Michigan Drunk Driving Case Evaluation

BACKGROUND INFORMATION

Date of Birth

Month

Day

Year

E-Mail Address

Gender

Male

Female

Approximate weight on date of arrest?

lbs.

Please describe your drinking habits

What is your marital/family status?

What is your occupation?

Where are you employed?

Do you have a Commercial Driver's License (CDL)?

Was your license valid on the date you were arrested?

If your driver's license is from outside Michigan, please specify the the state where you are licensed:

Is this your first arrest for a DUI/DWI/Drunk Driving in your lifetime, anywhere?

Please list and describe all prior drunk driving arrests and/or convictions:

Are you currently on probation or parole for any reason?

If yes, please explain:

CASE INFORMATION

Date of the Arrest

Month

Day

Year

Time of Stop

Hour

:

Minute

The time of the traffic stop is usually recorded on the temporary driver's license on line 5 of the form. If you refused to submit to a breath, blood, or urine test, then the stop time will NOT appear on your temporary driver's license. Police officers usually use a 24 hour military-time format (e.g. 6:00 p.m. is 18:00 hours, 11:00 p.m. is 23:00 hours, etc.).

Time of Arrest

Hour

:

Minute

This time will appear on all temporary driver's license forms provided by the police, even in refusal cases. This time SHOULD be different from the "Time of Stop" but police officers frequently enter the same time. This is a common mistake for police officers. Enter the information as provided by the officer.

City/Town/Municipality of Arrest

County of Arrest

District / Circuit Court Number or Location

Next Scheduled Court Date:

Month

Day

Year

LOCATION: Where were you stopped by the police?

JUSTIFICATION: Why were you stopped by the police?

Names of all witnesses in the vehicle:

Names of other potential witnesses:

Do you know if the police have video of your driving and field sobriety tests?

Was there an accident?

If there was an accident, was anyone hurt, injured, or killed?

FIELD SOBRIETY TESTING

Please describe your overall health:

Which field sobriety tests did the officer have you perform? Check all that apply.

PBT Result

g/210 L BrAC

How do you feel you performed on the various field sobriety tests? Please explain:

MEDICAL / PHYSIOLOGICAL

Were under the care of a doctor on the date of your arrest?

Are you prescribed drugs or medications that you take on a regular basis? If yes, please specify:

Do you have any prior injuries or disabilities that might have affected your driving or performance of field sobriety tests? If yes, please explain:

As to the following conditions, check all that apply:

CHEMICAL TESTING

Did you submit to a breath, blood, or urine test?

Did you refuse to take a chemical test?

If you refused to take a Datamaster or submit to a blood test and received a DI-93 form temporary driver's license, you only have 14 days to send a written request for hearing. If you do not send the request for hearing, you will automatically lose your license for at least one year, and six points will be added to your license. Mailed requests should be directed to: MICHIGAN DEPARTMENT OF STATE, DRIVER ASSESSMENT & APPEAL DIVISION, P O BOX 30196, LANSING MI 48909-7696. We recommend that you send it certified! We also have a "secret" fax number at our office.

Did the police have a search warrant to seize blood?

Did the police officer actually observe you for 15 minutes before taking a breath test at the police station?

Police officers are required to observe a person for 15 minutes before subjecting the person to a breath test on the Datamaster. BEFORE starting this observation, they are supposed to check the subject's mouth by physically looking inside it. If you have gum, drink anything, smoke, or have blood in your mouth, the breath test might be compromised. This is also very important for people who suffer from GERD, since most police officers don't bother to actually pay attention during the 15 minute observation period.

If you took a breath test at the police station, what was the first test result?

g/210 L BrAC

If you took a breath test at the police station, what was the 2nd test result?

g/210 L BrAC

If you took a breath test at the police station, what was the 3rd test result?

g/210 L BrAC

If you were subjected to a blood draw and know the result, please report that number here:

g/100 mL BAC

If you were subjected to a blood draw, please provide the hospital's information: