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	Date Arrested:	*(required)
	Convicted Of:
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Q 1:	Did the officer see you driving?	Yes No
Q 2:	Did you admit to driving?	Yes No
Q 3:	Did you have a valid license at the time of this incident?	Yes No
Q 4:	Was there an accident?	Yes No
Q 5:	Did you have valid insurance at the time of this incident?	Yes No
Q 6:	Was there anything mechanically wrong with your vehicle?	Yes No
Q 7:	Did the officer have a valid and legal reason for stopping you or contacting you in or around your vehicle?	Yes No
Q 8:	Was there any delay in responding to the lights or siren?	Yes No
Q 9:	Any difficulty parking the vehicle when being pulled over?	Yes No
Q10:	Any difficulty in producing your driver's license or registration?	Yes No
Q11:	Did you admit to drinking or doing any drugs?	Yes No
Q12:	Did you take any field sobriety tests (balance or coordination tests, such as standing on one foot, etc.) before being handcuffed?	Yes No
Q13:	Have you ever suffered any injury...?	Yes No
Q14:	Did you tell the officer that you have suffered injury involving your feet, ankles, knees, or back?	Yes No
Q15:	Have you ever had a problem involving your ears, or any other problem affecting balance?	Yes No
Q16:	Did you pass the field sobriety tests?	Yes No
Q17:	Did the officer give you a breath test out in the field?	Yes No
Q18:	If so, did the officer tell you it was voluntary, that you could refuse to take this test without penalty?	Yes No
Q19:	After you were handcuffed, did the officer give you a choice of taking a blood or breath test?	Yes No
Q20:	A urine test?	Yes No
Q21:	Do you know the results of the test?	Yes No
Q22:	Are you being charged with refusing to take a chemical test?	Yes No
Q23:	If so, did you refuse to take the test after being advised that your license would be suspended if you refused?	Yes No
Q24:	Have you ever been stopped or arrested for drunk driving before?	Yes No
Q25:	Have you ever been convicted of drunk driving before?	Yes No
:: BREATH TESTS ::
Q26:	Did the breath test operator observe you carefully for at least fifteen minutes immediately before your first blow in the breath-testing machine?	Yes No
Q27:	Did the breath test machine operator do anything to make sure that you didn't belch or regurgitate, or have anything in your mouth prior to the test?	Yes No
Q28:	Did you have any problems involving your mouth, teeth, or gums on the date of the incident?	Yes No
Q29:	Did you have any food traps or gum disease, or any other holes in your mouth (teeth removed, etc.) at the time of the incident?	Yes No
Q30:	Did you blow into the machine more than two times?	Yes No
Q31:	After taking the breath test, did the officer or operator tell you that the breath test machine does not retain a sample of your breath, and that you therefore had the right to take an additional chemical test of your blood or urine at no charge to you?	Yes No
	Do you know the results of the test? If so, what was your Blood-Alcohol Content percentage?
:: BLOOD ::
Q32:	Before the blood was drawn, was the area cleansed with a non-alcohol swab?	Yes No
Q33:	Did you take the blood test voluntarily?	Yes No
Q34:	Were you threatened that blood would be taken from you against your will?	Yes No
Q35:	Did you see anyone shake the blood vial vigorously just after it was drawn?	Yes No
:: URINE ::
Q36:	Were you asked to void your bladder completely, and then wait before the actual urine sample was taken?	Yes No
Q37:	Did the officer collect more than one urine sample?	Yes No
Q38:	Was the officer present when you provided your urine sample(s)?	Yes No
	Any Additional Comments?

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