The SASSI Institute 2016 Product Catalog

accurate Versatile

Effective 2016 Product Catalog

Objective VALIDATED

efficient informative

Drug Courts Employee Assistance Programs Spanish College DUI Evaluation Medical Program Evaluation

U.S. & Canada CANADA

Contents Scantron/Optical Scanning 8
Qualifications & Guidelines 3 Overview 8
Qualifications for Purchase 3 Pricing 8
Use Guidelines 3 Adult SASSI-4 8
Adolescent SASSI-A2 8
Product Overviews 4
Paper with Automated Scoring 9
Paper & Pencil Pricing 5 and Screening Reports 9
Overview 5 Overview 9
SASSI-4 5 Pricing 9
SASSI-A2 5 SAS-ASL 9
Spanish SASSI 5 SAVR-S2 10
BADDS 5 10
Starter Kits 5 Return Policy insert
Paper Sets 6 Copyright Information insert
Audio Recordings 6 U.S. Qualification Form insert
Scoring Keys 6 U.S. Order Form insert
User’s Guides & Manuals 6 Canada Qualification Form 11
BADDS Auto Calculation Sheets 6 Canada Order Form 11
Clinical Assistance 11
SASSI Online 7 Shipping Rates back cover
Overview 7 Shipping Information
Pricing 7 SASSI Training

Contact 800.726.0526 No-risk
Customer Service 30-day trial on
Ordering and general inquiries [email protected] small starter kits

Training Department 800.697.2774 see page 10 for more details
Questions or assistance specific to training [email protected]

Technical Support 888.251.4147

Software and online support [email protected]

Clinical Support 888.297.2774

Free Clinical consultation blank text for spaceing

Location 201 Camelot Lane, Springville, IN 47462
Website www.sassi.com

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Qualifications for SASSI Purchase First Time Orders

The SASSI-4, SASSI-A2, Spanish SASSI, SAS-ASL Initial orders require a completed Qualification
and SAVR-S2 are carefully developed screening Form. The ethical guidelines of the American
instruments that require proper administration, Psychological Association require us to have this
scoring, and interpretation. Therefore, eligibility to information at the time we fill your first order. For
purchase, administer and/or use these measures for mail and fax orders, complete and return the
clinical purposes is limited to individuals with training Qualification Form included in this catalog with
and experience in the area of assessment and should your order form.
be used by: You may also complete the Qualification Form
online at www.sasssi.com/qualify (online
Human service practitioners whose certifica- ordering is available to U.S. residents only).
tion and/or professional training includes assess-
ment (e.g., psychologists, social workers, certi- Use Guidelines
fied addictions counselors)
We hereby advise the Purchaser of the
or following guidelines:
Individuals who have completed SASSI The SASSI instruments are designed and distribut-
training that was presented by a certified SASSI ed for use as screening instruments and, as such, do
trainer. not yield diagnoses.
Individuals who do not have professional training can The SASSI instruments are also designed to identi-
administer and score the instruments if there is fy people with substance use disorders regardless
appropriate supervision. of the current course of the disorder; thus, individ-
It is suggested that you contact your state or provin- uals who are in remission or recovery may show
cial government for specific information on the laws test-positive results.
regulating assessment and testing in your area. The SASSI instruments and the BADDS should
not be used as part of a screening process to
Qualifications for BADDS Purchase discriminate against individuals, i.e., eliminate job
applicants, abridge people’s rights and entitlements
A bachelor’s degree in psychology or a related disci- for general assistance or other aid, or for any other
pline (e.g. counseling, education, human resources, purpose that may violate the Americans With
social work, criminal justice, etc.) and coursework Disabilities Act or other Human Rights laws in
related to psychological testing, your area.
Refer to the SASSI instrument manuals, the
or BADDS User’s Guide & Manual, or contact us for
Professional membership in an organization that information regarding development and valida-
requires training and experience in the use of psycho- tion.
logical assessments and surveys,
Product Pricing is in
or US & Canadian Funds
Individuals who have completed BADDS training
online.
Please note: If you do not meet the above criteria,
but are supervised by someone who does, you may
still use the BADDS. However, the Qualification
Form must be completed by the qualifying individual.

