Adam H. Putnam Commissioner Florida Department of Agriculture and Consumer Services Office of Agricultural Law Enforcement DUI WORKSHEET Section 119.071, F.S. EVENT Officer Name: ID #: Case #: Event Location: Day and Date: Time: am pm Event Type: Crash MV Violation Physical Control In Custody Date: Other: Weather: Hot Warm Cold Cool Dry In Custody Time: Humid Rain Foggy Cloudy Mild Damp Wet am pm Subject Name: Date of Birth: Address: Race: Sex: Age: DL#: State: Type: CDL: Yes No *SS#: Height: Weight: Hair: Eyes: Did you see subject driving? Yes No Was motor running? Yes No Did another Officer see subject driving? Yes No Or key in ignition? Yes No If parked, was subject behind wheel? Yes No *Employee provided AgLaw business card to subject containing written statement in compliance with Section 119.071, F.S., pertaining to collection of Social Security Numbers. VEHICLE IN MOTION Vehicle Description Year: Make: Model: Color: Tag #: State: Left at the scene Towed by or Released to: DUI Detection Guide: (Check all that apply) Turning with wide radius Slow speed (more than 10 mph below limit) Signaling inconsistent with driving actions Straddling center or lane marker Stopping (without cause) in traffic lane Slow response to traffic signals Appearing to be drunk Following too closely Almost striking object or vehicle Stopping inappropriately (other than in lane) Drifting Turning abruptly or illegally Weaving Tires on center line or lane marker Driving on other than designated roadway Accelerating or decelerating rapidly Swerving Braking erratically Driving into opposing or crossing traffic Headlights off Violation(s) Observed: Citation #: Vehicle Inventory Form Completed: Yes No FDACS 01409 01/15 Page 1 of 6
PERSONAL CONTACT Observations: Driver Did driver exit vehicle? Yes No Clothes Hat or Cap: Jacket or Coat: Shirt or Dress: Pants or Skirt: Breath Odor of Alcoholic Beverage: Strong Moderate Faint None Attitude Excited Talkative Sleepy Indifferent Cooperative Polite Hostile Aggressive Profane Face Color Pale Flushed Normal Other: Eyes/ Pupils Glassy Bloodshot Watery Dilated Normal Manner Falling Unsteady Leans on vehicle Sways Staggers Unusual Actions Hiccoughing Belching Vomiting Fighting Crying Laughing Speech Slurred Slow Thick tongue Accent Incoherent Rambling Stuttering Fair Good ENVIRONMENTAL FACTORS Environment: Area Conditions Day Night Wind Calm Windy Rain Traffic Heavy Moderate Light Area Description Parking Lot Roadside Other Area: Surface Condition Paved Level Hard Dry Other Surface: Lighting Street Light Car Lights Other Lighting: STANDARDIZED FIELD SOBRIETY TESTING TEST 1: HORIZONTAL GAZE NYSTAGMUS Date: Time Test 1 Performed: a.m. p.m. Refused Test 1: Yes No Video Taken: Yes No This test was explained to the subject and the subject was told the following: I am going to check your eyes. (Please remove your glasses.) Keep your head still and follow this stimulus with your eyes only. Do not move your head. Do you understand the instructions? Officer observed the following things: Lack of smooth pursuit in LEFT eye Lack of smooth pursuit in RIGHT eye Distinct nystagmus at maximum deviation in LEFT eye Distinct nystagmus at maximum deviation in RIGHT eye Nystagmus located prior to the onset of 45 degrees in LEFT eye Nystagmus located prior to the onset of 45 degrees in RIGHT eye Inability to keep head still and follow VGN (Vertical Gaze Nystagmus) with eyes only Swayed back and forth as if having problems maintaining balance Understood instructions Spontaneous Statements/Comments: Reminded numerous times to hold head still and follow stimulus with eyes only Did not understand instructions FDACS-01409 12/14 Page 2 of 6
STANDARDIZED FIELD SOBRIETY TESTING (Cont d.) TEST 2: WALK AND TURN TEST AREA CONDITIONS Ground surface level and free of obstructions? Yes No Any hip, back, leg, or foot problems that could hinder you during the test? Yes No If Yes, describe: Type of line: Tape Lane Line Other: Surface of test area: Asphalt Concrete Other: Location of test area: Condition of area: Dry Wet The following instructions were given to subject and demonstrated throughout the instructional phase. 1. Put your left foot on the line and put your right foot in front of it with your right heel touching your left toe. Keep your hands at your side. (Demonstrate.) 2. Do not start until I tell you to. 3. Do you understand the directions? 4. When I tell you to begin, take nine heel-to-toe steps on the line, turn around keeping one foot on the line, and return nine heel-to-toe steps. (Demonstrate heel-to-toe; three steps is sufficient.) 5. On the ninth step, keep the front foot on the line and turn by taking several small steps with the other foot. (Demonstrate turn.) 6. While walking, watch your feet at all times, keep arms at side, count steps out loud. Once you begin, do not stop until test is completed. 7. Do you understand the instructions? 8. You may begin the test. Subject did the following: Could not keep balance while listening to instructions Started before instructions were finished Stepped off line Used arms for balance Raises arms over six inches Took incorrect number of steps Could not do the test: Stepped off line 3 or more times Was in danger of falling Was unable to complete task (Score this item as all clues seen.) Did not touch heel-to-toe Understood instructions Did not understand instructions Lost balance while turning, turns incorrectly Staggered Stumbled Stopped walking to steady self Pauses to regain balance Spontaneous Statements/Comments: FDACS-01409 12/14 Page 3 of 6
STANDARDIZED FIELD SOBRIETY TESTING (Cont d.) TEST 3: ONE LEG STAND The following instructions were given to subject and demonstrated: 1. Stand with your heels together and your arms at your side. (Demonstrate). 2. Do not begin the test until I tell you to. 3. Do you understand? 4. When I tell you to, I want you to raise one leg, either leg, approximately six inches off the ground, foot pointed out. Keep both legs straight and keep your eyes on the elevated foot. 5. While holding that position, count out loud; one thousand and one, one thousand and two, one thousand and three, and so forth until told to stop. (Demonstrate raise leg and count). 6. Do you understand the instructions? 7. You may begin the test. Subject did the following things: Swayed while balancing Write count number that subject places Used arms to balance (over 6 in.) foot down on above foot. Hopped Put foot down Could not do the test: Put foot down 3 or more times Lost balance (Score all clues.) Subject switched balance leg during test: Left to Right Right to Left Understood instructions Did not understand instructions Spontaneous Statements/Comments: INTOXILYZER TEST Accepted Refused Implied Consent Warning Completed Yes No Instrument: Instrument Number: Location: B.A.T. Jail Other: Breath Test Results: Test #1: g/210 L Deficient Sample Reading Yes No Test #2: g/210 L Deficient Sample Reading Yes No Refused Test #3: g/210 L Deficient Sample Reading Yes No Refused Urine sample taken Subject malingered on test Blood sample taken Subject requested private test Arresting Deputy/Officer Signature/Agency: Intoxilyzer Operator Signature/Agency: Date: Time: a.m. p.m. FDACS-01409 12/14 Page 4 of 6
SUBJECT INTERVIEW MIRANDA WARNINGS Read the following statements to the subject: 1. You have the right to remain silent. Do you understand? Yes No 2. Anything you say can be used against you in court. Do you understand? Yes No 3. You have the right to talk to a lawyer for advice before we ask you any questions and to have him/her with you during questioning. Do you understand? Yes No 4. If you cannot afford a lawyer, one will be appointed for you before any questioning, if you wish. Do you understand? Yes No 5. If you decide to answer questions without a lawyer present, you will still have the right to stop answering at any time. You also have the right to stop answering at any time until you talk to a lawyer. Do you understand? Yes No After the warning, ask the following questions and secure an affirmative answer to each to obtain a waiver: 1. Do you understand each of these rights I have explained to you? Yes No 2. Have you previously requested any law enforcement officer to allow you to speak to an attorney? Yes No 3. With these rights in mind, do you wish to talk to us now? Yes No I certify that I have read the above warnings word for word to the arrestee, and he/she answered as shown. Name of Officer: Officer Signature: Name of Subject: Subject Signature: Date: Time: Location: INTERVIEWER MUST FILL IN BELOW: Interviewer s Name: Day and Date: Time: a.m. p.m. Were you operating a vehicle? Yes No Where were you going? What street or highway were you on? Direction of Travel? Where did you start from? What time did you start? a.m. p.m. Was it day or night? What time is it now? What is the date? What day of the week is it now? What city/county are we in? When did you last eat? What did you eat? Where did you eat? What were you doing the last 3 hours? Have you been drinking? Yes No What? How much? Where? With Whom? Time Started? a.m. p.m. Time Stopped? a.m. p.m. Can you feel the effects of the alcoholic beverages? Yes No Are you under the influence? Yes No Are you wearing an artificial limb? Yes No Do you have false teeth? Yes No Do you have a glass eye? Yes No Do you wear contacts? Yes No Hard Daily Do you have any physical defects? Yes No If so, what? Are you sick or injured? Yes No If so, what s wrong? When did you last sleep? How much sleep did you have? FDACS-01409 12/14 Page 5 of 6
INTERVIEWER MUST FILL IN BELOW: (Cont d.) Did you get a bump on the head? Yes No Were you in an accident today? Yes No Have you had any alcoholic beverage since the accident? Yes No If so, what beverage? Where? How much? When? Are you under the care of a Doctor or Dentist? Yes No If so, what is the Doctor or Dentist Name? Are you taking tranquilizers, pills, or medicines of any kind? Yes No If so, what kind? (Get a sample) Do you have epilepsy? Yes No Diabetes? Yes No Do you take insulin? Yes No Last dose? a.m. p.m. Have you used any type of drugs recently? Yes No If so, what were the drugs for? What kind of drugs? Last dose? a.m. p.m. PASSENGER INTERVIEWS NOT APPLICABLE Passenger #1 Information Passenger 1 Name: Passenger 1 Address: Passenger 1 Telephone: Passenger 1 Position in Vehicle: Did the passenger drink more or less than the driver? More Less Where were they coming from? Were they drinking together? Yes No What did the driver drink and how much? Did the driver say anything when stopped? Yes No If yes, what was said? Passenger #2 Information Passenger 2 Name: Passenger 2 Address: Passenger 2 Telephone: Passenger 2 Position in Vehicle: Did the passenger drink more or less than the driver? More Less Where were they coming from? Were they drinking together? Yes No What did the driver drink and how much? Did the driver say anything when stopped? Yes No If yes, what was said? Passenger #3 Information Passenger 3 Name: Passenger 3 Address: Passenger 3 Telephone: Passenger 3 Position in Vehicle: Did the passenger drink more or less than the driver? More Less Where were they coming from? Were they drinking together? Yes No What did the driver drink and how much? Did the driver say anything when stopped? Yes No If yes, what was said? FDACS-01409 12/14 Page 6 of 6