In order to assist us in evaluating your case, please print this questionnaire and complete it by circling or writing the appropriate answer.  You can then FAX or mail us a copy of the completed questionnaire.  Our FAX number is (805) 644-8505.  If you intend on retaining us, please also mail or FAX us a copy of your paperwork that indicates your court appearance date and location.  You may also email this completed form to our law office at: internetlawfirm@aol.com   

Name:  _______________________________

Telephone number you can be reached at:  (______)____________________

Date of birth:  _______________

Driver's license number:  ___________________________

Court appearance date and time:  _________________________

Court house you were cited to appear at:  ___________________

City you were arrested in:  ___________________________

Police agency that arrested you:  _________________________

1. Is this your first Driving Under the Influence (Drunk driving) charge?
a. Yes.
b. No.

If you have had prior DUI’s, please list them below:

* _____/ ____/____ ; ____/ ____/ ____;
          arrest date            conviction date            County

* _____/ ____/____ ; ____/ ____/ ____;
          arrest date            conviction date            County

2. Are you currently on probation or parole for any previous violations?
a. Yes.
b. No.

If your answer was “Yes”, please state if it is probation or parole, and what state and county it is in:
_______________________________________________________

3. On what date were you arrested for your DUI? ____/ ____/ ____

Did the officer take your driver’s license from you an give you a temporary license? __________________.

Did you contact DMV within ten days of your arrest to schedule a DMV hearing? _______________________. If so, what date and time is the hearing scheduled for? _______________________.

4. Approximately what time were you stopped by the policing agency?
_____: _____a.m. / p.m.

5. How much time went by between when you finished your last drink of alcohol and when you got stopped/contacted by the officer? ______________________.

6. If you drank at a club, bar, or restaurant, how did you pay for the drinks (cash or credit card)? ________________. If you paid by credit card try to get a copy of your bill and receipt so we can prove when and where you drank.

7. Did the officer have a valid reason for stopping or contacting you in the vehicle?
a. Yes.       c. I don’t know.
b. No.        d. Not applicable.

8. Did the officer indicate to you the reason for the traffic stop or contact with you?
a. Yes.
b. No.

9. If your answer to number six (8) was “Yes”, please identify the reason given by the officer (please circle all that apply).
a. Speeding.
b. Weaving.
c. Unsafe lane change.
d. Expired registration.
e. Tail light / Head light out.
f. Involved in a non-injury accident.
g. Involved in an injury accident (injuries at least to one person).
h. Roadblock / Checkpoint.
I. Other: .

10. If the officer did not see you driving, i.e., you were in an accident, parked, etc., answer the following questions:

a. Did you admit to driving?   Yes.   No.
b. Where were you standing when the officer first contacted you? ______________________________________________________
c. How close were you to the car when the officer contacted you? _____________________________.
d. Was your car blocking the road or in the road? Yes. No.
e. Were you involved in an accident? Yes. No.

11. Did the officer ask you if you had been drinking?

a. Yes.
b. No.

12. What time did you tell the officer you last drank? ____: ____a.m. / p.m.

13. If you drank alcoholic beverages, what type did you drink?

a. Beer.
b. Wine.
c. Hard liquor. (Specify type here: _________________)
d. Mixed drinks. (Specify kind(s) here:_______________ )
e. Other: _____________.

14. Think about the drinks that you had. The DA will be able to determine how much you had to drink based upon your test result so don’t underestimate how much you had. Please indicate, in total, how many drinks you had. (Remember: One drink is equal to 12 oz. of beer, a regular glass of wine, or 1 shot (1¼ oz.) Of hard liquor) __________________________________________
______________________________________________________

15. Were you on any prescription medications or other drugs at the time of the stop or soon before?

a. Yes.
b. No.
c. I don’t know.

16. If your answer to question sixteen (16) was “Yes”, please identify all medications and drugs that would have been in your system.:

________________________________________________.

17. Do you have any physical defects, injuries, or surgery that could have effected your Field Sobriety Test performance? If so, please describe: _______________________________________________________ _______________________________________________________.

It may be helpful if you obtain any medical records you have about your defect, injury, or surgery, and provide them to counsel.


18. Had you eaten within four hours prior to the arrest?
a. Yes.     b. No.

If “Yes”, please indicate what time and what you ate:

: _________a.m. / p.m. ; ____________________________.

19. Prior to being arrested, did you perform any Field Sobriety Tests (coordination or balance tests)?

a. Yes.
b. No.
c. I don’t know.

20. Please identify the Field Sobriety Tests which you were asked to perform (please circle all that apply).

a. Follow a pen, finger, or other object with your eyes without moving your head.
b. Standing with eyes closed, head tilted back, feet together, and arms at your side.
c. Standing on one foot for a period of time.
d. Writing the ABC’s.
e. Walking in a straight line heel-to-toe.
f. Touching your nose with your finger.
g. Writing numbers backwards
h. Patting one hand against another.
I. I did not take any Field Sobriety Tests.
J. Other: __________________________________.

21. Did you fail to satisfactorily perform the Field Sobriety Tests as demonstrated to you by the officer?

a. Yes.                       d. According to the officer, yes.
b. No.                         e. According to the officer, no.
c. I don’t know.           f. Not applicable.

22. While at the scene, did you blow into a field Breathalyzer or hand-held type gadget before you were arrested?

a. Yes.
b. No.

23. If your answer to number twenty-two (22) was “Yes”, what did the officer say was the result of the test?
_________Blood Alcohol Concentration (BAC) ; ei: .08 BAC

a. He / She did not tell me.
b. I don’t know.

24. Did the officer advise you that you could refuse to take the hand-held Breathalyzer?

a. Yes.
b. No.
c. I don’t know.
d. Not applicable.

25. After you were arrested, what type of chemical test did you take?

a. Blood.
b. Breath.
c. Urine.
d. No chemical test was taken.

26. What were the results of the chemical test given?
__________ Blood Alcohol Concentration (BAC) ; ei: .08 BAC

Did you choose the type of test (breath or blood) that you took or was it the officer’s decision to give you that test? ____________________________________________.

Was the test taken after you were arrested given within three hours of when you last drove? ________________.

27. Did you take the chemical test within one an one hour after you finished your last drink?

a. Yes.              c. I don’t know.
b. No.               d. Not applicable.


28. After you were handcuffed, approximately how many minutes/hours passed until you arrived at the chemical test location?
   ______________Hours ____________Minutes

29. After you arrived at the chemical test location, approximately how many minutes/hours passed before you were administered the first chemical test?
   ______________Hours ____________Minutes

30. Did the officer claim that you refused to voluntarily submit to a chemical test of your breath or blood? Yes. No. If your answer is yes, please circle the following that apply to you:

a. The officer told me that my license would be suspended for one year if I refused to take a chemical test, and I refused anyway.
b.  I refused during the initial vehicle stop or contact with the officer.
c.  I refused after I was arrested (handcuffed).
d.  I refused in the patrol car (before departing the scene).
e.  I refused during the patrol car ride to the chemical test location.
f.   I refused everything from the very beginning.
g.  I refused after we had arrived at the chemical test location.
h. The officer told me that I had refused when he first stopped me.
I.  The officer told me that I had refused while performing Field Sobriety Tests.
j.  The officer told me that I had refused when he handcuffed me.
k. The officer told me that I had refused while in the patrol car (before leaving the scene.
l. The office told me that I had refused while in transit to the chemical test location.
m. The officer told me that I had refused while at the chemical test location, however he did not tell me that I would lose my license if I refused.
n. The officer told me that I could refuse the test when he used a hand-held breathalyzer, so I did.
o. The officer never told me that I had to take a test, and he didn’t tell me that if I refused my license would be suspended.
p. Other:_____________________________________________
________________________________________________
 
31. Did the officer take your driver’s license or give you a paper called “Administrative Per Se Order of Suspension/Revocation and Temporary Driver License”?

a. Yes.
b. No.

32. Have you contacted the Department of Motor Vehicles (DMV) regarding your driving privileges?

a. Yes.
b. No.

33. If you have contacted the DMV, did you contact them within ten (10) days or thirty (30) days of your arrest?

a. Ten (10) days.
b. Thirty (30) days.

34. Were you or anyone in your car talking on a cell phone either shortly before or after being contacted by the police officer? Yes. No. If so, please get a copy of your cell phone bill so we can prove the time you were detained.

35. Were there witnesses as to when you had your last drink of alcohol? Yes. No. It can often be helpful to get written statements from people who were with you when you drank in order to prove when you finished drinking. Please discuss this with the attorney.

36. Was the car you were driving released to a passenger, towed, driven home by the officer, or parked at the scene? (Circle one.)

37. To your knowledge, did the officer tape record anything regarding your case? Yes. No.

38. Did you have to post bail or were you released on your own recognizance? (Circle one.)

39. If you had to post bail what was the amount: ________________, and did you use a bail bondsman or post the entire amount of bail with your own money:____________________________________________________.

Regarding the Chemical Test(s)
Please fill out the appropriate section that corresponds with the type of chemical test administered to you.

A. THE BREATH TEST

1. What law enforcement agency were you taken to in order to complete this test?

__________________; ei: Ventura Police Department, Ventura County Jail


2. Did at least fifteen (15) minutes or more pass from when you arrived at the jail and when the breath test was administered? ____________________________________.

3. Did an officer keep you under his continuous observation for 15 minutes prior to the administration of the breath test? ______________________________.

4. After the breath test was administered, did the officer(s) advise you that you had the right to take a blood or urine test in addition to the breath test (in order to insure the accuracy of the breath machine or so that a sample could be preserved for future testing?

a. Yes.
b. No.
c. I don’t know.

5. Did you take a blood or urine test in addition to the breath test?

a. Yes.
b. No.
c. I don’t know.

(If your answer was yes, please fill out the corresponding section for the additional test you took.)

B. THE URINE TEST

1. Did you completely empty your bladder for the first sample?

a. Yes.
b. No.
c. I don’t know.

If your answer was “No”, please explain why: _____________________.

2. Did the officer collect your urine the second time you urinated?

a. Yes.
b. No.
c. I don’t know.

3. Did an officer watch you closely or fail to respect your privacy when you provided the sample?

a. Yes.

b. No.
c. I don’t know.

C. THE BLOOD TEST

1. At what medical facility was the test administered? ________________.

2. Once at the medical facility, approximately how many minutes passed before the blood was actually drawn?

   _________________Minutes

3. At the medical facility, was the blood draw forced by the officer(s) or did you volunteer your arm freely?

a. Forced.
b. Volunteered.

4. At the medical facility, did a nurse or officer present you with release forms to sign that gave permission for the blood draw?

a. Yes.
b. No.
c. I don’t know.
5. Did the person (nurse) who drew the blood mix the tube well before giving it to the officer? _________.


Goals and Concerns Regarding You DUI Case

1. If you have any major concerns or goals regarding your DUI / DMV case, please identify them below.
  __________________________________________________

2. What is your biggest concern regarding your DUI? (ei: license suspension, jail time, etc...)