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Product Overviews

SASSI-4 Adult Substance Abuse Subtle Screening Inventory-4

Identifies high or low probability of substance use disorders and includes a prescription drug scale that identifies
individuals likely to be abusing prescription medications. It also provides a measure of profile validity and clinical
insight into level of defensiveness and willingness to acknowledge experienced consequences of substance use disorder.

Age: 18 years and up Reading Grade Level: 4th - 5th Accuracy: 92% based on empirical studies

Formats Available: Paper & Pencil, SASSI Online, Scantron/Optical Scanning (Coming Soon)

SASSI-A2 Adolescent Substance Abuse Subtle Screening Inventory-A2

Identifies high or low probability of substance use disorders in clients. It also provides clinical insight into family
and social risk factors, level of defensive responding, and consequences of substance misuse teens endorsed.

Age: 12-18 years Reading Grade Level: 4.4 Accuracy: 94% based on empirical studies

Formats Available: Paper & Pencil, SASSI Online, Scantron/Optical Scanning

Spanish SASSI Spanish Substance Abuse Subtle Screening Inventory

A Spanish language screening instrument empirically validated in clinical settings for use with Spanish-speaking
adults from diverse ethnic backgrounds (e.g., Colombian, Mexican, Puerto Rican).

Age: 18 years and up Reading Grade Level: 5th Accuracy: 84% based on empirical studies

Formats Available: Paper & Pencil, SASSI Online

BADDS Behaviors & Attitudes Drinking & Driving Scale

Identifies preintervention risk of future impaired driving, and changes in DUI-related risky behaviors & attitudes
following intervention. Ideal for initial risk assessment, pre and post test screening, and program evaluation.

Age: 18 years and up Reading Grade Level: 3.1 Formats Available: Paper & Pencil
Validation Samples: DUI offenders, Traffic offenders with no history of DUI, Adults in treatment for

substance use, College students, High School students in driver’s education

SAVR-S2 Substance Abuse in Vocational Rehabilitation Screener2

A brief screener validated for use with clients with disabilities, to identify high or low probability of substance
use disorders, including misuse of medications.

Age: 18 years and up Reading Grade Level: 5th Accuracy: 86% based on empirical studies
Formats Available: Scoring & Report Service

SAS-ASL Substance Abuse Screener in American Sign Language

An instrument specifically developed in American Sign Language and validated to screen for substance use disorders
among adult Deaf and Hard of Hearing clients in vocational rehabilitation, mental health, and social service settings.

Age: 18 years and up Reading Grade Level: 4th Accuracy: 87% based on empirical studies
Formats Available: Scoring & Report Service

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Paper & Pencil Pricing

Overview: Counselor hand scores completed questionnaire using a scoring key. Results are immediately available.

Fifteen minutes to administer & score. No-risk 30-day trial on small starter kits, see page 10 for more details.

Starter Kits First time orders for the paper & pencil
product must be a Starter Kit.

Small Starter Kits - 30-day trial (see page 10)
Price Product Code
$140.00 Adult SASSI-4 K401
$140.00 Adolescent SASSI-A2 K202
$265.00 Combination Adult/Adolescent K423
$65.00 Spanish SASSI EK101SM
$110.00 BADDS Pretest BKSM
$185.00 BADDS Pretest w/auto-calc. BKSMA
$145.00 BADDS Pre-Posttest BKPSM
$220.00 BADDS Pre-Posttest w/ auto-calculation sheet* BKPSMA

Large Starter Kits
Price Product Code
$250.00 Adult SASSI-4 K401L
$250.00 Adolescent SASSI-A2 K202L
$485.00 Combination Adult/Adolescent K423L
$195.00 Spanish SASSI EK101LG
$225.00 BADDS Pretest BKLG
$305.00 BADDS Pretest w/auto-calc. BKLGA
$360.00 BADDS Pre-Posttest BKPLG
$435.00 BADDS Pre-Posttest w/ auto-calculation sheet* BKPLGA

Kit Contents:

Adult & Adolescent SASSI Starter Kit includes paper forms and profiles, scoring key, User Guide & Manual.
Small Kit - 25 paper forms and profiles Large Kit - 100 paper forms and profiles

Combination Adult and Adolescent Kit includes paper forms and profiles, scoring keys, User Guide & Manuals.
Small Kit - 25 Adult and 25 Adolescent Large Kit - 100 Adult and 100 Adolescent

Spanish Starter Kit includes paper forms and profiles, scoring key, Administration & Scoring Instructions,
Development & Validation Information, and an English translation of the questionnaire.

Small Kit - 25 paper forms and profiles Large Kit - 100 paper forms and profiles
BADDS Pretest Starter Kit is designed for those using the BADDS as a pretest measure only. The kit includes
paper forms and profiles, Reliability & Validity information, Summary of the BADDS, and the User’s Guide & Manual.

Small Kit - 50 paper forms and profiles Large Kit - 100 paper forms and profiles
BADDS Pre-Posttest Starter Kits are designed for those using the BADDS as a pre-post measure to assess
intervention effectiveness. The kit includes paper forms (2 per client), pre-post profiles (1 per client), Reliability &
Validity information, Summary of the BADDS, and the User’s Guide & Manual.

Small Kit - 50 paper forms and 25 pre-post profiles Large Kit - 200 paper forms and 100 pre-post profiles
*BADDS Autocalculation Sheet - Interactive PDF that automatically calculates BADDS scale scores.

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Paper & Pencil Pricing continued

SASSI-4, SASSI-A2, Spanish SASSI & BADDS Paper Sets SASSI Volume Discounts
SASSI sets include paper forms and profiles
BADDS sets include paper forms, pre and posttest profiles Quantity (# of forms) Per Pkg Total Price

Small Set (pkg of 25) Price Product Code 4 pkgs (400) $180.00 $720.00
Adult SASSI-4 $60.00
Adolescent SASSI-A2 $60.00 P401SM 5 pkgs (500) $175.00 $875.00
Spanish SASSI $60.00 P202SM
BADDS $45.00 E01SM 6 pkgs (600) $170.00 $1,020.00
BSM 10 pkgs (1000) $165.00 $1,650.00

Large Set (pkg of 100) Price PrPo4d0uc1tLCGode 25 pkgs(2500) $150.00 $3,750.00
Adult SASSI-4 $190.00 P202LG
Adolescent SASSI-A2 $190.00 K423LG 50 pkgs (5000) $135.00 $6,750.00
Combo. Adult/Adol.* $195.00 E101LG
Spanish SASSI $190.00

*Large Combination Adult/Adolescent Set contains BADDS Volume Discounts
50 Adult and 50 Adolescent paper forms and profiles.
Quantity (# of forms) Per Pkg Total Price
Scoring Keys 4 pkgs (100) $41.25 $165.00
Adult SASSI-4 Price PKro4d0u1cKt CEoYde
Adolescent SASSI-A2 $10.00 K202KEY 16 pkgs (400) $40.00 $640.00
Spanish Key $10.00 E101KEY
$10.00 20 pkgs (500) $38.75 $775.00

User Guides & Manuals Price PPr4o0du1cUt GCoMde 24 pkgs (600) $37.50 $900.00
SASSI-4 User Guide & Manual $80.00 P202UG 40 pkgs (1,000) $35.00 $1,400.00
SASSI-A2 User’s Guide $35.00 MB202 100 pkgs (2,500) $33.75 $3,375.00
SASSI-A2 Manual $45.00 BUGM 200 pkgs (5,000) $32.50 $6,500.00
BADDS User’s Guide & Manual $75.00 E101AI
Spanish SASSI Administration $5.00 BADDS Auto Calculation Sheet
& Scoring Instructions Price Product Code Auto-Calculation Price Product Code
$25.00 Score Sheets $80.00 BAF
Audio Recording $25.00 P401CD
Adult SASSI-4 $25.00 P202CD
Adolescent SASSI-A2 E101CD
Spanish SASSI

SASSI-4 User Guide & Manual provides non-technical, step-by-step information on administering and scoring the
SASSI-4 and basic information on interpreting profiles. It also provides detailed information on the development and
validation of the SASSI-4 measures.

SASSI-A2 User’s Guide provides non-technical, step-by-step information on administering and scoring the SASSI-A2
and basic information on interpreting profiles.

SASSI-A2 Manual provides detailed information on the development and validation of the SASSI-A2 and contains a
section on specific clinical issues.

BADDS User’s Guide & Manual provides empirical research on the development of the BADDS, detailed instructions
on administration & scoring, guidelines for interpreting results, and sample profile reports.

Spanish SASSI Administration & Scoring Instructions provides information on the development of the Spanish
SASSI, detailed instructions on administration & scoring, and guidelines for interpreting the results.

Audio CD is for clients who have reading difficulties, it is a professionally read version of the SASSI questionnaire on CD.

BADDS Auto Calculation Sheet is an interactive PDF that automatically calculates BADDS scale scores. Includes the
Individual Profile Score Calculation Sheet that calculates total scale scores for each client and provides brief narrative
statements regarding level of impaired driving risk, and the Class/Group Score Calculation Sheet that calculates
percentages and averages for group scores. Shows change in scores following intervention.

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SASSI nline Pricing

Overview: SASSI Online is a web-based system for the administration and scoring of SASSI

questionnaires which provides narrative reports on client screening results. Through your secure
workspace, backed by our Security Commitment*, SASSI Online enables you to order and adminis-
ter questionnaires, receive immediate scoring of clients’ responses, and review client results and
profile reports, all using a standard web browser and an internet connection. Can be purchased in
single or large volume quantitites.

Available Questionnaires:Adult SASSI-4,Adolescent SASSI-A2, and Spanish SASSI

SASSI Online benefits include:
Multiple administration options which include,:

Keyboard Administration, that allows the client to directly enter their responses, through an emailed link,
or while in the counselor’s office. As well as the ALL NEW PAPER DELIVERY OPTION! Questionnaires
can now be downloaded, printed, and given to the client to complete. Once completed the counselor can enter
the responses into our easy entry feature.

Web accessible and compatible with almost all common browsers, computers, and devices including tablets
and smartphones.

Immediate results, including the decision rule outcome, a graph of the client’s scale scores, and a narrative
report on the client’s SASSI scores.

Quantity Price Per
Questionnaire
1-9 Administration
10-24
25-49 $12.50
50-99
$10.00

$8.50
$8.25

100-499 $7.25
500-999 $6.50
$5.50
1,000

For larger quantities please call for pricing.

*The SASSI Institute's Online Security Commitment ensures our systems and processes will meet or exceed all state and federal

regulations including HIPAA, 42CFR, and other regulations regarding confidential client data. We encrypt all data transmissions
and de-identify client information. Identifiable client information is maintained as encrypted data. The SASSI Institute will not
release client identifiable information without the express written consent of the client.

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Scantron/Optical Scanning Pricing

Overview

Electronically scanned forms provide rapid scoring for programs that conduct a large number of substance
use evaluations. Reports can be customized on a contractual basis to meet program needs.

Developed to work on Scantron optical scanners which are sold separately by Scantron Corp.

Please call customer service if you are interested in implementing the Scantron SASSI.

Scantron Option 1 Scantron Option 2
Includes decision rule results, graph of client scores, Includes decision rule results and graph of client
and narrative client reports. Prices include cost of scale scores only. Prices include cost of related
related software. Forms sold in packages of 100. software. Forms sold in packages of 100.

Quantity Per Form Total Price Quantity Per Form Total Price
100 $7.20 $720.00 100 $1.80 $180.00

500 $6.55 $3,275.00 500 $1.65 $825.00
1,000 $4.50 $4,500.00 1,000 $1.55 $1,550.00
1,500 $4.10 $6,150.00 1,500 $1.50 $2,250.00

2,500 $3.05 $7,625.00 2,500 $1.35 $3,375.00

For larger quantities please call for pricing. For larger quantities please call for pricing.

Adult Forms Only Product Code Product Code
S101NC Adult Forms Only S201NC
Adolescent Forms Only S102NC Adolescent Forms Only S202NC

Adult SASSI-4 Scantron is currently in development for use with SASSI Online.
Customers with questions, please call technical support at 888.251.4147 for release timeline.

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DUI Evaluations Welfare Drug Courts Jails Program Evaluation

Scoring & Report Service (SRS)

Overview

Through our Scoring & Report Service (SRS) the counselor downloads and prints the SAVR-S2 or SAS-ASL
questionnaire from the SRS website, asks client to complete it, and then faxes to our automated system
which scores it and returns an interpretive report on client screening results. The SAS-ASL includes a
video in American Sign Language for the client to view while completing the paper form. The report includes
each client’s overall screening result, as well as identification of key issues affecting each client.

Reports are delivered within two business days (often same day) via e-mail or fax.
Available through the SASSI Institute’s Scoring & Report Service (SRS) at sassi-srs.com.
The SRS provides interpretive auto-score reports on client screening results.

Available Questionnaires: SAS-ASL and SAVR-S2

Once registered, counselors can acces both instruments.
Registered users of the SRS have convenient online access to User Guides, client and counselor instructions,
as well as other support materials.

Quantity Price Per
1-9 Report
$12.50
10-24 $10.00
25-49 $8.50
50-99 $8.25

100-499 $7.25
500-999 $6.50
$5.50
1000

For larger quantities please call for pricing.

For information on how to register your organization and purchase auto-score reports through the
Scoring & Report Service, go to: www.sassi.com/srs or call customer service at 800.726.0526.

SAVR-S2 is also available in large print & Braille

For validation information on the SAVR-S2 or SAS-ASL please contact us.
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Copyright Notice

The SASSI instruments and BADDS are copyrighted instruments, which includes the questionnaires,
profiles, questionnaire items, T scores, scales, norms, score reports, scoring keys, and all related materials
and, as such, they are protected by the copyright laws of the United States, Canada, and other countries.
They may not be reproduced or transmitted in whole or in part, in any form or by any means, including
creating derivative products or presentations, copying into computer storage media of any kind, copying
onto audiovisual storage media, photocopying, or copying of any other kind without prior written perm-
ission of the publisher. Unauthorized reproduction of any part of the copyrighted materials is unethical
as well as a violation of federal copyright laws.
Questions are not to be reproduced, paraphrased, or translated in any way. The SASSI Institute, Inc. and
Jewell & Hupp, L.L.P. make no estimate of accuracy for questionnaire items that have been paraphrased,
translated, or for screening accuracy resulting from administration of only selected test items on the
instruments.

Return Policy

Small Starter Kits - 30-day trial
To guarantee your satisfaction and ensure that our questionnaires will be useful in your practice, you may
try a Small Starter Kit for thirty (30) days at no risk. At the end of the thirty (30) day trial period you will
have an additional thirty (30) days to either pay the invoice or, if you decide not to keep the Starter Kit,
send back the remaining materials and we will credit your account for the invoice total.
Trial option not available on Large Starter Kits.
All other purchases
If your order is found to be incorrect it may be returned for exchange or credit within sixty (60) days
from date of purchase. If your order has been damaged in shipping please retain all of the original
packaging and call Customer Service at 800.726.0526 for assistance.
Any items advertised in our current catalog may be exchanged within one (1) year from date of purchase
if they are in saleable condition. These items may be subject to a 15% re-stocking fee.

10

U.S. Qualification Form

Prior to processing your order, this form must be completed and signed by an individual who meets one of
the following professional qualifications and who is authorized to sign for the undersigned organization:

Please mark the item which best describes your professional qualification:

 Lic./Cert. Psychologist  Lic./Cert. Social Worker
 Psychiatrist or other MD  Lic./Cert. Rehabilitation Counselor (e.g., CRC, Rh.D.)
 Licensed Psychiatric Nurse  Research Ph.D./Clinical Ph.D.
 Lic./Cert. Addictions Counselor (e.g., CADC, LCDC)  IC&RC (e.g., AODA, CCJP, CCDP)
 Lic./Cert. Counselor/Therapist (e.g., LMFT, LPC)
 Other Lic. or Cert.(specify): Specify:
 Non-licensed or certified (fill out additional info):  Training (specify):

 SASSI  Other:

Educational background City & State:

Major: Trainer Name:

Degree: Year: Month: Year:

Please mark the item which best describes your current work setting (mark all that apply):

 Substance Abuse Treatment Program  Military
 Medical, Hospital, HMO  Welfare, Child Protective Services
 Behavioral Health Facility  Workforce Development
 Jail, Prison  Vocational Rehabilitation
 Probation, Parole, Pre-sentencing  EAP, Union, DOT-SAP
 Drug Court  Education
 Assessment  Private Practice
 Other (specify):

How did you first hear/find out about the SASSI Institute (please supply specifics and mark all that apply):

 Mandated use  Internet
 Word of mouth  SASSI Institute newsletter
 Current setting uses:  SASSI  BADDS  SASSI Institute information packet
 Used before in another position  Published articles
 Journal ads:  SASSI Training
 Conference: Name & Date:
 Other (specify):

Purchaser agrees to indemnify and hold The SASSI Institute and its owners, officers, directors, employees, indepen-
dent contractors, suppliers, and affiliated parties harmless against all claims, liabilities, demands, damages, judg-
ments, settlements, or expenses of whatever nature (including reasonable attorneys’ fees and expenses) arising out
of or in connection with the use or misuse of tests or test materials, scoring, or other services connected to test
administration of substance use measures created by and/or distributed by The SASSI Institute.

