| Under 21 years of age at the time of the arrest? |
Yes
No
|
| Any mechanical problems with your vehicle? |
Yes
No
|
| Was there a child under 14 years of age in the car? |
Yes
No
|
| Did you refuse to take a chemical test? |
Yes
No
|
| Was your blood alcohol level a .20 or higher? |
Yes
No
|
| If you were on the freeway, were you speeding over 30 mph beyond the posted speed limit? |
Yes
No
|
| If you were on surface streets, were you speeding over 20 mph beyond the posted speed limit? |
Yes
No
|
| If you were involved in an accident, were there any injuries to anyone in your vehicle or the other party's vehicle? |
Yes
No
|
| Did the officer ask you to perform a field sobriety test? |
Yes
No
|
| Did you perform a field sobriety test? |
Yes
No
|
| Did the officer advise you of your Miranda rights? |
Yes
No
|
| If so, did you waive your Miranda rights? |
Yes
No
|
| Did the officer ask you to blow into a hand held breath device at the scene? |
Yes
No
|
| If so, did the officer advise you that you had the right to refuse that on scene breath test? |
Yes
No
|
| If so, how many times did you blow into that on scene breath test? |
|
| At your arrest, were you advised that you had a choice between a blood or breath test? |
Yes
No
|
| If so, which did you take? |
|
| If you took a breath test, was the officer continuously observing you for fifteen minutes prior to the administration of that test? |
Yes
No
|
| If you took a chemical test (i.e., blood or breath test), do you know the result? |
Yes
No
|
| If so, what was the result? |
|
| If you took a breath test, how many times did you blow into the machine? |
|
Check each box that applies:
I'm Diabetic
I'm Epileptic
I have dental work in my mouth. |