DUI WORKSHEET Enter your email address to receive a copy of this form submission.(Required) Law Incident# Time Name Location Time Started Vehicle Year Make Model Color License Pulse & Time of day:(Pre FSTs) Pre FST Time 1. What have you been drinking? 2. How much? Where? 3. What time did you start drinking? 4. What time did you stop drinking? 5. What time is it right now? Actual Time? 6. When did you last sleep? How long? 7. When did you last eat? Describe 8. Are you sick or injured? Yes No Explain 9. Do you have any physical defects? Yes No Explain 10. Are you diabetic or epileptic? Yes No Explain 11. Do you take insulin? Yes No Explain 12. Are you under the care of a doctor or dentist? Yes No Explain 13. Are you taking any medication or drugs? Yes No Explain 14. Do you feel the effects of the medicine or drugs? Yes No Explain 15. Do you have high blood pressure or heart disease? Yes No Explain 16. Have you ever had a severe head injury? Yes No Explain 17. Do you have brain damage? Yes No Explain 18. Recent surgery performed? Yes No Explain 19. Anything wrong with your vehicle? Yes No Explain 20. Were you driving the vehicle? 21. Where did you start driving? 22. Where were you going? 23. What led to you being stopped (or involved in T/C)? 24. Have you been drinking/using drugs since the accident? What? 25. Do you still feel the effect of the drinks/drugs? Shoe Type: Surface: EyewearNormally Wears: Glasses Contacts N/A Horizontal Gaze Nystagmus Have subject remove eyeglasses and ask about contact lenses. Instruct subject to stand with feet together, with their hands by your side. Position stimulus 12-15 inches in front of their nose, slightly elevated. Instruct subject to follow tip of stimulus with their eyes only. Keep head still. Check for equal pupil size, resting Nystagmus, and equal tracking. 6. Check for lack of smooth pursuit(2 seconds from the forward gaze to side, repeat) Left Right 7. Check for Distinct and Sustained Nystagmus at Maximum Deviation(hold for minimum of 4 sec. Repeat) Left Right 8. Check for Nystagmus prior to a 45 degree angle(hold for a minimum of 4 sec. Repeat) Left Right 9. Check for Vertical Gaze Nystagmus Yes No 10. Lack of Convergence(put glasses back on) Yes No Clues: (1) Lack of Smooth Pursuit. (X2) (2)Distinct and Sustained Nystagmus at Maximum Deviation (x2) (3)Nystagmus prior to 45 degrees (x2)TOTAL SCORE(Decision Point 4; Max: 6) NOTES:One Leg StandInstructions: Stand with your feet together and your arms at your sides like this. Do not start the test until told to do so. When I tell you to start, raise one leg, either leg, with your foot approx. six inches off the ground, keeping the raised foot parallel to the ground (demonstrate how their leg/foot should look). Keep both legs straight with your arms at your sides. Holding that position, count out loud in the following manner, 1001, 1002, 1003 and so on, until told to stop. Do you understand the instructions? (demonstrate with counting but do not look at your foot) Keep your arms at your side at all times and keep watching your raised foot. Do you understand? Begin test (officer times subject and discontinues test after 30seconds.) Clues Sways Uses arms to balance Hops Puts foot down TOTAL SCORE(Decision Point: 2; Max: 4) NOTES:Walk and Turn Place your left foot on the line, (demonstrate placement of foot) Put your right foot on the line, in front of your left foot with the heel of the right against the toe of the left foot. (demonstrate placement of both feet) Place your arms down at your sides (demonstrate). Maintain this position until I have completed the instructions. Do not start to walk until told to do so. Do you understand the instructions? When I tell you to start, take 9 heel-to-toe steps along the line, turn, and take 9 heel-to-toe steps down the line. (demonstrate a min of 3 steps) When you turn, leave your front foot on the line and turn by taking a series of small steps with your other foot, like this. Then return by taking 9 heel-to-toe steps. (demonstrate a min of 3 heel-to-toe return steps) While you are walking, keep your arms at your sides, watch your feet at all times, and count your steps out loud. Once you start walking, don’t stop until you have completed the test. Do you understand the instructions? Begin Test. Clues: Can’t balance during instruction Stops while walking Steps off the line Turned improperly Starts too soon Misses heel to toe Uses arms to balance Wrong number of steps TOTAL SCORE(Decision Point: 2; Max: 8) Pulse & Time of day:(Conclusion of FSTs) Conclusion of FST time DRE TestsRomberg Balance:Internal clock at 30 seconds Side to Side Sway Front to back sway Circular Sway Pulse & Time of day:(Before blood draw) Before blood draw time Pupil Size:Room LightLeft EyeRight EyeDarknessLeft EyeRight EyeIndirectLeft EyeRight EyeDirectLeft EyeRight EyeHippus Yes No Rebound Dilation Yes No Reaction to Light Lack of Convergence Eyelids(retracted / droopy / flutter / normal) Able to follow stimulus? Pupil size equal? Other Noted Objective Symptoms or Information:Chemical Test Admonishment Statements (Birchfield Options):Blood Only (drugs only or drugs and alcohol): “You are under arrest for operating a motor vehicle while impaired by drugs [and alcohol]. Will you submit to a blood test? If you choose not to submit to a blood test, a search warrant will be sought. In addition, your refusal can be used against you in court and the DMV will suspend your license. Having this in mind, are you willing to submit to a blood test?” Blood and Breath (alcohol only): “You are under arrest for operating a motor vehicle while impaired by alcohol. Will you submit to either a breath test or a blood test? If you refuse either test, a search warrant will be sought. In addition, your refusal can be used against you in court and the DMV will suspend your license. Having this in mind, are you willing to submit to a breath test or blood test?” ***** Document the defendants statements word for word when it comes to either a voluntary submission or a refusal! If it is not a clear voluntary submission then get a warrant***** If you are doing a refusal and want DMV to suspend their license you must read the Chemical Test Admonition from the back of the (New / revision 01/2019) DMV DS 367. Read it word for word and document the subjects answers. This can be done in the jail after the arrest but must be done prior to a warrant draw.