D. SHACKELFORD SHIPP, JD
ATTORNEY AT LAW
300 VAGNEUR LANE
BASALT, COLORADO 81621
(970) 927-2255
FAX: “Master Trial Advocate”
(970) 927-6633 NITA, Notre Dame Law School
E-MAIL: Who’s Who in America Law
danshipplaw@comcast.net Nat’l College for DUI Defense
CONFIDENTIAL INFORMATION
TRUTHFULLY COMPLETE EVERY PART OF THIS FORM IN GREAT DETAIL AS SOON AS POSSIBLE. DETAILED ANSWERS WILL BE USED TO EVALUATE YOUR DEFENSE. ALL PERSONAL DATA IS CONFIDENTIAL. USE EXTRA SHEETS OF PAPER WHEN WE DO NOT SUPPLY ENOUGH ROOM FOR YOUR ANSWERS. PLEASE MAKE A COPY OF THIS QUESTIONNAIRE FOR YOURSELF BEFORE RETURNING IT TO OUR OFFICE.
(1)CLIENT INTAKE QUESTIONNAIRE
Full Name _________________________________________________ Nickname _____________________
Birth Date ___________________Age:____________Birthplace:____________________________________
Social Security Number _____________________ How were you referred to us(or how did you learn about)
our office? (Circle one ) INTERNET: Google, Bing, Yahoo, Dex, Media – .PHONEBOOKS:
,
Names & Numbers, _ Dex, Yellow Pages – RADIO, TELEVISION, NEWSPAPER
REFERRED BY: name)___________________________________Other:_____________________________
IMPORTANT QUICK REFERENCE DATA
DATE OF ARREST
____/____/____
M Tu W Th F Sa Su
(circle one) |
TIME OF ARREST
AM/PM
(circle one) |
COURT DATE
_____/_____/20_____ ______________AM/PM
|
DUI OFFENSE (1ST.2ND.ECT.) |
COUNTY HANDLING CASE
Please circle one:
Garfield: Rifle Glenwood Sprgs
Pitkin Eagle Summit Mesa
Other:____________________ |
||
HOME ADDRESS:Street _______________________________________________
City _________________ State ________ ZIP ______
E-MAIL:__________________________________ |
HOME PHONE( )CELL ( ) OTHER ( ) |
ALLEGED BAC%
1ST___________
2ND __________
Tests pending? Yes/No Refused Test? Yes/No |
||||
OTHER MAILING ADDRESS: (to be used for mail in this case) Driver’s License No.
Street ______________________________City ______________ State __________ZIP ________________ Driver’s License No._______________________ State Licensed In________________________________ Restrictions on License? Yes/No (circle one) If so what_________________________________________ Possess A Commercial Driver’s License (CDL)?_____________Have you had any moving violations in the State of Colorado in the last 18 months? If so, please explain:______________________________________ ________________________________________________________________________________________ |
||||||
(2) EMPLOYMENT
Employer_________________________________________________________________________________
Job Title__________________________________________________ How Long?______________________
Annual Income: _______Under $25,000 _______$25,000 to $50,000 _______ Over $50,000 _________
Prior Employment___________________________________________________________________________
How long? _______________Any problems with present employment? ________________________________
Vehicle used in employment? Yes/No (circle one)
Would you be fired, restricted in duties, passed over for promotion or demoted/unable to work?
a) if convicted of DUI?_________________________________________________________________
b) if your license of suspended?__________________________________________________________
c) if suspended, but you had a “work permit”?_______________________________________________
Do you have a company owned vehicle? Yes/No (circle one)
Are you insured by your company’s insurance carrier? Yes/No/Not Applicable (circle one)
How many miles driven to/from/at work on a routine day?___________________________________________
How many total miles driven each week (business and personal miles) _________________________________
Is public transportation readily available to you? Yes/No (circle one)
What is the possibility you could relocate to another state IF ABSOLUTELY NECESSARY to protect your right to drive?______________________________________________________________________________
(3) EDUCATION
High School_______________________________________ Last Year Attended ________________________
City & State______________________________________________________ Graduated Yes/No (circle one)
College___________________________________________ Last Year Attended ________________________
Major___________________________________________________________ Graduated Yes/No (circle one)
GRAD/TECH School_______________________________ Last Year Attended ________________________
Special Training (trades, vocational, businesscollege, post graduate, etc.)_______________________________
(4) FAMILY
Married/Single/Divorced/Widowed/Engaged (circle one), If married, how long? ________________________
Spouse/Partner’s Name_______________________________________________________________________
Spouse/Partner’s Employment_________________________________________________________________
Does your spouse/partner drink alcoholic beverages? Yes/No (circle one) If so how much? Daily/Weekly/
Occasionally (circle one)
Please provide the name and phone number of an immediate family member who does not reside with you who will most likely know your whereabouts at all times:
Name______________________________________________ Phone number___________________________
(5) POSTING BOND
Was a bond required? Yes/No (circle one). If no, skip this section. If so, How much? _____________________
Form of bond posted: Cash/Credit Card/Real Estate/Family/Friend/Commercial bondsman? (circle one)
Who:___________________________________What time did you post bond? At ________________ o’clock ___________ Min. on ____/____/____: Phone No.__________________________
(6) Department of Motor VEHICLES HEARING
If BAC was .080 or more, or you refused testing, do you want me to handle your license suspension hearings (assuming that a timely request has been filed)? Yes/No (circle one)
If so, have you filed a timely DMV request for hearing? Yes / No (circle one)
(or do you want our office to assist you in requesting the hearing)? Yes / No (circle one)
Do you understand that you have (had) a very short amount of time (7 days after receipt of the notice of revocation in which to appeal an administrative suspension)? Yes / No (circle one)
Do you understand that these administrative proceedings are separate proceedings from your DUI and any other pending criminal (traffic) offenses? Yes / No (circle one)
Have you provided me with everything you have received from the Department of Public Safety, any other State’s licensing agency or from the arresting officer? Yes / No (circle one)
Have you received notification from the arresting officer or from the Colorado Department of Public Safety notifying you of a suspension or revocation of your privilege to drive? Yes/No (circle one) When?___________, and if so please provide me copies.
(For persons licensed in another state) A refusal in Colorado may or may not affect your right to drive in your home state. When you drop off this questionnaire, ask for the phone number of an attorney from your state who specializes in DUI defense, so that we can get an answer to that question.
(7) MEDICAL HISTORY
Weight________________________________Height________________________Age___________________
General health conditions_____________________________________________________________________
Any physical disabilities?_____________________________________________________________________
Had you been involved in any special diet or exercise programs?: Yes / No
If yes please list specifics:____________________________________________________________________
__________________________________________________________________________________________
At time of your arrest, were you dieting or fasting? Yes / No (circle one) If yes, for how long and what type of diet were you on?___________________________________________________________________________
Any prescribed medications taken by you, daily or periodically? Yes / No (circle one)
If so, what drug and for what condition?_________________________________________________________
Any non-prescription medicine, herbal or Chinese supplement(s) taken by you daily or periodically? Yes / No
If so, what?________________________________________________________________________________
For what symptoms or indications?_____________________________________________________________
How much was taken?_______________________________________________________________________
What time was it taken?______________________________________________________________________
Who prescribed it?__________________________________________________________________________
Were you taking ANY medicine, cough syrup, aspirin, Tagamet, inhalers, etc. (prescribed or over-the-counter) when arrested (within 24 hours of arrest)? Yes / No (circle one)
What?______________________________ Why?_____________________________________
Any Specific health problems? (Explain in the blanks that follow)
Were you sick at time of arrest? If so, with what?__________________________________________________
Did you have a fever? If so, what was your temperature (approximately)_______________________________
Did you go to a doctor with illness? If so, who and when? __________________________________________
Hearing, inner ear or auditory problems__________________________________________________________
Heart, blood pressure, angina or circulatory_______________________________________________________
Dizziness or depth perception__________________________________________________________________
Eyes, including any surgery or injuries___________________________________________________________
Glasses Yes / No (circle one) Contact Lens Yes / No If so, “hard” lenses? Yes / No (circle one)
Allergies__________________________________________________________________________________
False Teeth or “Bridge” work: Yes/No (circle one) Full/Partial Upper/Lower (circle one)
If so, describe in detail:_______________________________________________________________________
If so, what type of dental adhesive do you use? None, or_______________________________________ Brand
Did you have a tongue ring or other piercing in place when doing a breath test? Yes / No (circle one).
Problems with walking or standing (orthopedic or other)____________________________________________
Legs______________________________________________________________________________________
Knees_____________________________________________________________________________________
Feet______________________________________________________________________________________
Arthritis___________________________________________________________________________________
Arms_____________________________________________________________________________________
Stomach or Esophagus (Hiatal hernia, gastric reflux, chronic or regular heartburn, etc.) _________________________________________________________________________________________
Lungs/Breathing/Asthma/Emphysema___________________________________________________________
Diabetes, hypoglycemia or “blood sugar” irregularities?_____________________________________________
Do you ever suffer from “heartburn” or “acid stomach”? Yes / No (circle one)
At time of your arrest, did you have any problems with this stomach/esophagus condition prior to or during your confrontation with police? Yes/No/Don’t Recall/ N/A. If so, describe: ____________________________
__________________________________________________________________________________________
Have you EVER suffered significant injuries from any traumatic event (e.g. childhood injuries, etc.) Yes/No (circle one) If so, give details: _________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
At time of your arrest, did you have blood in your mouth for any reason? Yes / No (circle one) If so, describe __________________________________________________________________________________________
Do you smoke? Yes/No (circle one) If yes, how much?_____________________________________________
At time of your arrest, were you smoking? Yes / No (circle one)
__________________________________________________________________________________________
Any history of mental illness or disorder? Yes / No (circle one) If so, describe: __________________________
__________________________________________________________________________________________
Ever been treated by a psychiatrist or psychologist? Yes/ No (circle one)
Who_____________________________________________ Where___________________________________
When_________________________ Result______________________________________________________
Have you ever been involved in any alcohol or drug treatment program? Yes / No (circle one)
If yes to any of the foregoing, why, where and when were you treated?_________________________________
__________________________________________________________________________________________
Have you ever attended Alcoholics Anonymous, AL ANON or similar substance abuse support groups? Yes/No (circle one), Describe ________________________________________________________________________
Do you believe that you are presently dependent on alcohol or drugs of any type? ________________________
Have any members of your immediate family (including aunts, uncles and grandparents) had a problem with alcohol/drugs? If so, who?____________________________________________________________________
Had you been involved in unusual work or other activities (such as two jobs, overtime, etc.) which might cause fatigue, eyestrain, etc.?:_______________________ If yes, please specify______________________________
____________________________________________________________________________________________________________________________________________________________________________________
Does your employment expose you to chemicals, solvents, gases, volatile liquids, etc? Yes / No
Please Descibe:_____________________________________________________________________________
FEMALES, if you were on your period, the blood alcohol level shown by breath tests may be elevated by a small amount. If you are only minimally (.002 -.003) over the limit please address where you were time wise with respect to your period. __________________________________________________________________
Did you use a hot tub within 6 hours of your arrest? Yes / No (circle one)
(8) AWARDS/RECOGNITIONS/HONORS
Describe any business, educational or professional awards, honors, recognitions or accolades _______________
__________________________________________________________________________________________
__________________________________________________________________________________________
(9) ALCOHOL/DRUGS
Usual alcoholic beverage you drink _____________________________________________________________
Usual drug to use ___________________________________________________________________________
Is there a particular alcoholic beverage you do not drink? Yes / No (circle one) what?:_____________________
__________________________________________________________________________________________
Do you switch around, depending on mood? Yes / No (circle one)
In general, when do you drink alcoholic beverages or use drugs? _____________________________________
__________________________________________________________________________________________
At the time of your arrest, what was the reason/occasion/cause for you to have been drinking or using drugs prior to driving? ____________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
How often per week (or per month) do you consume alcohol/drugs? ___________________________________
__________________________________________________________________________________________
On a day/evening when you are consuming alcohol/drugs, how much do you normally use? ________________
__________________________________________________________________________________________
Is it common for you to “mix” or change the type of alcohol that you use (e.g. drink beer and have occasional “shots”)? __________________________________________________________________________________
At the time of your arrest, did you “mix” types of alcohol/drugs prior to being arrested? ___________________
(10) EFFECTS OF A POSSIBLE CONVICTION
What effect would a conviction have on you personally? ___________________________________________
_________________________________________________________________________________________
Would a conviction affect your marriage (relationship)? ____________________________________________
Are you involved in any “domestic” (divorce, child custody, etc.) case or judicial dispute that a DUI conviction or license suspension might affect? Yes/No (circle one) If so, explain: _________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Do you ever have to “prove” insurability to drive a “company” vehicle? Yes / No (circle one)
Do you ever need to rent a rental car, for personal/business use? Yes / No (circle one)
In what ways would a DUI conviction or license suspension affect your employment? Explain: _________________________________________________________________________________________
Have you investigated the cost of insurance in the event of a DUI conviction or suspension of your license?
Yes / No (circle one) Describe:_________________________________________________________________
Are you professionally licensed (i.e. teacher, attorney, registered nurse, etc.) or specially licensed (i.e. pilot, cab driver, realtor, stockbroker, etc.) such that you may lose such license as a result of a conviction? Yes / No: _________________________________________________________________________________________
_________________________________________________________________________________________
Does your job involve “security clearance” or “top secret” status such that your employer may be unwilling to accept a DUI conviction and let you continue working? Yes / No (circle one)
If your license is issued by another state (other than Colorado) are you aware that full penalties, including possible suspension of your license and added insurance assessments required by your state may go into effect against you at home if you plead guilty or are convicted in Colorado? Yes / No (circle one)
(11) EVENTS OF THE DAY OF ARREST
Did you sleep the night before? Yes / No (circle one) How long? _____________________________________
Was your day particularly depressing, exhausting, frustrating or sad? Explain: ___________________________
__________________________________________________________________________________________
What were the weather conditions at the time of arrest:______________________________________________
During the 24-hour period just prior to your arrest, describe your activities IN GREAT DETAIL from the time you woke up until the arrest occurred (list them in chronological order): (USE BACK OF THIS SHEET IF NECESSARY Tell me who you were with, what you drank, at what time the drinks were consumed, what size of drinks that you had, etc.____________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Describe actions and conversations upon leaving the place where you were just prior to being arrest: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________
What was your intended destination when you were arrested? ________________________________________
__________________________________________________________________________________________
Where were you parked prior to leaving your last location? __________________________________________
Was it raining or snowing? (Yes/No (circle one) Other conditions ____________________________________
With whom did you last talk or see before arrest? __________________________________________________
Address: _________________________________ Phone: __________________________________________
Friend? Yes/No (circle one) Relationship: __________________________________________
What did you talk about? _____________________________________________________________________
__________________________________________________________________________________________
Do I have your permission to interview the person/people named above? Yes / No (circle one)
(12) ROUTE DRIVEN BEFORE ARREST
What route did you follow from your last location before the arrest occurred? ___________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Traffic conditions you encountered on roadways prior to being arrested? _______________________________
Was the arresting officer state patrol, sheriff’s deputy, city police, other? (circle one).
Was he assisted by another officer? State patrol, sheriff’s deputy, city police, other? (circle one).
(13) ROADBLOCKS
Was arrest at a roadblock or license check? Yes / No (circle one). If no, skip this section.
How far ahead did you see it? _________________________________________________________________
Were any signs posted as you approached this location, such as “sobriety checkpoint” or “roadblock ahead”? Yes / No (circle one)
How many other cars were there ahead of yours? __________________________________________________
Did any cars ahead of you get “pulled over” for further testing of their driver(s)?Yes / No
How long did you wait in line before getting to an officer? __________________________________________
Were you given any advance notice of the roadblock (i.e. was the roadblock well marked and visible from
Flares, fluorescent cones, blue lights, etc.) Yes / No (circle one) if so, give details.________________________
____________________________________________________________________________________________________________________________________________________________________________________
Describe the exact wording and actions of the FIRST officer who approached your window (i.e. did he/she take your license first, ask questions first, put a breath tester in your mouth first, ask you to look at and follow his/her finger, etc.)________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Were you stopped and questioned more that once while “in line”? Yes/No (circle one)
Were you stopped by a “chase” car after turning around (U-turn) or turning into a driveway, parking lot or down a side street? Yes / No (circle one) If so, give details why you turned around or failed to go through the
roadblock and describe where you were trying to go: _______________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
(14) AUTOMOBILE YOU WERE DRIVING
Make_______________________ Model_______________________ 2Dr/4Dr/wagon/van/pickup (circle one)
Owner of vehicle:__________________________________________________________________________
When the officer first came in contact with your car, what was occurring ? I was:
(CIRCLE ALL THAT APPLY)
Stopped, in car-awake Yes / No. Stopped, out of car Yes / No. Stopped, inside car-asleep Yes / No. Wreck, unconscious Yes / No. Wreck, outside of car Yes / No. Wreck, left the scene Ye s /No.
Other ____________________________________________________________________________________
Radio: On / Off: Windows: Up / Down: Head Lights: On / Off: Changing Lanes? Yes / No Were you smoking? Yes / No: Were you in a conversation with a passenger? Yes / No: Adjusting the radio? Yes / No
Were you otherwise distracted within the vehicle? Yes / No If so, how: _______________________________
____________________________________________________________________________________________________________________________________________________________________________________
Going straight down the road? Yes / No Turning? Yes / No Backing up? Yes / No
Stopped? Yes / No
(15) BLUE LIGHT
Blue light used by officer? Yes/No (circle one) Siren Used? Yes/No (circle one)
Did you see the officer before blue light came on? Yes/No (circle one)
Where was officer? Coming from other direction/Following/Side of Road/ Unknown (circle one)
What speed were you traveling, or were you “stopped” or parked? ____________________________________
__________________________________________________________________________________________
In what lane were you ? ______________________________________________________________________
Immediately after seeing the blue light, what was the first thing you did? _______________________________
__________________________________________________________________________________________
How long (approximately) did it take you to pull over and stop once you saw the blue/red lights? _______________minutes_______seconds. What did you think you had done wrong to attract the officer’s attention?____________________________________________________________________________________________________________________________________________________________________________
In relation to your vehicle, where did the officer park the police vehicle? ______________________________
_________________________________________________________________________________________
Diagram relative location of vehicles on the roadway after parking in response to the officer’s blue light:
Describe first thing you did after stopping vehicle: _________________________________________________
__________________________________________________________________________________________
Did you try to cover up the smell of alcohol/drugs on your breath? Yes / No. If yes, how?__________________
Did you turn off the engine? Yes / No Did you turn off your lights? Yes / No
Did you turn off the radio? Yes / No Did you roll down the window? Yes / No
Did you get out of your vehicle? Yes / No At the Officer’s Instruction/On Your Own
Did you have any difficulty doing any of these things? Yes / No (circle one)
(16) DRIVER’S LICENSE AND INITIAL CONTACT BY THE OFFICER
Any restrictions on your license?_______________________________________________________________
If so, were these restrictions being complied with when stopped? _____________________________________
Where was your license when you first began looking for it? Please describe in detail_____________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Did you get it “ready” before the officer asked for it? Yes / No (circle one)
If you did not have your “plastic” license in your possession at the time of the “stop”, give details about where the license was, and why it was not in your possession: _____________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What were the officer’s first words to you when he/she encountered you? Be Exact___________________
____________________________________________________________________________________________________________________________________________________________________________________
What did you say in response? _________________________________________________________________
What did you say in response to this question? ____________________________________________________
Other conversation between you and the officer: __________________________________________________
__________________________________________________________________________________________
Were there any witnesses to this conversation? Yes/No (circle one) If ALL witnesses not already listed, list them here (Names, addresses and phone number): _________________________________________________
__________________________________________________________________________________________
Did officer comment on your breath “smelling like alcohol/drugs”, or similar words? Yes/No
Were any containers of alcohol/drugs visible to the officer as he/she observed from outside your vehicle?Yes/ No/ Not Certain (circle one).If so, what type and were they full and unopened, partially full (seal broken) or empties:___________________________________________________________________________________
__________________________________________________________________________________________
Did the officer confiscate the containers, for use as “evidence” against you in this case? Yes/No/Not Certain (circle one)
Was any other suspicious or illegal item or items (i.e. weapon, rolling papers, bong, marijuana pipe or “roaches”?) visible from outside you vehicle when the police approached your vehicle?
Yes / No (circle one) If so, give details __________________________________________________________
__________________________________________________________________________________________
(17) CONVERSATION BEFORE (OR IN CONNECTION WITH) ARREST
When (if ever) did the officer say, “You are under arrest” (or similar words to indicate that you were not free to leave) or otherwise indicated by his actions (example: taking your license and not returning it) that you could not “just walk away” from the scene?___________________________________________________________
__________________________________________________________________________________________
______________________________________________________________________________Were you questioned by any other officer(s) after this “time of obvious detention”? Yes/ No /N/A (circle one) If so, give specific questions, answers and other details: _____________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
At the time of these questions being asked, had the officer already take your license (or other important documents) from you? Yes / No (circle one), If so, did you ever have them returned to you before his/her questions began? Yes / No (circle one)
Did you give any “spontaneous” or voluntary statements to the police, which were not prompted by or made in response to their interrogations? [i.e. “Officer, please give me a break”]
Yes/No (circle one) If so, what? _______________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What was your response/reaction to learning that you were going to be detained or arrested? __________________________________________________________________________________________
What was the next thing officer said to you after you were told that you were under arrest/being detained? __________________________________________________________________________________________
__________________________________________________________________________________________
Your response _____________________________________________________________________________
__________________________________________________________________________________________
Next (etc.?) ________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Did the arresting officer ever tell you (at the scene or after you were taken in) what other offenses that he/she was charging you with? Yes/No (circle one) If so, what did the officer say? _
__________________________________________________________________________________________
If not, when did you first learn that you had been charged with this (these) offense(s)? ____________________
__________________________________________________________________________________________
(18) INSURANCE AND REGISTRATION
Did the officer ask for “proof of insurance”? Yes/ No (circle one)
Did you produce proof of insurance it? Yes/No/Had no card (circle one)
In what state was the insurance issued? ________________. Was it yours? Yes/No (circle one). If no, whose? ________________________________________________________________________________________
What company provided you coverage? ________________________________________________________
Did officer ask for registration papers? Yes/No (circle one). In what state registered? ____________________
(NOTE: IF CHARGED WITH “NO PROOF OF INSURANCE”, PROVIDE PROOF OF INSURANCE TO THIS OFFICE WITH THESE ANSWERS)
(19) FIELD SOBRIETY TESTS OR ROADSIDE SOBRIETY TESTS
Did the officer direct you to perform coordination/roadside sobriety tests? Yes / No (circle one) Did the officer tell you the tests were voluntary and it was your choice? Yes / No (circle one)
Exactly when (how many minutes, seconds after getting out of car) were you first requested to (told to) perform these tests? ________________________________________________________________________________
__________________________________________________________________________________________
What was the exact wording used by the officer in making this “request or demand”? ___________________
__________________________________________________________________________________________
Did the officer ask you any preliminary questions about your physical limitations or impairments or present illnesses/medications before beginning the “test” with you? Yes/No (circle one). If so, what? __________________________________________________________________________________________
Describe the shoes (if any) you were wearing during the tests: _______________________________________
Shoes On/Off (circle one) Were heels higher than 2 1/2 inches Yes / No (circle one).
Were there any street lights (or other lights) above or near your locations to illuminate the area? Yes / No (circle one) Describe the lighting in the area: ___________________________________________________________
__________________________________________________________________________________________
Before doing any or all of these tests, did you request to call an attorney? Yes / No (circle one)
Where were lights in relation to tests (including car headlights)? (Diagram on back of this page)
Describe the location where you performed these roadside sobriety test, including any “moving” traffic conditions, noise levels, lights or turbulence from passing vehicles, wind, etc.: (Very Important)_________________________________________________________________________________
__________________________________________________________________________________________
What were the agility or coordination tests that you performed in the order given and how did you do? [NOTE: This question is not directed to any hand-held breath testing device used, which has its own section below.]
Test Type | Officer said I did OK/Failed | I thought I did OK/Failed |
(1) | ||
(2) | ||
(3) | ||
(4) | ||
(5) | ||
(6) |
Road or shoulder conditions where tests were given: (circle where applicable)
Level / Sloping Smooth / Rocky Wet / Dry Grass / Dirt Holes / Ruts
Wide / Narrow Windy / Calm Line to Walk / No line to Walk
Raining / Snowing Hot / Cold Glasses On / Off / N/A Contacts In / Out/N/A
Crying / Nervous / Can’t Recall Traffic: Heavy / Light
Distractions? Yes / No (circle one) What? __________________________________________
______________________________________________________________________________
Emergency lights still flashing while tests being conducted? Yes / No (circle one)
People gathered? Yes/No (circle one) How many? ___________________________________________
Temperature _________ Humidity __________ Moonlight? Yes / No (circle one)
Explain in writing and with diagrams (such as footprints) the manner in which the officer instructed you, or demonstrated to you how each test was to be performed (add extra sheets if needed) __________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Were you asked to recite the alphabet? (or part of the alphabet)? Yes No (circle one)______________________________________________________________________________________
Did you officer say the ABC’s through the letter Z before asking you to? Yes / No (circle one)
Did the officer demonstrate any or all the tests before you did them? Yes / No (circle one)
If so, describe which ones and exactly what he/she did or said before asking you to perform: __________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What compelled you or caused you to attempt to perform these voluntary field sobriety tests? __________________________________________________________________________________________
Did the officer ever indicate to you that these agility test were 100% voluntary or optional? Yes / No (circle one)
Did the officer ever indicate (in any manner or fashion) that you by not taking the field sobriety tests, that you would either lose your license or be subjected to immediate arrest or would be convicted of DUI for refusing? Yes/No (circle one)
If so, what exact words or conduct were used? ___________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Did you ever blow into HAND-HELD BREATH TESTER at the scene of the stop? Yes / No/N/A
If so, were you permitted to SEE the digital reading that the tester indicated? Yes /No /N/A
If so, what was it?___________________________________________________________________________
If not permitted to see it, did the officer tell you the result? Yes /No /Not Applicable (circle one)
What did he/she say about the result? ___________________________________________________________
Before having you blow into the hand-held breath tester, did the officer advise you that you could either refuse or agree to provide a sample of your breath for such preliminary testing? Yes/No (circle one) If so, give details: _________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Were you asked or required to “blow” more than one time into the hand-held breath machine? Yes/No (circle one) Give details, if so: ______________________________________________________________________
_________________________________________________________________________________________
Did the officer ever indicate (in any manner or fashion) that by not blowing into the hand-held breath tester that you would lose your license or be subject to arrest? Yes/No (circle one)
If so, what exact wording or conduct did the officer use to convince you to “blow” into the hand-held tester? _________________________________________________________________________________________
_________________________________________________________________________________________
At what point was the hand-held test given to you? Before/Midway/After/N/A(circle one) the other physical agility tests that you described in Section 19?
Was there any physical or vocal resistance by you or interference with the officer’s arrest procedures by others while you were being detained or arrested? Yes/No (circle one) If so, explain fully:______________________
fully:_____________________________________________________________________________________
_________________________________________________________________________________________
Did you ever curse the officer or use profanity “directed” at him/her? Yes/No (circle one)
If so, give details: __________________________________________________________________________
_________________________________________________________________________________________
(20) ARREST
Was any one with you when you were arrested? Yes/No (circle one). If so, who and what is the address and phone number? _____________________________________________________________________________
Were you ever told you were “ under arrest” or similar wording to indicate that you were going to jail? Yes / No (circle one) When, and by whom? ______________________________________________________________
Were you told exactly why you were being arrested? Yes / No (circle one)
If the officer told you one offense (e.g. DUI), did he/she also advise you about being charged with the other traffic offenses for which you were ticketed? Yes / No (circle one)
What was the last thing you said (or did) before the officer told you that you were under arrest?______________________________________________________________________________________________________________________________________________________________________________What was the officer’s exact wording to you about your being placed under arrest?______________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(21) EXPRESS CONSENT RIGHTS
At the time you were offered a breath/blood/urine test by the officer (not the hand field alcohol sensor) were you read or advised of your express consent rights as follows:
“ (Mr. or Mrs.) _______ You are required to take, complete or cooperate in completing an evidential chemical test to determine the alcoholic content of your blood or breath. The chemical test you choose is the test you will be taking. You cannot choose a different test later. If you choose a blood test, two (2) tubes of blood will be drawn. One tube belongs to you and you may have it tested at a Health Department Certified Independent Laboratory of your choice. If you choose a breath test, two (2) breath samples will be analyzed by a certified evidential breath alcohol testing device following an approved standard operating procedure. You will not receive a sample to have independently tested by a certified laboratory.
If you refuse to take, complete or cooperate in completing an evidential chemical test to determine the alcoholic content of your blood or breath, your driving privilege may be revoked..”
Yes/No/Not certain (circle one)
When you heard these words, did you understand these warnings and the penalties and consequences stated by the officer? Yes/No (circle one)
If no, what was you interpretation of the words the officer read you?_______________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
If your license was FROM OUTSIDE THE STATE OF COLORADO OR IF YOUR LICENSE WAS COMMERICAL were you given any additional warnings by the officer? Yes / No (circle one). What?______________________________________
______________________________________________________________________________
If you “took the officers test(s)”, answer the following two questions:
Did you realize that you had an absolute right to refuse the State-administered test? Yes/No
Did the officer “speed read” or hurry the reading of these warnings? Yes/No (circle one) If you believed then or believe now that the reading of these advisements was deficient in any way, please give details: ______________________________________________________________
______________________________________________________________________________
Did you realize or did the officer advise you that the period of your suspension of your driving privileges for a refusal to take a breath/blood/urine test was for one year, if you had no prior DUI? Yes/No (circle one)
FOR THOSE LICENSED BY ANOTHER STATE Did the officer ever make any statement to you to the effect that because you were licensed by another state, it would be in your best interest to take the State’s Test? Yes/No (circle one) If “yes”, give details; ______________________________
______________________________________________________________________________
______________________________________________________________________________If your driver’s license was issued by a state other than Colorado, at time of the arrest, did you realize or did the officer advise you that a refusal to submit to the State-administered test would only prevent you from being able to drive in Colorado for one year, perhaps with no impact on your license or right to drive in your home state (or any other state except Colorado). Yes/No (circle one) If “no,” would knowing the truth about this have changed your decision as to whether to take the test or not? Yes/No (circle one)
(For EVERYONE, whether or not you took a test)
Other than the wording given to you from the “warning” on the proceeding pages, did the officer say anything else or elaborate or explain your obligation to submit to the official chemical sobriety test or the penalties which befall you if you refused to submit to it? Yes/No (circle one)
If “yes”, give wording used by officer: _____________________________________________
____________________________________________________________________________________________________________________________________________________________
What were you doing (or what was “going on” around you) at the time that the officer was giving you these “express consent” warnings? ________________________________________
______________________________________________________________________________
Did the officer take special steps to make certain that you were listening to these warnings? Yes/No (circle one) At the time these warnings were given to you, had the officer told you or otherwise let you know by his/her conduct (e.g. handcuffs, searching you, putting you in patrol vehicle, etc.) that you were not free to leave the scene at that time or that you were under arrest for DUI? Yes/No (circle one) Explain:___________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Did you have any reason why you would not (or could not) take any of the particular test(s) (e.g. against religion, fear of needles, etc.)? Yes/No (circle one) If yes, describe___________________________________________________________________________________
(22) MIRANDA WARNINGS
Were you given your warnings at anytime either oral or written? (“You have the right to remain silent. You have the right to an attorney. If you want an attorney and can’t afford one, the court will appoint one for you,” etc.) Yes/No (circle one) If so, by whom were these given, where were they given to you and (most important) WHEN? __________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Were there any witnesses to these Miranda warnings being given? Yes / No (circle one) Who?__________________________________________________________________________________________
Did you ever try to assert your right to speak with an attorney at anytime? Yes / No (circle one)
How did you assert this right to the officer? ______________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Were you confused about what your rights were? Yes / No (circle one)
(23) CONVERSATION AFTER ARREST
What did the officer say or ask first after you were arrested? _________________________________________
__________________________________________________________________________________________
Precisely what was said or asked next and by whom? ______________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Were you struck, pushed, injured, verbally abused or “roughed up” by the officer(s) when you were arrested?
Yes / No (circle one) If so describe:____________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(24) ACTIONS AFTER ARREST
Were you handcuffed? Yes/No (circle one) Front or back?__________________________________________
Did that make you mad? Yes/No (circle one) Say anything to officer? __________________________________
(25) OTHER PEOPLE PRESENT
Were other people present during the arrest or during the time the field sobriety tests were being given to you? Yes/No (circle one) Who? ____________________________________________________________________
If names are not known, describe each of them to the best of you ability and where and when you encountered this person(s): ______________________________________________________________________________
__________________________________________________________________________________________
Did any of them talk to you, become involved in anyway in your arrest, or test you? Yes / No (circle one) Who? __________________________________________________________________________________________
(26) CAR TOWING OR REMOVAL FROM SCENE
(Complete this section if applicable)
What happened to your car? __________________________________________________________________
Was it towed away? Yes/No (circle one) By what towing service? _________________________________
Were you present when it was taken (towed) from the scene? Yes / No (circle one)
What were you doing (or where were you) when the tow truck arrived? ________________________________
_________________________________________________________________________________________
Did the tow truck operator observe any of your “sobriety” testing? Yes / No (circle one)
Was your vehicle searched? Yes / No (circle one) Were you present? Yes / No (circle one)
Was anything removed (missing) from your vehicle or was it “ransacked”? Yes / No (circle one)
If so, describe in detail: ______________________________________________________________________
__________________________________________________________________________________________
If you had a cellular phone available, did the officer ever offer to let you call someone to come get your vehicle or offer an alternate towing company? Yes / No (circle one)
If “yes”, how long after you were “arrested” did the tow truck arrive?__________________________________
Did you ever hear or notice the officer requesting a “transport” or “tow” vehicle on his/her two-way radio? Yes / No (circle one) If yes, when did you hear this? ________________________________________________
Did arresting officer stay at the scene until the vehicle was towed away? Yes /No (circle one)
(27) TRANSPORTATION TO HEADQUARTERS/JAIL
Describe everything that took place in route to the headquarters or the jail: Conversations (who said what, when): ___________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Did you have anything in you mouth while you were being transported to jail? (i.e. chewing gum, smokeless tobacco, cough drops, tic-tac, cigarette, a penny, etc.)? Yes / No (circle one) What?______________________
_________________________________________________________________________________________
Did you ask the transporting officer any questions or talk to the person during the trip? Yes/No (circle one) If so, what did you say? _______________________________________________________________________
_________________________________________________________________________________________
What did the officer do or say during this time? (whistle, hum, etc.): __________________________________
_________________________________________________________________________________________
Were you cooperative with the officer? __________________________________________________________
(28) AT THE STATION/JAIL/TESTING FACILITY
Did you see a clock when you arrived? Yes/No (circle one) Time: ______________________________
How many officers? ________________ Conversation with anyone? Yes / No (circle one)
Who? ____________________________________________________________________________________
_________________________________________________________________________________________
Were you asked any health or environment contamination questions, such as “are you taking any medication”, “do you have false teeth or a bridge”, “have you been around any paint vapors or other chemicals today”, etc., before you took the State’s test? Yes / No (circle one)
If so, what were you asked, and what was your response to these questions? ____________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Searched? Yes / No (circle one) Fingerprinted? Yes / No (circle one) Videotaped? Yes/No (circle one)
Was a “mug shot” taken of you? Yes / No (circle one)
Were you fingerprinted before your breath test?___________________________________________________
Did you wash your hands before your breath test? If so, where did you wash them? Type of soap?__________
__________________________________________________________________________________________
Did you sign any papers? Yes / No (circle one) If so, what type of papers? ______________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Did the arresting or testing officer make any statements about you, or about the circumstances of your arrest, or about your alcohol “reading”, or anything else of significance to other officers? Yes / No (circle one) What was said? _________________________________________________________________________________
__________________________________________________________________________________________
Did the arresting officer (or any officer) ask you about prior DUI offenses or comment to you that your computer record showed prior DUI(s)? Yes/No (circle one)
Did you say anything to the officer about prior DUI(s) that you had? Yes / No (circle one) If yes, give details: ________________________________________________________________
__________________________________________________________________________________________
Was the arresting officer physically present in the room where you were given the test, and did he/she keep you in view for at least 20 minutes at the testing facility? Yes / No (circle one)
Explain: __________________________________________________________________________________________
__________________________________________________________________________________________
Did any officer(s) make comments to the arresting officer or testing officer or to YOU? Yes / No (circle one) What did they say? _________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Were you permitted to go to the rest room? Yes / No (circle one) When? _______________________________
Permitted to make a telephone call? Yes / No (circle one) If “yes”, when was this permitted?_______________
__________________________________________________________________________________________
To whom?_________________________________________________________________________________
(29) BREATH TESTS
(The next three sections should be completed by you ONLY if you were administered a breath test by the police after your arrest. If no breath test was given, skip these sections and complete Section 32 of this questionnaire)
Testing officer’s/operator’s name: _____________________________________________________________
Officer’s/Operator’s police agency: ____________________________________________________________
Did the arresting officer perform your breath test? Yes / No (circle one)
Was Officer/Operator present when you arrived for testing? Yes / No (circle one)
Did the breath test operator arrive afterwards? Yes / No (circle one) When? _______________________
Did operator turn on the breath machine 20 minutes before asking you to “blow”? Yes / No
Did you hear the breath machine make any computer-generated “beeps” or “chirps” before or during your testing? Yes / No (circle one) If “yes”, what do you recall hearing, and when did you hear it? _________________________________________________________________________________________
______________________________________________________________________________Did he/she or any other officer(s) in the testing room have their walkie-talkie, cell phone or portable radios on their belt?
Yes / No (circle one)
While in the room where the testing was being conducted, did you ever hear or observe an officer (any officer) use radio equipment in communication with the dispatcher or with other officers? Yes / No (circle one) If “yes”, give details:_________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Was anyone smoking in the testing room prior to or during the time you were being tested? Yes / No (circle one)
How long before the testing operator begin “observing” you prior to the testing in minutes? _______________
Was his observation of you continuous and uninterrupted? Yes/No (circle one) if no, describe __________________________________________________________________________________________
Where was the arresting officer during this time? _______________________________________________
Time of first test: ________________________________ Reading: __________________________________
Time of second test: ______________________________ Reading: __________________________________
Did you hear any police radio transmissions on any walkie-talkie or cell phone conversations during the time you were waiting to be tested? Yes / No (circle one) If so, who was the officer and what did you hear? __________________________________________________________________________________________
__________________________________________________________________________________________
Were there witnesses to your breath/blood/urine test? Yes / No (circle one)Who?_________________________
Describe approximate room temperature and lighting conditions: _____________________________________
Did anyone ask to look inside you mouth before you were tested? Yes / No (circle one)
If so, give details: ___________________________________________________________________________
__________________________________________________________________________________________
At the test location, did anyone ask you if you had been around any paint vapors, volatile chemicals or solvents during the day prior to when you were stopped? Yes / No (circle one)
Give details:_______________________________________________________________________________
_________________________________________________________________________________________
Did anyone ask you about false teeth, “bridge” work or dental plates? Yes / No (circle one) Give complete details: ___________________________________________________________________________________
Did you have a “fever” or elevated body temperature when tested? Yes / No (circle one) If so, was the elevated body temperature from hot tub/dancing/exercising/sunbathing/monthly “cycle” (women)/or other exertion (circle one) Indicate other causes: ______________________________________________________________
_________________________________________________________________________________________
Did you have any difficulty performing the breath test? Yes / No (circle one) If so, give details: __________________________________________________________________________________________
______________________________________________________________________________
Did police say you refused as a result of your inability to blow into the machine. If a repeat “blow” was required on the official sobriety breath test (not the hand-held test), was the mouthpiece changed each time? Yes / No (circle one) Explain _____________________________________________________________________
Were you allowed to smoke, drink water or put anything into your mouth within 20 minutes before the breath test was administered? Yes/No (circle one) If so, give details: ________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
During the day, WERE YOU EXPOSED TO (i.e. did you inhale fumes or did your skin or clothing come in contact with) any type of solvents or chemicals at home or at work (e.g.: hair spray, nail polish, nail polish remover, paint stripper, paint fumes, paint thinner, brass polish, acetone-based chemicals, glue, gasoline, kerosene, turpentine, methanol, toluene, xylene, isopropanol, acetone, etc.). Yes/No/Can’t Recall/NA (didn’t take breath test) (circle one) If so, what?_________________________________________________________
_________________________________________________________________________________________
How long before your arrest had you ceased using/last been exposed to the chemicals or fumes? _________________________________________________________________________________________
Had you eaten a sandwich or light bread shortly before being pulled over? How long before? What kind of bread?____________________________________________________________________________________
Did anyone including the police officer see the bread? ______________________________________________
Did you use chewing tobacco or snuff before or at the time of driving? Yes / No/(circle one) If so, what and when?____________________________________________________________________________________
Have you been diagnosed with Diabetic condition? ________________________________________________
Had you used a mouthwash/throat spray/cold or cough remedies before being pulled over? Yes / No/(circle one) If so, what and when? _______________________________________________________________________
Did you leave the breath test room between your two blows ? Yes / No (circle one)
(30) CONVERSATION WITH BREATH TEST OPERATOR
Did the breath testing operator ask you any questions? Yes/No (circle one) If so, what? ___________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Did the breath testing operator give you any instructions or explain how the machine worked or how you were to “blow” into the machine? Yes/No (circle one) If so, what? ________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Was the arresting officer present and observing all procedures at all times during the testing process? Yes/No/Same officer (circle one) If not, describe his/her actions, location or conduct while testing was being performed: ________________________________________________________________________________
__________________________________________________________________________________________
When you gave the breath sample, was your body in an upright standing/seated position (perpendicular to the floor) or were you leaning forward to reach the mouthpiece from a sitting or standing position? Describe in detail: ____________________________________________________________________________________
__________________________________________________________________________________________
Did you ever see the numerical reading on the breath-testing machine? Yes/No (circle one)
If so, what was the numerical reading? _________ Did officers comment on the “result” in anyway? Yes/No (circle one) If so, what was the statement or comment and by whom?__________________________________
_________________________________________________________________________________________
__________________________________________________________________________________________
Did the breath test operator ever write anything on your citation or on your test result slip? Yes/No (circle one) If so, what did he/she write? __________________________________________________________________
__________________________________________________________________________________________
(31) BREATH TESTING ROOM LAYOUT
Diagram the layout (show room dimensions, door location, chairs, table, breath testing machine, phone, storage area, cabinets, any other appliances (e.g. microwave), rest room, booking area, exhaust fan):
(32) BLOOD/URINE TESTS
(THIS SECTION SHOULD ONLY BE COMPLETED IF YOU WERE GIVEN A BLOOD OR URINE TEST BY THE POLICE, IF YOU REFUSED, SKIP IT
Did you give blood/urine sample? Yes / No (circle one) If NO, skip this section.
Where were you taken to obtain the blood/urine test? ______________________________________________
Who took you for a blood/urine test? ___________________________________________________________
When did this occur, in relation to your time of arrest? _____________________________________________
Had you already given a breath sample before taking a blood/urine test? Yes / No (circle one)
Did you consent to having this blood/urine sample taken from you? Yes / No (circle one)
What were you told or asked by the police in order to obtain your consent for this sample to be taken from you? _________________________________________________________________________________________
_________________________________________________________________________________________
Describe/name the person who drew (took) your blood/urine sample? _________________________________
Were you required to sign any forms before the nurse/doctor/technician would take your blood/urine? Yes/No (circle one)
If so, what did you sign? _____________________________________________________________________
FOR BLOOD SAMPLES, did the person who took your blood sample use any type of cloth or swab to cleanse the surface of your skin before taking the sample? Yes / No (circle one) If so, describe in detail what was done to prepare the skin.__________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
FOR BLOOD SAMPLES, as the needle was removed from your arm, was a swab or cloth held over the puncture site by the person who took the sample? Yes / No (circle one) If so, describe how this was done: ______________________________________________________________
______________________________________________________________________________
What happened to the blood/urine sample after it was collected from you? (Be specific as possible) ______________________________________________________________________
______________________________________________________________________________
Did the officer provide a testing kit to the person drawing/taking the blood/urine? Yes/No (circle one).If so, describe the kit and who and how it was handled:_____________________________
_____________________________________________________________________________
(33) RIGHT TO COUNSEL
Were you ever advised by anyone that you had the right to consult an attorney? Yes / No (circle one) By whom? _____________________________________________ When? ______________________________________
Did you ever ask to call an attorney? Yes / No (circle one)
Did you call an attorney? Yes / No (circle one) If so, when? _________________________________________
If you were denied the right to call an attorney before deciding whether to take the State’s test, did the officer (or anyone at the station) explain why you were being denied access to legal counsel? IF SO, WHAT?___________________________________________________________________________________
Who told you that you could call the attorney? __________________________ When? ___________________
When were you told you could make a phone call to anyone else, if you desired? ________________________
Did the police cooperate with you in providing phone access? Yes / No (circle one) If not, or if you were delayed in being provided phone access or if your calls were limited by the police, give details: __________________________________________________________________________________________
__________________________________________________________________________________________
Who helped you (or refused to assist you)? _______________________________________________________
__________________________________________________________________________________________
Where was the phone? _______________________________________________________________________
Where was the arresting officer while you were calling? ____________________________________________
Where was the breath testing operator? __________________________________________________________
Could you talk privately? Yes/No (circle one)
Whom did you call? Their number?_____________________________________________________________
What did you talk about? _____________________________________________________________________
__________________________________________________________________________________________
(34) SOBRIETY TESTS AFTER ARREST (AT STATION OR JAIL)
Were any agility or coordination tests administered after your arrest and transport to jail/Detox? Yes / No (circle one) If so, by whom? ________________________________________________________________________
When? _______________________________________ Where? ___________________________________
Were you advised you did not have to perform them? Yes / No (circle one)
Were you given Miranda warnings before you did these tests? Yes / No (circle one)
What tests (if any) were administered at the jail/Detox after you were taken into custody?
Test No. 1: ________________________________________________________________________________
Test No. 2: ________________________________________________________________________________
Test No. 3: ________________________________________________________________________________
(35) FORMS SIGNED
Did you ever sign your name? Yes/No (circle one) When was the first time? ____________________________
Next? ____________________________________________________________________________________
What documents did you sign and why? _________________________________________________________
__________________________________________________________________________________________
Did you ever refuse to sign any document? Yes / No (circle one) What? _________________________________
Why? ____________________________________________________________________________________
(36) VIDEO OR AUDIO TAPING
Was video or audio taping done at arrest scene or at testing site? Yes /No /Unknown (circle one)
Any clue(s) (i.e. officer mentioned it) that a tape may have been being made? Yes / No (circle one) Explain: __________________________________________________________________________________________
__________________________________________________________________________________________
Did you know that a tape was being made when it was being made? Yes / No (circle one)
Did anyone advise you a video or audio tape was being made? Yes / No (circle one)
Did you see a tape recorder or a video camera? Yes / No (circle one)
What do you think that a tape would show? ______________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(37) OTHER PEOPLE PRESENT DURING TESTING OR BOOKING
Were other people there? Yes / No (circle one) Who? ______________________________________________
_________________________________________________________________________________________
Conversations with anyone? Yes / No (circle one) Who? ____________________________________________
_________________________________________________________________________________________
What about? ______________________________________________________________________________
__________________________________________________________________________________________
As part of your “booking,” was the question asked, “Do you feel any effects of alcohol/drugs at the present time?” Yes / No (circle one) If so, what was your response?_________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
As part of you “booking,” was the question asked, “Are you presently under the influence of alcohol or drugs?” (or, “Are you intoxicated?”) Yes / No (circle one) What was your response? ____________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
At any time during “booking” were you asked about prescription medications, inhalers, shots, etc., that you needed to take or keep with you while in custody? Yes / No (circle one) If so, by whom and what were you asked? ____________________________________________________________________________________
__________________________________________________________________________________________
(38) JAIL CONFINEMENT
Confinement alone or with others? _____________________________________________________________
With whom? _______________________________________________________________________________
For what was he/she arrested? _________________________________________________________________
__________________________________________________________________________________________
Could he/she be a witness for you? Yes / No (circle one)
Did you have a conversation with him/her? Yes/No (circle one)
What about? _______________________________________________________________________________
(39) RELEASE
What was your date of release? ____/____/____ at what time ___________AM/PM (circle one)
Released by yourself? Yes/No If no, were you released to someone (Bondsman, friend, family member)? Yes / No (circle one)Who? _______________________________________________________________________
Phone Number? ___________________________________________________________________________
How did that person know to come to assist you? __________________________________________________
Any conversation with him/her? Yes / No (circle one)What did you talk about? __________________________
__________________________________________________________________________________________
Would he/she be a witness to your sober conduct? Yes / No (circle one) If so, give details: ____________________________________________________________________________________________
May I contact the witness? Yes / No (circle one) Best day and time? __________________________________
(40) ACCIDENT
(This section is to be completed only if an accident of some type had occurred in connection with your DUI arrest)
Were you involved in an accident? Yes/No (circle one) If No , skip this section.
One car or more that one car involved? __________________________________________________________
Describe accident: __________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Did the airbag go off in your vehicle? Yes / No (circle one)
Did you notice white power on you or in the car? Yes / No (circle one) Please Describe the dust:
__________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________
Did you ride in an Ambulance? Yes / No (circle one)
Did the ambulance crew administer any drugs intravenously? Yes / No (circle one) What Drugs:
____________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________
Describe your Injuries:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Were you in your vehicle when the officer first arrived on the scene? Yes / No (circle one)
If “no”, give details of where you were in relation to the vehicles: _____________________________________
__________________________________________________________________________________________
Were other persons from your vehicle there, too? Yes/No (circle one)
After the accident, did you ever leave the immediate area (for any purpose, such as call a tow truck, call police, etc.)? Yes/No (circle one) If so, give details of how long you were gone, where you went, why you left, etc.: _________________________________________________________________________________________
_________________________________________________________________________________________
Were there any injuries or death to any other person(s)? Yes/No (circle one) If so, give full details on separate sheet.
Do you recall the circumstances leading up to the accident? Yes/No (circle one) If so, give details: _________________________________________________________________________________________
_________________________________________________________________________________________
Did the officer ask you what you had to drink and when? Yes/No (circle one)
Were you given Miranda advisements before being questioned? Yes/No (circle one)
Prior to this case, had you EVER been the driver of a vehicle in which another person (passenger, person(s) in other car, pedestrian(s) were injured or killed? Yes/No (circle one)
If so, give details: __________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
(41) SPOUSE/FIANCÉE/PARENT/LIVING PARTNER’S ATTITUDE
Does spouse (Fiancée/parent/living partner, etc.) know about your arrest? Yes/No (circle one)
Is she or he angry or supportive of you? ________________________________________________________
What are her/his comments? _________________________________________________________________
________________________________________________________________________________________
Can this person be counted upon for financial support? Yes/No (circle one)
(42) DRIVING AND CRIMINAL RECORD
Have you had a prior DUI/DWAI in your LIFETIME—ANYWHERE? Yes/No (circle one)
If so, when? _________________________ City _______________________ State ___________________
Court which handled case: The _______________________________ Court of ________________________
Any other DUI convictions (including nolo contendereplea) during your lifetime, anywhere? Yes/No (circle one) {NOTE: the prosecutor will have this information, and I must know the entire history to be able to properly analyze your chances at trial.}
If any other DUI offenses anywhere, list all below, including court, city, state, and date (month and year) of arrest: ___________________________________________________________________________________
_________________________________________________________________________________________
Represented by an attorney? Yes/No (circle one) If so, by whom? ____________________________________
Plea: _____________________ Trial? Yes/No (circle one) Result? ___________________________________
What court? _____________________________ Judge’s name ______________________________________
Presently on probation for prior DUI/DWAI? Yes/No (circle one)
On probation for any offense(s)? Yes/No (circle one) If so, give details: ________________________________
Ever involved in an accident involving death or serious injury regardless of whether DUI involved? Yes/No (circle one) If so, fully state the circumstances: ___________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Was your license under suspension anywhere when arrested in this case? Yes/No (circle one) Give details: __________________________________________________________________________________________
__________________________________________________________________________________________
Prior Driving Suspension (whether in effect now or not)? ___________________________________________
__________________________________________________________________________________________
Prior SERIOUS Traffic Violations (racing, attempting to elude an officer, hit and run, leaving the scene of an accident, etc.) (Show offense(s) below and approximate date(s) of occurrence)?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Prior MINOR Traffic Violations (show offense(s) and approximate date(s) of occurrence?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Prior criminal record of any type (not already mentioned), especially alcohol-related or drug-related charges, such as “underage possession of alcohol”, “open container violation”, “possession of marijuana”, ”public
intoxication”: __________________________________________________________________________________________
__________________________________________________________________________________________
(43) OTHER ATTORNEYS
Prior to coming to me for legal assistance, did you consult with any other attorney(s) about the present DUI case? Yes/No (circle one) If so, with whom did you consult?_________________________________________
_________________________________________________________________________________________
__________________________________________________________________________________________
Do you understand what you are free to follow that attorney’s advice (or any other attorney’s advice) and that you are in no way bound to use my legal services in your case unless you hire me? Yes/No (circle one)
(44) REFUSAL OF THE STATE’S BREATH, BLOOD OR URINE TESTS
(Complete this section ONLY IF you REFUSED (or allegedly refused) to submit to the State’s breath or blood tests as requested by the arresting officer.)
What actions were taken or statements were given by the police officer just prior to your refusal to take the state’s test(s)? ______________________________________________________________________________
__________________________________________________________________________________________
Why did you refuse (or why did the officer claim that you refused) the state’s test(s)? _____________________
__________________________________________________________________________________________
In what way (or with what words or conduct) did you (allegedly) refuse to take the state’s test(s)? __________________________________________________________________________________________
__________________________________________________________________________________________
Were you aware that your license (or privilege to drive on Colorado highways) would be suspended for one year by administrative action (Department of Motor Vehicles) for refusing to submit to the state’s test(s)? Yes/No (circle one)
Did you believe you could get a “work permit” if your license was suspended for a refusal? Yes/No (circle one). Why?_____________________________________________________________________________________
(For first offenders—persons with no DUI convictions) At the time of your arrest did you mistakenly believe (based upon the officer’s wording to you) that you would get the same or worse penalty (suspension of one year or more) if you took the test and failed, as if you refused it? Yes/No (circle one) If “yes”, elaborate: __________________________________________________________________________________________
__________________________________________________________________________________________
At the time that you refused the state’s test(s), had the officer(s) done anything to frighten you or say anything to offend you to such a degree that you were unwilling to cooperate with them? Yes/No (circle one) If so, explain: ___________________________________________________________________________________
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Were you suffering any pain, discomfort or other physical or mental impairment which would have justified your refusal of (or explained your refusal of) the state’s test(s)? ______________________________________
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(45) OTHER CHARGES FROM SAME INCIDENT
(IF YOU WERE CHARGED WITH ANY OTHER OFFENSES OR CRIMES, GIVE THE FOLLOWING INFORMATION ON EACH SEPARATE OFFENSE.)
1. Offense: ________________________________________________________________________________
Describe the driving or activities that led to this charge made against you: ______________________________
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Were you aware that you committed this offense? Yes/No (circle one)
If “no” give details to explain: _________________________________________________________________
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Any witnesses or evidence relating to this offense that supports your claim of innocence? Yes / No (circle one) Explain: __________________________________________________________________________________
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2. Offense:_________________________________________________________________________________
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Describe the driving or activities that led to this charge made against you:_______________________________
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Were you aware that you committed this/these offense? Yes/No (circle one)
If “no” give details to explain: _________________________________________________________________
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Any witnesses or evidence relating to this offense that supports your claim of innocence? Yes/No (circle one) Explain: __________________________________________________________________________________
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3. Offense: __________________________________________________________________________________________
Citation No. __________________________________________________________________________________________
Describe the driving or activities that led to this charge made against you:_______________________________
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Were you aware that you committed this offense? Yes/No (circle one)
If “no” give details to explain: _________________________________________________________________
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Any witnesses or evidence relating to this offense that supports your claim of innocence? Yes/No (circle one) Explain: __________________________________________________________________________________
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(46) OTHER MATTERS
If you want to bring anything to our attention but have not previously done so please do it here.
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IMPORTANT NOTE: When returning these forms, if you have not supplied me with copies of the following, please do so.
1. All traffic citations (summons) that you received after being arrested.
2. Any “breath test” machine tape.
3. Any accident report from the case.
4. Any incident report from the case.
5. Any bond release forms received.
6. Any personal items inventory forms (jail intake or documents received)
7. Tow company records.
8. The license revocation form.
9. Any previous DUI offenses that are in your possession.
10. Notice of revocation
TO THE BEST OF MY KNOWLEDGE AND BELIEF, THE FORGOING INFORMATION IS TRUE AND CORRECT.
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NAME
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DATE