Fill and Sign the Dui Form

DUI Questionnaire Name: Address: City: State: Zip: Home Phone: Business Phone: Cellular or Pager: Facsimile: E-mail address: Drivers License No.: Your class of license: State where licensed? Do you have a CDL license? Yes No If yes, class of license? ARREST : Did the officer confiscate your license? Yes No If yes, why? Booking #: Court Date: Time: Court Name: Division/Room:      Arresting Officer's Name and Badge No.: City of Arrest: What were you charged with (include Code section if known)? Was the crime for which you were arrested a felony or misdemeanor? Have you been convicted of a DUI before? Yes No If yes, when and where?   Outcome: Have you been convicted of other offenses? Yes No If yes, what and when?   Are you on probation or parole? Yes No If yes, for what? Do you have any pending cases? Yes No If yes, for what? Have you ever had a withheld judgment? Yes No Was anyone else arrested? Yes No If yes, name(s) of all persons arrested: Describe any statements you made to the police about the alleged crime: Have you discussed the alleged crime with anybody else? Yes No If so, who did you discuss it with and what did you tell them? What is the amount of the bond you posted? Are there any special bond conditions? Yes No Did you spend any time in jail? Yes No If yes, how much time? EVENTS ON ARREST DATE Date of this incident: Describe your activities from the time you woke up until your arrest: When did you eat last prior to being stopped? Are you on a special diet? Yes No. If yes, what? Time started drinking: Location drinking: What were you drinking? Time of last drink? Total drinks: Did the person that prepared your drinks use a jigger, shot glass, or measuring device?     Who witnessed your drinking? Time of stop: What law enforcement agency stopped you e.g. State Police, County Sheriff, or City Police? DRIVING BEFORE THE STOP Please describe where you drove between the time you stopped drinking alcoholic beverages or taking a drug and when the police stopped you: Where were you driving to? Please describe the weather conditions: Was there any road construction on the route you were driving? Yes No If yes, please describe the road construction and its location(s): When did you first observe the police who stopped you? Were you driving or stopped when the police contacted you? If you were driving, please describe your driving after the police first contacted you:    ACCIDENT Were you involved in an accident? Yes No If yes, please describe the accident.     STOPPED VEHICLE If your vehicle was stopped when the police first contacted you and the police did not stop you, then please answer the following questions: Were you awake or asleep when the police first contacted you? Where were you located in the vehicle when the police first contacted you? Yes No Where were your car keys located when the police first contacted you? Was the car engine running when the police first contacted you? Yes No Were the car headlights on when the police first contacted you? Yes No Was the car radio on when the police first contacted you? Yes No Was the car AC or heat on when the police first contacted you? Yes No STOP BY OFFICER Reason officer gave for stop? Do you agree with that reason? In general terms, what happened after the officer stopped you? Please indicate which of the following field sobriety tests were given and the order given by putting 1, 2, 3 in front of the appropriate test (and describe briefly how you did on the test and any adverse conditions; e.g. flashing lights, slope of ground, weather conditions, passing traffic, interruptions and the like) Horizontal gaze nystagmus test (eye test) How did you perform on test? Adverse conditions: Walk and Turn How did you perform on test? Adverse conditions: One leg stand How did you perform on test? Adverse conditions: Alphabet How did you perform on test? Adverse conditions: Counting test How did you perform on test? Adverse conditions: Other tests: How did you perform on test? Adverse conditions: Anything else happen at the scene that they consider significant? Any questions asked at the scene? Yes No If yes, what? Were you given the Miranda warnings at the scene? Yes No If yes, when? Did you waive Miranda rights? Yes No Did you ask for a lawyer at any time? Yes No If yes, at what point? After you were arrested, what type of chemical test did you take? Blood . Breath Urine No chemical test was taken Who chose what type of test that you took? What were the results of the chemical test given? Blood Alcohol Concentration (BAC) Do you know who gave the blood test (usually a phlebotomist)? Was the test taken after you were arrested given within three hours of when you last drove? Yes No I don’t know Not applicable Did you take the chemical test within one an one hour after you finished your last drink? Yes No I don’t know Not applicable After you were handcuffed, approximately how many minutes/hours passed until you arrived at the chemical test location? After you arrived at the chemical test location, approximately how many minutes/hours passed before you were administered the first chemical test? Did the officer claim that you refused to voluntarily submit to a chemical test of your breath or blood? Yes . No. If yes, please check the following that apply to you: The officer told me that my license would be suspended for one year if I refused to take a chemical test, and I refused anyway. I refused during the initial vehicle stop or contact with the officer. I refused after I was arrested (handcuffed). I refused in the patrol car (before departing the scene). I refused during the patrol car ride to the chemical test location. I refused everything from the very beginning. I refused after we had arrived at the chemical test location. The officer told me that I had refused when he first stopped me. The officer told me that I had refused while performing Field Sobriety Tests. The officer told me that I had refused when he handcuffed me. The officer told me that I had refused while in the patrol car (before leaving the scene. The office told me that I had refused while en route to the chemical test location. The officer told me that I had refused while at the chemical test location, however he did not tell me that I would lose my license if I refused. The officer told me that I could refuse the test when he used a hand-held breathalyzer, so I did. The officer never told me that I had to take a test, and he didn’t tell me that if I refused my license would be suspended. Other: Did the officer take your driver’s license or give you an Order of Suspension/Revocation and Temporary Driver License? Yes No IF BREATH TEST: How long were you observed prior to the test? Did you have anything in your mouth (gum, chew, tongue ring)? Yes No Did the officer check your mouth? Yes No Do you remembering burping or belching before test? Yes No Anything unusual happen with respect to the breath test? Did the officer have any trouble programming it? Yes No If so, please describe:      How many officers were in the room when the breath test was administered? Did the officer ask you if you had any exposure to paints, glues, solvents or consumed any alcohol of solvent other than ethyl alcohol? Yes No If yes, what did you tell the officer? Was that answer correct? Yes No If no, how would you have answered the question? HEALTH HISTORY Any physical defects or limitations that affect their balance, speech or dexterity? Yes No If yes, what? On date of incident? Yes No What it was? Under doctor’s care? Yes No How it affects you{. Do you have a hiatal hernia? Yes No Do you have acid reflux? Yes No Were you taking any drugs or medications? Yes No If yes, what? Are there any warnings with respect to the use of medication with alcohol? Yes No Do you have a history in your family of diabetes? Yes No If yes, who? Have you ever been checked for diabetes? Yes No Do you have false teeth or plates? Yes No Do you believe that you were under the influence? Yes No Do you believe that you were drunk? Yes No Do you believe that your driving was affected by the alcohol that you consumed? Yes No What would you like to see happen with respect to the pending charge? (Dismissed, reduced, etc.)? Please provide information about witnesses who saw you drinking or who had contact with you at any time before or within a reasonable period of time after the arrest. Please list the name(s), address(es) and telephone number(s) of all witnesses.