DUI Evaluation Form 1. License, Legal & DWI/DUI History Driver's License No: State of License: Date of Birth: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Are you on Probation: YES NO Have you been previously charged with a DWI/DUI? YES NO Have you contacted the DMV (to save your driving privileges) yet? YES NO If you have contacted DMV within the ten (10) day limit, when is your appointment (date and time)? Date: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Time: 1 2 3 4 5 6 7 8 9 10 11 12 AM PM I need my license for the following reasons: Job Requirement Work Commute School Medical Family Needs Transporting your children Dates & Location of Arrest and Court Next Court Date: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Name of Court Las Vegas Justice Court Las Vegas Municipal Court North Las Vegas Township Henderson Municipal Court 2. Field Sobriety/Blood/Breath Testing Information Was the field sobriety test administered on location of arrest stop? YES NO Which of the following tests were you given: Handheld Breath Test Did the officer advise you that you could refuse to take the hand-held gadget breath test? YES NO I don't know/Not applicable Walk-and-turn 9 steps heel to toe Did the officer tell you that your failed or passed? YES NO One-Leg Stand Did the officer tell you that your failed or passed? YES NO Follow a pen, finger, or other object with your eyes, not moving your head Did the officer tell you that your failed or passed? YES NO Saying or writing the Alphabet Did the officer tell you that your failed or passed? YES NO Touching your nose with finger Did the officer tell you that your failed or passed? YES NO Standing with my head tilted back and eyes closed, feet together Did the officer tell you that your failed or passed? YES NO Patting your hands together Did the officer tell you that your failed or passed? YES NO Counting on your fingers Did the officer tell you that your failed or passed? YES NO 3. Analysis Questions - Chemical Test/Chemical Test Refusal Please select the type of chemical test you took (or whether you took a chemical test at all): Blood Breath Urine No Chemical test taken If you are charged with refusing a chemical test, The cop told me I would have my license suspended if I refused a blood, breath or urine test, and I refused anyway. I refused during the initial vehicle stop or contact with the cop. I refused when they handcuffed me. I refused in the patrol car. I refused on the ride, in the patrol car, to the chemical test location. I refused at the chemical test location. I refused everything from the beginning. The cop told me I refused when he first stopped me. The cop told me I refused when we were doing Field Tests. The cop told me I refused when he handcuffed me. The cop told me I refused when we were in the car. The cop told me I refused when we were driving to the chemical test location. The cop told me I refused when we were at the chemical test location, but he didn't tell me I would lose my license if I refused. The cop told me I could refuse the test when he used a hand-held breathalyzer, so I did. The cop never told me I had to take a test and he didn't tell me I Approximately how many minutes went by from the time you were arrested (when they handcuffed you) until you arrived at the chemical test location (blood, breath or urine test location)? For the breath test, after you arrived at the place where the breath machine was located, did you wait at least 15 minutes before your first breath into the machine? YES NO I don't know/Not applicable Did you take an additional blood or urine test? I did not give an additional sample I wasn't sure if i should give and additional sample I knew i was over the limit anyway I don't remember The officer(s) talked me out of doing it The officer(s) told me it would be used against me too The officer(s) didn't tell me this right of mine I gave a urine sample after the breath test I gave a blood sample after the breath test Other Did you request your own independent blood, breath, or urine test during the arrest? YES NO Which law enforcement agency arrested you? Nevada Highway Patrol (NHP) Las Vegas Metropolitan Police (Metro) North Las Vegas Police (NLV) Henderson Police Other 4. Case Details Did an accident occur? YES NO Did any injuries occur? YES NO Was there a witness(es) who could testify for you? YES NO Did you request an attorney? YES NO Did the officer take your driver's license or give you a paper called "Administrative Per Se Order of Suspension/Revocation, Temporary Driver License Endorsement"? YES NO Did you consume alcoholic drink, prescription medications or other drugs. Alcoholic Drinks Prescription Medications Other Drugs Think about the drinks you had. Many people under estimate how many drinks they had, or cannot remember. This is extremely important to your case though. In order to calculate your Blood Alcohol Level please indicate how many drinks you had total (one drink is equal to a 12 ounce beer, a regular glass of wine, or 1 shot-1 1/4 ounces-of hard liquor)? None Consumed One (1 drink) Two (2 drinks) Three (3 drinks) Four (4 drinks) Five (5 drinks) Six (6 drinks) Seven (7 drinks) Eight (8 drinks) Nine (9 drinks) Ten (10 drinks) Eleven (11 drinks) Other Amount of drinks Approximately what time did you finish your LAST alcoholic beverage? I don't Know/Not applicable What time did you tell the officer you last drank? Anti-depressant Pain Medication Valium/Tranquilizer Marijuana Methamphetamine Powdered Cocaine Crack Cocaine Heroin Ecstasy If Others Please indicate List the drug(s) you intake Can you document the prescription taken was from your physician? YES NO Describe the last snack/meal consumed and timeframe of snack/meal before�your arrest. Hadn't eaten within the time limit Bar Snacks Small Meal Medium Meal Large Meal Extremely Large Meal Other Meal Best Time to Schedule a Consultation: Best Way to Schedule a Consultation Phone Email 5. Contact Information Name:* Address: City: State: Zip: Phone Number:* Email Address:* Submit
