DUI QUESTIONNAIRE

1. Did the officer see you driving? yes no

2. Did you admit to driving the vehicle? yes no

3. Did the officer have a valid and legal reason for stopping you or contacting you in/near the vehicle? yes no

4. Did you admit to drinking or doing drugs? yes no

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

6. Did the officer tell you that you could refuse to take the hand-held field breath test? yes no

7. Did you fail to satisfactorily perform the balance and coordination tests as demonstrated to you by the officer? yes no

8. Did you take a blood, breath, urine or saliva test within 1-1/2 hours after finishing your last drink of alcohol? yes no

9. Did you choose the blood, breath, urine or saliva test that you took?
yes no

10. Were your test results greater than .12%? yes no

11. If you are charged with refusing to take a blood, breath, urine, or saliva test, did you refuse to take a test after being told that your license would be suspended or revoked, or that it would be a crime to refuse, if you refused?  yes no

12. Did you voluntarily take the blood test?  yes no

13. 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 machines? yes no

14. 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

15.Did you blow into the breath test machine only two (2) times?
yes no

16.Were the results within .02% of another?
yes no

17. 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

18. If you took the urine test, did you completely empty your bladder the first time you urinated? yes no

19. Did the officer collect your urine twice? yes no

20. Was the officer with you when you provided both urine samples?
yes no

21. Did you drink any alcoholic beverages, or take any drugs within 5 - 10 hours of being stopped by the officer? yes no


22. Did you feel the effects of the alcohol or drugs (i.e. feel a buzz, feel drunk or high, unable to drive)? yes no

23. Did the officer treat you fairly and professionally? yes no

24. Facts about the arrest: