Virginia DUI/DWI Preliminary Case Analysis Form

First name:
Last name:
State of residence:
County/City of residence:
Preferred phone number:
Best time to call:
Email address:
State of operator's license:
Did you eat within 8 hrs of the offense?
yes	no	If yes, please describe:
Did you consume any alcohol within 8 hrs of the offense?
yes	no
Are you a commercial driver?
yes	no
County of offense:
Offense location:
Why did the officer stop your car?
Were you involved in an accident?
yes	no	If yes, please describe:
Were there any passengers in your car?
yes	no	If yes, any under age 18?	yes no
Did you perform any field sobriety tests?		If yes, select all that apply:
yes	no	1 leg stand Walk & Turn Nose touch Finger touch Eye test ABCs
yes	no	Numbers Other Describe
Did you perform a roadside breath test?
yes	no	if yes, provide BAC results:
Did you make any statements to the officer?
yes	no
Were you read Miranda rights?
yes	no
Were you placed under arrest?
yes	no
Select applicable test you performed:
Breath Test		If yes, provide BAC results:
Blood Test
Refused Test
Do you have any prior DUI convictions?
yes	no
Were you released on a bond?
yes	no	If yes, what is the amount?
Do you have a pending court date?
yes	no	If yes, please provide date:
Briefly describe what happenedl: