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Start by clicking the "Name" space provided below. Input your name, then Tab to move to the next response. |
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1) About how many minutes had you been driving when you were stopped by the police? |
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| 2) Did the officer actually witness you driving?
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| 3) Did the officer tell you why he/she stopped your vehicle? |
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| 4) If the answer to question #3 was yes, indicate the reason for the vehicle stop (check all that apply): |
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| 5) About what time were you stopped? |
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| 6) After you were stopped were you asked if you had been drinking? |
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| 7) If you answered yes to question #6, what did you tell the officer? |
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| 8) Did the officer ask you if you had any medical problems, or were under the care of a doctor and/or physician? |
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| 9) Did the officer ask you when you had last slept? |
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| 10) Did the officer ask you when you had last eaten? |
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| 11) About how many minutes elapsed from the time that you were stopped until you were placed in handcuffs? |
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| 12) Were you required to perform any field balance and/or coordination exercises prior to being hand cuffed? |
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| 13) If the answer to question #12 was yes, please check the field tests you were required to perform (check all that apply): |
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| 14) Did you blow into a breath tester at the stop (also known as a "hand held PAS")? |
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| 15) Which chemical test did you take (check all that apply): |
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| 16) From the time you were hand cuffed, about how many minutes did it take to arrive at the location where the chemical test was given to you? |
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| 17) From the time you arrived at the location where the chemical test was given to you, about how many minutes passed until you were first tested? |
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| 18) From the time you finished your last alcoholic beverage, about how much time elapsed to the time you submitted to a chemical test? |
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| 19) Were you allowed to select the test? |
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| 20) If you gave a breath test, did the officer advise you that you were allowed to ask to receive a blood or urine test? |
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| 21) If you gave a breath test, did the officer that tested you keep a constant eye on you for 15 minutes before the breath test was given? |
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| 22) If you gave a breath test, and also took an additional test, which test did you take (check all that apply): |
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| Personal Information: |
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| Date of Birth |
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| Weight |
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| When you drink alcohol, which type of beverage do you normally consume (check all that apply): |
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| To complete the next section, assume that the amount of alcohol in 1.2 ounces of 80 proof hard liquor is equivalent to one 12 ounce beer, or four ounces of unfortified wine. |
| In a given week how many drinks would you normally consume? |
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| When did you last eat prior to submitting to the test? |
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| What did you eat? |
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| About how many minutes elapsed from the time that you finished your final alcoholic beverage to the time you were stopped by the police? |
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| Additional Comments: |
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