Day 1 BD-1

Day 1 BD-1
Date
Name

First NameLast Name
Reason you were stopped?

SpeedingDriving too slowLights not workingHad a wreckOther moving violationOther
Arrest occured in what county?
Was a breath test taken?

YesNo
What was it?
Why wasn't it taken?
Was a blood test taken?

YesNo
What was it?
Why wasn't it taken?
Before my arrest, I was

Drinking alcohol after workEngaged in a recreational activity while using alcohol (or drugs) (example: ball game, fishing, camping, cook off, party, work function, etc.)Coping with problems (relationship, work, family, etc.)Other
How many hours had you been drinking/drugging?
I had been using: (check all that apply)

beerwineliquormarijuanaopiatespillsmethamphetamineOther
What type of pills?
I was with:

SpouseFriend(s)Co-WorkersAloneFamilyStranger/other
During the weekdays, I tend to drink on (place the number of drinks/amount of drugs used next to a.m/p.m.
Monday: # a.m.    # p.m.
Tuesday: # a.m.    # p.m.
Wednesday:    # a.m.      # p.m.
Thursday:      # a.m.      # p.m.
Friday:      # a.m.      # p.m.
During the weekends, I tend to drink on (place the number of drinks/amount of drugs used next to a.m/p.m.
Saturday: # a.m. # p.m.
Sunday: # a.m. # p.m.
Summarize any other comments about your drug/alcohol usage and the events leading up to your arrest below:
Should be Empty: