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DUI Evaluation Reporting Form Mobile App

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. 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.

  • Lendlease
  • The Cooperative
  • PG&E
  • oxy
  • Red Bull
  • Mirvac

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Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    This form is required as the standardized reporting format for DUI evaluations.

  • Ico textbox

    Court and Case Title

  • Ico textbox

    Case Number

  • Ico textbox

    Sentencing Judge

  • Ico date

    Sentencing Date

  • Ico time

    Sentencing Time

  • Ico textbox

    Defendant Name

  • Ico dropdown

    Gender

  • Ico textbox

    Defendant Street Address

  • Ico textbox

    Defendant City

  • Ico dropdown

    Defendant State

  • Ico textbox

    Defendant Zip Code

  • Ico textbox

    Defendant Telephone Number

  • Ico textbox

    Defendant Aliases

  • Ico textbox

    Defendant SS#

  • Ico date

    Defendant Date of Birth

  • Ico date

    Date of Evaluation

  • Ico dropdown

    Marital Status

  • Ico textbox

    Other:

  • Ico textbox

    Arrest/Charge

  • Ico date

    Date of Charge

  • Ico dropdown

    Disposition

  • Ico textbox

    Other:

  • Ico textbox

    Location

  • Ico textbox

    BAC (if applicable - for refusal, indicate "Refused")

  • Ico textbox

    Breath

  • Ico textbox

    Urinalysis

  • Ico textbox

    Blood

  • ...and More!

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