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DUI Questionnaire

Retainer Form
DUI Questionnaire
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1. Did the officer take your driver's license or give you a paper called "Administrative Per Se Order of Suspension/Revocation, Temporary Driver License Endorsement"?
 
Yes No
 
2. Have you contacted the DMV as requested on the Administrative Per Se Order?
 
Yes No
 
If not, immediately call us toll free at 866-CRIME-OO
 
3. If you have contacted the DMV within the 10 day limit, when is your appointment (date and time)?
 
 
4. Have you ever been arrested for a DUI/DWI charge before?
 
Yes No
 
5. What date were you arrested for the current offense?
 
 
6. Approximately what time were you arrested?
 
 
7. Approximately how many minutes went by from the time you were arrested (when they handcuffed you) until you arrived at the chemical test location (blood, breath or urine test location)?
 
 
8. Approximately how many minutes went by from the time you arrived at the chemical test location until you took the first chemical test (blood, breath or urine test)?
 
 
9. Did the officer have a valid reason for stopping or contacting you while you were in your vehicle?
 
Yes No

I don't know/not applicable
 
10. What did the officer say was the reason for the traffic stop or contact with you (check any that apply)?
 
Speeding
Weaving
Involved in accident - No injury to anyone
Involved in accident - Injuries to at least one person
Roadblock/Checkpoint
Unknown - I don't know
S/he didn't tell me
 

11. If none of the above apply, please indicate the reason for the stop of your vehicle or contact with you?

 
 
12. Did the officer see you driving?
 
Yes
No
I don't know/not applicable
 
13. Did you admit to driving?
 
Yes
No
I don't know/not applicable
 
14. If you consumed alcoholic beverages, what type did you drink (highlight all that apply)?
 
 
15. If 'Other', please indicate type of beverage?
 
 
16. Think about the drinks you had. Many people under estimate how many drinks they had, or cannot remember. However, this is extremely important to your case. In order to calculate your Blood Alcohol Level please indicate how many drinks you had total (one drink is equal to a 12 ounce beer, a regular glass of wine, or 1 shot (1 1/4 ounces of hard liquor)?
 
 
17. Approximately what time did you finish your LAST alcoholic beverage before you were pulled over?
 


I don't know/not applicable
 
18. What time did you tell the officer you last drank?
 
 
19. If you were on prescription medications or other drugs, what type? (highlight all that apply)?
 
 
20. If 'Other', please indicate type of medication or drug?
 


I don't know/not applicable
 
21. What size meal did you have before the arrest?
 
 
22. When, before the arrest, did you eat?
 
 

Analysis Questions-Field Sobriety Tests/Reasonable Cause to Arrest
 
23. Did you perform any coordination or balance tests (Field Sobriety Tests - FST's) prior to being arrested?
 
Yes
No
I don't know/not applicable
 
24. Please select the field sobriety tests you were requested to perform? (check all that apply):
 
Did not take any field tests
Follow a pen, finger, or other object with you eyes, not moving your head
Standing with my head tilted back and eyes closed, feet together
Standing on one foot for a period of time
Patting your hands together
Counting on your fingers
Saying or writing the ABC's
Walking a straight line, or heel-to-toe
Touching your nose with finger
Other
 
25. If 'Other', please indicate what they made you do?
 


I don't know/not applicable
 
26. Did you blow into a field breathalyzer or hand-held type gadget?
 
Yes No
 
27. If you know, what was the result of the hand-held breathalyzer gadget test?
 


I don't know/not applicable
 
28. Did the officer advise you that you could refuse to take the hand-held gadget breath test?
 
Yes
No
I don't know/not applicable
 
29. Did you fail to satisfactorily perform the balance and coordination tests as demonstrated to you by the officer?
 
Yes
No
I don't know/not applicable
 

Analysis Questions - Chemical Test/Chemical Test Refusal
 
30. Please select the type of chemical test you took (or whether you took a chemical test at all):
 
Blood
Breath
Urine
No chemical test taken
I don't know/not applicable
 
31. What were the results of the test, if you know?
 


I don't know/not applicable
 
32. Did you take the chemical test (blood, breath or urine at the station or jail) within 1 1/2 hours after finishing your last drink?
 
