DUI Field Observations

MM slash DD slash YYYY
Time
:

Intoxication Signs / Symptoms

Interview Questions

Check if Yes
Interview Questions
Check if Yes

1. GAZE NYSTAGMUS

Tracking
Pupil Size

H.G.N

Blindness (Right / Left)
Glasses / Contacts
Able to follow Stimulus
Lack of smooth pursuit
Vert. Gaze Nysragmus
4/6 clues = 88% chance of BAC > 0.08

2. ONE LEG STAND

One Leg Stand Checkbox
2/4 clues = 83% chance of BAC > 0.08

3. RHOMBERG BALANCE

(30 SECOND TIME EST.)
RHOMBERG BALANCE Checkbox

4. DRUG RECOGNITION

Normal Range 60 to 90 BPM

Pupillary Comparison / Dilation

Normal Range 3.0mm to 6.5mm

Reaction to Direct Light

N=Normal, S=Slow, or M=Minimal Rebound
Left
Right

5. WALK AND TURN

Walk & Turn Checkbox
9 Steps – 1st Set
9 Steps – 2nd Set
2/8 clues = 79% chance of BAC > 0.08

6. CHEMICAL TEST(S)

P.A.S. TEST
Admonition
MM slash DD slash YYYY
At
:
MM slash DD slash YYYY
At
:
BREATH TEST
MM slash DD slash YYYY
At
:
At
:
MM slash DD slash YYYY
MM slash DD slash YYYY
At
:
BLOOD DRAW
MM slash DD slash YYYY
At
:
URINE SAMPLE
MM slash DD slash YYYY
At
:

TROMBETTA ADVISEMENT:

The breath machine does not retain a sample of your breath. You can provide an additional sample of your blood, at no cost to you, which may be analyzed by either party to determine the alcoholic content of your blood.
DO YOU WISH TO PROVIDE ANOTHER SAMPLE?

PAS ADMONITION PER CHP-202:

UNDER 21 or DUI Probation – You are obligated by law to submit to a PAS test.

21 or OVER – I am requesting that you take a preliminary alcohol screening test to further assist me in determining whether you are under the influence of alcohol. You may refuse to take this test; however, this is not an implied consent test and if arrested, you will be required to give a sample of your blood or breath, for the purpose of determining the actual alcoholic and drug content of your blood.
MM slash DD slash YYYY
MM slash DD slash YYYY