By: Date:
(Please sign name)

Name: Title:
(Please print)

Organization Name:

Address:

City, State, & Zip: Fax: E-mail:
Phone:

11-02-10

U.S. Order Form

For initial orders, please include a completed Qualification Form (see p. 3 for qualifications) The information contained
on this form is confidential.
For repeat orders, Date We do not sell or share your

please indicate information with anyone.

Customer ID Customer ID Number (Repeat orders only) Purchase Order Number (If required)

(if known)

Customer Name (if different than below) E-mail Address

INVOICE TO:

Name
U.S. Order Form
U.S. Order FormOrganizationPhone

Mailing Address Fax

City State/Zip

SHIP TO:

Name (if different than above)

Organization Phone

Street Address Fax

City State/Zip Quantity Price Per Item Total
Product Code Product Description

Method of Payment: Product
Total:
Invoice (Net 30-Days) Check Enclosed Shipping/

MasterCard Visa Thank you Handling:
for your order! Subtotal:
American Express Discover
Sales tax:
Credit Card Number
CVV Code*(required) Expiration Date Indiana Only

Total:

Name of Card Holder (Printed) United States Shipping Fees Shipping
Shipping

Signature of Card Holder Order Total Cost Order Total Cost
$0-$40 $6 $1001-$1250 $30
$41-$70 $11 $1251-$1400 $34

$71-$125 $13 $1401-$1700 $38
$126-$250 $15 $1701-$2100 $42

*Your CVV Code is a verification code printed on your credit $251-$500 $20 $2101-$2500 $47
card. On the American Express card it is a 4 digit number
located on the front of the card. On Visa, MasterCard, and $501-$800 $23 $2501-$2900* $54
Discover it is a 3 digit number located on the back of the card
on the signature line (the last 3 digits). $801-$1000 $26
For Next Day Air, 2nd Day Air, or 3 Day Select shipping rates,
FOUR WAYS TO ORDER:
please call customer service.

*For orders exceeding $2900.00

Phone: 800.726.0526 Mail: 201 Camelot Lane  Springville, IN 47462 Fax: 800.546.7995 Web: www.sassi.com

CANADA Canada Qualification Form

Prior to processing your order, this form must be completed and signed by an individual who meets one of
the following professional qualifications and who is authorized to sign for the undersigned organization:

Please mark the item which best describes your professional qualification:

 Lic./Cert. Psychologist  Lic./Cert. Social Worker
 Psychiatrist or other MD  Lic./Cert. Rehabilitation Counselor (e.g., CRC, Rh.D.)
 Licensed Psychiatric Nurse  Research Ph.D./Clinical Ph.D.
 Lic./Cert. Addictions Counselor (e.g., CADC, LCDC)  IC&RC (e.g., AODA, CCJP, CCDP)
 Lic./Cert. Counselor/Therapist (e.g., LMFT, LPC)
 Other Lic. or Cert.(specify): Specify:
 Non-licensed or certified (fill out additional info):  Training (specify):

 SASSI  Other:

Educational background City & Province:

Major: Trainer Name:

Degree: Year: Month: Year:

Please mark the item which best describes your current work setting (mark all that apply):

 Substance Abuse Treatment Program  Military
 Medical, Hospital, HMO  Welfare, Child Protective Services
 Behavioral Health Facility  Workforce Development
 Jail, Prison  Vocational Rehabilitation
 Probation, Parole, Pre-sentencing  EAP, Union, DOT-SAP
 Drug Court  Education
 Assessment  Private Practice
 Other (specify):

How did you first hear/find out about the SASSI Institute (please supply specifics and mark all that apply):

 Mandated use  Internet
 Word of mouth  SASSI Institute newsletter
 Current setting uses:  SASSI  BADDS  SASSI Institute information packet
 Used before in another position  Published articles
 Journal ads:  SASSI Training
 Conference: Name & Date:
 Other (specify):

Purchaser agrees to indemnify and hold the SASSI Canada a division of 1303821 Ontario Inc., and its owners, officers,
directors, employees, independent contractors, suppliers, and affiliated parties harmless against all claims, liabilities,
demands, damages, judgments, settlements, or expenses of whatever nature (including reasonable attorneys’ fees
and expenses) arising out of or in connection with the use or misuse of tests or test materials, scoring, or other
services connected to test administration of substance use measures created by and/or distributed by SASSI Canada.

