1. Did the officer see you driving?

yes

no

I don't know/not applicable

-
2. Did you admit to driving the vehicle?

yes

no

I don't know/not applicable

-
3. Did the officer have a valid and legal reason for stopping you or contacting you in/near the vehicle?

yes

no

I don't know/not applicable

-
4. Did you admit to drinking or doing drugs?

yes

no

I don't know/not applicable

-
5. Did you take any field balance and coordination exercises before arrest and handcuffing? (i.e. standing on one foot, walking a straight line, etc.)

yes

no

I don't know/not applicable

-
6. Did the officer tell you that you could refuse to take the hand-held field breath test?

yes

no

I don't know/not applicable

-
7. Did you fail the field balance and coordination exercises?

yes

no

I don't know/not applicable

-
8. Did you take the blood, breath or urine test within 1 ½ hours after finishing your last drink?

yes

no

I don't know/not applicable

-
9. Did you choose the blood, breath, or urine test that you took?

yes

no

I don't know/not applicable

-
10. Your test results were greater than .12%?

yes

no

I don't know/not applicable

11.  If you are charged with refusing to take a blood, breath, or urine test, did you refuse to take a test after being told that your license would be suspended or revoked if you refused?

yes

no

I don't know/not applicable

BLOOD

12. Before taking your blood, your arm was wiped with a non-alcoholic swab to prevent contamination?

yes

no

I don't know/not applicable

13. I voluntarily took the blood test?

yes

no

I don't know/not applicable

14. The phlebotomist (blood taker) mixed the blood tubes very well before giving them to the officers?

yes

no

I don't know/not applicable

BREATH

15. Did the breath test machine operator watch you closely for at least 15 minutes (20 minutes is recommended) before your first breath into each of the breath machine(s)?

yes

no

I don't know/not applicable

16. Did the breath test machine operator check to make sure you didn't burp, belch, vomit, or have anything in your mouth prior to the test?

yes

no

I don't know/not applicable

17. Did you blow into the breath test machine only two (2) times?

yes

no

I don't know/not applicable

18. Were the results within .02% of one another?

yes

no

I don't know/not applicable

19. After completing the breath test, did the officer/operator tell you that the breath test machine destroys your breath sample and therefore, you had the additional right to take a blood or urine test free of charge?

yes

no

I don't know/not applicable

URINE

20. Did you completely empty your bladder the first time you urinated?

yes

no

I don't know/not applicable

21. Did the officer collect your urine twice?

yes

no

I don't know/not applicable

22. Was the officer with you when you provided both urine samples?

yes

no

I don't know/not applicable

LASTLY

23. Did you drink any alcoholic beverages, or take any drugs, within 5-10 hours of being stopped by the officer?

yes

no

I don't know/not applicable

24. Did you feel the effects of the alcohol or drugs (i.e. feel a ‘buzz,' feel drunk or high, unable to drive)?

yes

no

I don't know/not applicable

25. Did the officer treat you fairly and professionally?

yes

no

I don't know/not applicable

=======================================

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DATE OF ARREST:    *

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