for Often on the right side of the scale. Mark only one X for each item or pair of opposite terms on your answer sheet. Can t Often Often Decide Often Often 93. Unsuccessful Successful 94. Adequate Inadequate 95. Accepted Rejected 96. Unattractive Attractive 97. Discontented Contented 98. Cooperative Uncooperative 99. Strong Weak 100. Friendly Unfriendly 101. Unhappy Happy 102. Intelligent Dull 103. Boring Interesting 104. Loved Unloved 105. Disliked Liked 106. Positive Negative 107. Insecure Secure 108. Withdrawn Outgoing 109. Stable Unstable 110. Dangerous Harmless 111. Nervous Calm 112. Hostile Friendly 113. Worthy Worthless 114. Hopeful Hopeless Copyright Protected. All Rights Reserved. v4.01

5 NAME: ID# AGE: VAI ANSWER SHEET ACCURATELY COMPLETE THIS INFORMATION DATE OF BIRTH: SEX: MALE FEMALE EDUCATION: (HIGHEST GRADE COMPLETED) ETHNICITY (RACE): MARITAL STATUS: In the following, give the total number including the present violation. 1. Number of moving violations or tickets you received in the last 5 years: 2. Number of times you have attended traffic safety school in the last 5 years: 3. Number of times your license has been suspended in your lifetime: 4. Number of times your license has been revoked in your lifetime: SECTION 1 Put an X under the number (1, 2, 3, or 4) that describes you best. Use the following scale to select your answers. 1. Rare or Never 3. Often 2. Sometimes 4. Often Copyright Protected. All Rights Reserved. v4.01

6 SECTION 2 The statements in this section are to 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 on your answer sheet. T F T F T F T F SECTION 3 Compare the opposite terms. Select the term that is accurate for you, then put an X next to the number that describes you best. Often Often Can t Decide Often Often Often Often Can t Decide Often Often Copyright Protected. All Rights Reserved. v4.01