By: Date:
(Please sign name)

Name: Title:
(Please print)

Organization Name:

Address:

City, Province, & Postal Code: Fax: E-mail:
Phone:

11-02-10

CANADA Canada Order Form

For initial orders, please include a completed Qualification Form (see p. 3 for qualifications)

For repeat orders, The information contained
on this form is confidential.
please indicate Date We do not sell or share your
information with anyone.
Customer ID

(if known) Customer ID Number (Repeat orders only) Purchase Order Number (If required)

Canada Order Form Customer Name (if different than below) E-mail Address
Canada Order Form
INVOICE TO:

Name

Organization Phone

Mailing Address Fax

City Province/Postal Code

SHIP TO:

Name (if different than above)

Organization Phone

Street Address Fax

City Province/Postal Code
Product Code
Product Description Quantity Price Per Item Total

Method of Payment: Product
Invoice (Net 30-Days)
Check Enclosed Tfohranykouryoourder! Total:
Visa (Only VISA Accepted) Shipping/
Handling:
Credit Card Number
Subtotal:
CVV Code* (required) Expiration Date
Province
Sales tax:

If Applicable

Total:

Canadian Funds

Name of Card Holder (Printed) Canada Shipping Information

Signature of Card Holder Orders shipped to the Yukon or Northwest Territores are
*Your CVV Code is a verification code printed on your sent via USPS only. All other orders shipped to Canada
credit card. It’s a 3 digit number located on the back of are sent at the best available rate via USPS or UPS. If you
the card on the signature line (the last 3 digits). would like a shipping quote before placing your order,
please contact Customer Service 1.800.726.0526.

THREE WAYS TO ORDER: Phone: 800.726.0526 Mail: 201 Camelot Lane  Springville, IN 47462 Fax: 800.546.7995

Private Practice Drug Courts Employee Assistance Programs SBIRT

888.297.2774

Our clinicians are available to assist you with FREE consultation and help
with administration, scoring and interpretation for all of our instruments

Shipping Information

United States Shipping Fees
Shipping Shipping
Order Total Cost Order Total Cost
$0-$40 $6 $1,001-$1,250 $30
$41-$70 $11 $1,251-$1,400 $34
$71-$125 $13 $1,401-$1,700 $38
$126-$250 $15 $1,701-$2,100 $42
$251-$500 $20 $2,101-$2,500 $47
$501-$800 $23 $2,501-$2,900* $54
$801-$1,000 $26

For Next Day Air, 2nd Day Air, or 3 Day Select shipping rates,
please call customer service.

*For orders exceeding $2,900.00 and all foreign countries,
please call for shipping charges.

Canada Shipping Information

Orders shipped to the Yukon or Northwest Territores are sent via USPS only.
All other orders shipped to Canada are sent at the best available rate via USPS
or UPS. Canada Orders for Scoring Keys only will be shipped via USPS First

Class Mail.

If you would like a shipping quote before placing your order, please contact
Customer Service 800.726.0526.

Shipping Policy

Orders received before 5 p.m. eastern time will be shipped the next business day.
Orders are shipped the best way, either United Parcel Service (UPS) ground or Post Office (USPS). Rush
orders in the US are shipped by UPS (Next day air, 2nd day air, or 3 day select) for an additional fee. Rush
orders in Canada are shipped by UPS Worldwide Express Plus, Express, or Expedited (not available in all

areas) for an additional fee. For rush orders or questions about shipping,
please call Customer Service at 800.726.0526.

All Alaska and Hawaii orders will be shipped via USPS Priority Mail.

11

Training Opportunities

If you are interested in participating in a workshop to learn how to
administer, score, and clinically interpret the SASSI or BADDS please
visit our website at www.sassitraining.com for registration information.

Training is offered in peer group settings, online live webinars, & previously recorded sessions online.
Continuing education credits and certificates of completion are provided.

201 Camelot Lane | Springville, IN 47462
Phone: 800.726.0526 | Fax: 800.546.7995

www.sassi.com | [email protected]
Free Clinical Consultation: 888.297.2774

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