Do you have any previous drunk driving convictions?

Yes
No

If yes how many?

Select 1 2 more than 2

Were you involved in an accident?

Yes
No

If yes was anyone hurt?

Yes
No

Were any of the following field sobriety tests performed (check all that apply)?

Handheld Breath Test
Walk-and-Turn 9 Steps Heel to Toe
One-Leg Stand
Follow-thePen-With-Eyes
Say the Alphabet
Touch Your Nose
Other

Are you currently on probation or parole for any offense?

Yes
No

Please describe your situation:

Were you arrested at the scene?

Yes
No

Breath Test

Yes
No

Result

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