DUI Evaluation Reporting Form

Form Template

The DUI Evaluation Reporting Form is used for conducting DUI evaluations resultant from an individual under the influence of drugs and/or alcohol operating, or attempting to operate, a motor vehicle.

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Language: English
Country: United States of America

The form collects information related to alcohol and other substance abuse issues from the offender.

The DUI Evaluation form covers legal information, beginning with the court in which the conviction/charge occurred, then on to previous arrests/convictions/charges related to substance abuse issues. The tests performed are noted and detailed - this includes a breath test, a urinalysis, and a blood test to evaluate the use of illicit drugs, and/or blood alcohol content (bac). The individual performing the DUI evaluation has a face-to-face interview with the offender, and goes through treatment options, drivers license record, previous substance abuse programs, or alcohol programs that the offender has enrolled in, along with information about whether those were completed or not. A survey of the substances that the offender uses is conducted, noting the level of use/abuse, and dependency, the method of use, and the date of the last use. The defendant has the opportunity to provide a narrative of their arrest, along with a self-evaluation of their substance abuse. A family history is conducted, as family drug and alcohol abuse can influence the risk of other family members abuse of drugs and alcohol. The chosen screen tools are listed, and the person conducting and alcohol and drug evaluation provides a recommendation for treatment needs, along with detailed reasons behind said needs.

An appropriate treatment plan is put together, along with costs and duration, and recommended to the defendant.

Features
  • Signature Capture
  • Conditional Fields
  • Submission Editing
  • Reference Data
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Platforms
  • iPhone
  • iPad
  • Android
  • Windows
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Integrations
  • Quickbooks
  • Salesforce
  • Google Docs
  • Dropbox
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