Yes
No
I don't know/not applicable
 
33. If you are charged with refusing a chemical test - Which of the following apply?
 
The cop told me I would have my license suspended if I refused a blood, breath or urine test, and I refused anyway.
I refused during the initial vehicle stop or contact with the cop.
I refused when they handcuffed me.
I refused in the patrol car.
I refused on the ride, in the patrol car, to the chemical test location.
I refused at the chemical test location.
I refused everything from the beginning.
The cop told me I refused when he first stopped me.
The cop told me I refused when we were doing Field Tests.
The cop told me I refused when he handcuffed me.
The cop told me I refused when we were in the car.
The cop told me I refused when we were driving to the chemical test location.
The cop told me I refused when we were at the chemical test location, but he didn't tell me I would lose my license if I refused.
The cop told me I could refuse the test when he used a hand-held breathalyzer, so I did.
The cop never told me I had to take a test and he didn't tell me I would loose my license for refusing.
Other
 
34. If "other", please explain what happened:
 
 

If you took a breath test (NOT the hand-held road test):
 
35. After you arrived at the place where the breath machine was located, did you wait at least 15 minutes before your first breath into the machine?
 
Yes
No
I don't know/not applicable
 

36. If at least 15 minutes went by after arriving where the breath machine was located, what were you and the officer(s) doing during that period of time (highlight all that apply)?
 
 
37. If 'Other', please indicate what happened?
 
 
38. After the breath test was completed, did the officer advise you that you had the right to take a blood or urine test, in addition to the breath test, to insure the accuracy of the breath machine or so you could have a sample collected for future testing?
 
Yes
No
I don't know/not applicable
 
39. Did you take an additional blood or urine test?
 
 

If you took the urine test:
 
40. For the urine test, did you completely empty your bladder the first time you urinated?
 
Yes
No
I don't know/not applicable
 
41. If no, why not?
 
 
42. For the urine test, did the officer collect your urine the second time you urinated?
 
Yes
No
I don't know/not applicable
 
43. For the urine test, did an officer watch you closely or fail to respect your privacy when you provided the sample?
 
Yes
No
I don't know/not applicable
 
44. What type of law enforcement officer was the arresting officer (the one who gave you tests, handcuffed you, took you to jail)?
 
 
45. Please input the arresting officer's last name and badge or serial number if you know it:
 
 

Information necessary to contact you for an evaluation
and/or to confirm the survey data entered with public records
 
46. Name the city where the arrest took place?
 
 
47. In which California Superior Court are you scheduled to appear?
 
 
48. In which Nevada Justice or Municipal Court are you scheduled to appear?
 
 
49. When is your court date?
 
 
50. Have you consulted with another attorney since your arrest?
 
Yes  No
 
51. Are you aware that a conviction and/or driver's license suspension for DUI/DWI will result in an insurance cancellation or a possible increase in cost between $15,000 to $25,000 during the next seven years?
 
Yes No
 
 
Your Name:
 
Your Email Address:
 
Your Home Address:
 
City:
 
State:
 
Zip code:
 
Home Phone:
 
Business Phone:
 
Pager Phone:
 
Cell Phone:
 
Fax Number:
 
Contact Preference:
 
Date of Birth:
 
Driver's License Number and State:
 
Occcupation:
 
Annual Income:
 
Your budget to have an attorney represent you:
Place of employment
 

Congratulations. If you have checked your answers, please either send the email by pressing the below button, or you can erase all data fields by clearing them below.
 
 

This information will be used to help evaluate your case. An appointment for a FREE initial case evaluation and consultation by an Attorney can be scheduled ONLY if you request. There is no fee for this service. Remember to call us ANYTIME TOLL FREE in Nevada and all States outside California at (866)CRIME-00 or throughout California at (213)300-7444 if you have any questions.
 
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