NEW CLIENT QUESTIONNAIRE

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: ___________________________________________________________________________________

__________________________________________________________________________________________

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)? ______________________________________

_________________________________________________________________________________________

 

 

(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: ______________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Were you aware that you committed this offense? Yes/No (circle one)

If “no” give details to explain: _________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Any witnesses or evidence relating to this offense that supports your claim of innocence? Yes / No (circle one) Explain: __________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

2. Offense:_________________________________________________________________________________

_________________________________________________________________________________________

Describe the driving or activities that led to this charge made against you:_______________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Were you aware that you committed this/these offense? Yes/No (circle one)

If “no” give details to explain: _________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Any witnesses or evidence relating to this offense that supports your claim of innocence? Yes/No (circle one)  Explain: __________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

3. Offense: __________________________________________________________________________________________

Citation No. __________________________________________________________________________________________

Describe the driving or activities that led to this charge made against you:_______________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Were you aware that you committed this offense? Yes/No (circle one)

If “no” give details to explain: _________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Any witnesses or evidence relating to this offense that supports your claim of innocence? Yes/No (circle one) Explain: __________________________________________________________________________________

_________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

 

 

(46) OTHER MATTERS

 

If you want to bring anything to our attention but have not previously done so please do it here.

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

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.

 

______________________________________

NAME

______________________________________

DATE

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