Did the officer see you driving? Yes No
Did you admit to driving the vehicle? Yes No
Did the officer have a valid and legal reason for stopping you or contacting you in/near the vehicle? Yes No
Did you admit to drinking or doing drugs? Yes No
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
Did the officer tell you that you could refuse to take the hand-held field breath test? Yes No
Did you fail to satisfactorily perform the balance and coordination tests as demonstrated to you by the officer? Yes No
Did you take a blood, breath, urine or saliva test within 1 1/2 hours after finishing your last drink of alcohol? Yes No
Did you choose the blood, breath, urine or saliva test that you took? Yes No
Were your test results greater than .12%? Yes No
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
Did you voluntarily take the blood test? Yes No
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
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
Did you blow into the breath test machine only two(2) times? Yes No
Were the results within .02% of another? Yes No
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
If you took the urine test, did you completely empty your bladder the first time you urinated? Yes No
Did the officer collect your urine twice? Yes No
Was the officer with you when you provided both urine samples? Yes No
Did you drink any alcoholic bevarages, or take any drugs within 5-10 hours of being stopped by the officer? Yes No
Did you feel the effects of the alcohol or drugs (i.e. feel a buzz, feel drunk or high, unable to drive)? Yes No
Did the officer treat you fairly and professionally? Yes No
